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THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION
In this issue
Culture and health 3
Federico Mayor & Hiroshi Nakajima Traditional medicine and WHO 4
Xiaorui Zhang Building on local health culture 6
Haile Moria m Kahssay Medicine for a small planet 8
Marc S. Micozzi Food beliefs and taboos 10
Mohammed Abdussalam & Fritz Koferstein Our common nutritional heritage 12
James Akre Ritual and culture 13
Helmut L. Sell Babies need their mothers
beside them! 14
James J. McKenna Sudden infant death syndrome 16
Hazel Brooke Psychotherapy and culture in Africa 18
Karl Pelzer Who are we to say? 20
Ellen M. Einterz Culture and depression 22
S. Douki & K. Tabbane Culture and preventive care at
school: Geneva 24
Philippe Grange! Promoting community safety 26
Leif Svanstrom & Moo Sundstrom Culture, health and the media 28
Moria Tereza Maldonado & Mark Belsey New drugs from the rain forests 30
Norman R. Farnsworth
World Health • 49th Yeor, No. 2 Morch-April1996 IX ISSN 0043-8502
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World Health • 49th Year, No. 2, March-Aprill996
Editorial
Culture and health
Or Hiroshi Naka;ima, Director-General of WHO.
W
ritten in 1946, WHO's Constitution provides us with a strikingly modem definition of health. It is "a state of complete physical, mental and social well-being and not merely the ab- sence of disease or infirmity". This notion of well-being is often under- stood today in terms of people's perceptions of their quality of life as individuals and members of society.We must realize, however, that such perceptions are largely shaped by the values and symbolic representa- tions which prevail in any group or culture.
As cultural representations of the human body, time, life, death and disease vary, so do people's
approaches to action, prevention and treatment. Procreation, childbirth, weaning, sexuality, death, disease and suffering are not just private experiences but all have an intrinsic social dimension. The health condi- tions in which they take place are often determined as much by cultural practices as by biological and envi- ronmental factors. For example, traditional practices such as female genital mutilation, or food taboos during pregnancy and childhood, can have serious consequences for peo- ple's health. Similarly, until recently, though highly addictive and harmful to health, smoking was generally accepted as part of social life. The
Mr Federico Mayor, Director-General of UNESCO.
current increase in noncommunica- ble diseases such as cancer, diabetes and cardiovascular diseases can only be understood in connection with the worldwide spread of new lifestyles and diet.
To reduce sickness and death among mothers and children, to promote family planning, to prevent sexually transmitted diseases, to foster the rational use of health services or the social integration of the disabled, to improve nutrition or to control violence, we must be able to influence behaviours, cultural attitudes and lifestyles. From that point of view, WHO's community and family health approaches are particularly important for achieving social and cultural relevance in health work. UNESCO also has a major role to play in devising appro- priate means of communicating about health so that each community can develop healthy lifestyles that are in harmony with its social, cul- tural and economic environment.
As health workers and educators we have a twofold responsibility:
firstly, to provide equitable access to safe and effective health care and services; and secondly, to provide the necessary knowledge, information and infrastructure that will enable people to take care of themselves and promote their own health and that of their families. To be effective and
3
sustainable, our health policies and interventions, including our educa- tion programmes, must be based not only on hard scientific and epidemio- logical evidence but also on people's personal experience of life and health and their own priorities and constraints.
To ensure community participa- tion, we must build health develop- ment on what people know and what they want and are therefore prepared to support in the long run. We must also be able to rally the cooperation of respected community members such as traditional healers and birth attendants. While maintaining our concern to make safe and effective care of good quality available to all, we must show our willingness both to learn from others and to share our knowledge and experience with them. Much empirical knowledge, for example on medicinal plants, has been accumulated by various cul- tures and traditions which we must recognize and preserve as part of the common cultural and scientific heritage of mankind.
As lead agency for the United Nations World Decade for Cultural Development, UNESCO has chosen this year to focus more particularly on "Culture and health". In May 1996, a joint UNESCO/WHO International Conference will be held in Chiang Rai, hosted by the
Government of Thailand, to assess the work carried out to date and propose further avenues for coopera- tion so that health and culture can be developed in a mutually supportive manner which will benefit all peo- ples in all countries. •
Hiroshi Naka;;ma Federico Mayor
4 World Health • 49th Year, No. 2, March-April1996
Traditional medicine and WHO
Xiaorui Zhang
Traditional medicine plays a very important role in primary health care in many
developing countries, and its use has increased in recent years. To enhance its safety and eff~ctiveness, WHO supports research and training activities in Member States.
matter of ensuring that traditional medicine is examined critically and with an open mind.
A progress report on traditional medicine and modem health care presented to the World Health Assembly in 1991 emphasized five major areas of concern: national programme development; health systems and operational research;
clinical and scientific investigations;
education and training; and exchange of information. The Programme's future directions were to focus on three main activities: national poli- cies, medicinal plants, and acupunc-
A traditional practitioner in Congo treating his patient.
ture. Then in 1994 at the World Health Assembly governments called on the Director -General
"to consider the contribution WHO might make to promot- ing respect for, and maintenance of, indigenous knowledge, traditions and remedies, in particular, their pharmacopoeia".
I
n 1977, the year WHO's Tradi- tional Medicine Programme was established, the World Health Assembly urged governments "to give adequate importance to the utilization of their traditional systems of medicine, with appropriate regula- tions, as suited to their national health systems".WHO is well aware that many elements of traditional medicine are beneficial, but others are not. In this respect, the Organization encourages and supports countries in their efforts to find safe and effective remedies and practices for use in health ser- vices. However, this does not amount to a blind endorsement of all forms of traditional medicine; it is a
National policy
As there is a shortage of medical doctors and pharmaceutical products, most of the population in developing countries still rely mainly on tradi- tional practitioners and local medici- nal plants for primary health care.
Practitioners include traditional birth attendants, herbalists, and bone- setters. In Ghana, for example, the ratio of medical doctors to the total population is 1:20 000, whereas for traditional practitioners it is 1 :200.
In Swaziland these figures are 1:10 000 and 1:100 respectively.
Traditional birth attendants conduct 95% of the births in rural areas and
70% of the births in urban areas in some countries.
During the last decade there has been a growing interest in traditional and alternative systems of medicine in industrialized countries. In the United States, a survey made in 1992 showed that about a third of the population made at least some use of alternative treatment such as herbal medicines, acupuncture, chiropractic and homoeopathy. Surveys in European countries showed similar interest; 60% of the Dutch and Belgian public have expressed their willingness to pay extra health insur- ance for alternative medicine, and 74% of the British public favour complementary medicine being available on the national health service.
Herbal medicine
Medicinal plants and herbs are of great importance to the health of individuals and communities; be- . tween 35 000 and 70 000 species have at one time or another been used for medical purposes, and international use of herbal medicines and natural products is steadily increasing. In 1993, the total sales of herbal medicines in China amounted to more than 14 billion yuan (US$
2.4 billion), not including US$ 400 million worth of exports. The Malaysian Government estimates that sales of traditional medicine currently amount to US$ 60 million.
In the United States and Canada, sales of herbal medicines showed a growth rate of 15% in 1990, while the national growth rates in western European countries ranged from 5%
to 22%. In Japan, there was a 15- fold increase in herbal sales between 1979 and 1989, while sales of phar- maceutical products multiplied by only 2.6.
Despite the existence of herbal medicines over many centuries, only a relatively small number of plant
World Health • 49th Yeor, No. 2, Morch-Aprill996
species - about 5000 - have been studied for their possible medical applications. Safety and efficacy data exist only in respect of a much smaller number of plants, their ex- tracts and their active ingredients, as well as of preparations containing them. The establishment and use of regulation procedures and quality control have become major concerns in both developing and industrialized countries.
Acupuncture
Acupuncture is today being used worldwide because of the simplicity of its application, its minimal side- effects and its low cost. It has been in constant use in China for thou- sands of years, and spread to other oriental countries long ago. A big increase in the use of acupuncture and in training and research on it has also occurred worldwide in the last two decades. By 1990, the total number of acupuncturists in Europe had reached 88 000, of whom 62 000 were medical doctors, while
acupuncture users totalled 20 mil- lion. Consumer surveys consistently showed positive public attitudes to complementary medicine; 90% of the pain clinics in the United Kingdom and 77% in Germany use acupuncture.
Important advances have been made in our understanding of the mechanisms of acupuncture. In particular, great progress has been made in clinical research on acupuncture analgesia, which has been used during surgery and for the treatment of acute and chronic pain.
As the use of acupuncture has grown, so has the need for training.
Since the 1970s, WHO has sup- ported training in acupuncture by establishing collaborating centres and awarding fellowships. According to a report by three WHO collaborat- ing centres for traditional medicine in China, more than 6000 foreign stu- dents from over 100 countries were trained there during the last decade.
In Europe, there are 242 permanent training schools of acupuncture with more than 7800 students.
Training and research
In order to ensure the safe and effec- tive use of traditional medicine, WHO supports research and training activities. There are now 24 WHO Collaborating Centres for Traditional Medicine; eight of them are involved in training and research on acupunc- ture while the others are conducting research on herbal medicines. The main role of the Collaborating Centres is to support WHO in imple- menting its policies and decisions regarding traditional medicine. In addition to their achievements in research and the integration of tradi- tional medicine into national health care systems, these centres have made a major contribution to the international standardization of herbal medicines and acupuncture, and the exchange of information.
Governments in countries where traditional medicine is widely prac- tised are also showing an interest in research in this field. In China, for instance, each province has a college and a research institute for Chinese traditional medicine. In India, the government provides financial sup- port for the research and develop- ment of the Ayurvedic and Unani systems and their increasing involve- ment in the delivery of health ser- vices. Such systems are seen as allies in the delivery of primary health care. National research insti- tutes have been established in such countries as Burundi, Cameroon, Mali, Peru, the Philippines, Sudan and VietNam.
Research institutes and founda- tions have also been established in industrialized countries. In the United States, for example, the Office of Alternative Medicine was initiated through a congressional mandate and was located in the National Institutes of Health in 1992.
The goal of this office is to evaluate alternative or unconventional med- ical treatments, and research on acupuncture is a main aspect. In the United Kingdom, several research councils for acupuncture and com- plementary medicine have long been in existence, committed to encourag-
Selling medicinal plants culled from tropical forests in Brazil.
s
ing collaborative research to find proof of the efficacy and safety of acupuncture and other forms of traditional medicine. European Cooperation in the Field of Scientific and Technical research (COST), which aims to improve pan- European collaboration in science and technology, was set up by the European Commission, which also funds the project. In June 1993, a COST group was established with a mandate to investigate the therapeu- tic significance of unconventional medicine, its cost-benefit ratio and its sociocultural importance as a basis for the evaluation of its possible use or risks in public health.
WHO strongly supports the further promotion and development of the rational use of traditional medicine throughout the world.
There is no doubt that this branch of medicine is making and will continue to make a very significant contribu- tion to our efforts to achieve health for all. •
Or Xiaorui Zhang is Chief of the Traditional Medicine Unit, World Health Organization,
I 21 I Geneva 27. Switzerland.
6 World Health • 49th Year, No. 2, Morch-Aprill996
Building on local health culture
Haile Mariam Kahssay
T
he term "community health worker" (CHW) is used generi- cally by WHO to refer to men and women who are trained and supported by the health sector to work in their own communities.Some countries prefer to call them voluntary health workers, and they may also be known as village health guides (India), health cadres (Indonesia), or community health agents (Ethiopia).
CHWs play a unique role because they belong both to the community and to the health sector. They make a practical and proven contribution to the core of the primary
health care approach, which is the involvement of peo- ple. This is absolutely essential if the health sector is to promote good health rather than just control diseases. Mutual under- standing and cooperation are often difficult because the health sector is guided mainly by the sciences of medicine and public health, whereas the community is guided mainly by its own health culture, with its rich variety of attitudes, beliefs and practices. The CHW can greatly help to ease this relationship and thus im- prove the health services by providing a combination of scientific or management expertise and knowledge of the community and its culture.
Health personnel tend to assume that people do not know anything. They often see communities as empty vessels into which scientific knowledge has to be
The community health worker makes a practical and proven contribution to the core of the primary health care approach, which is the involvement of people. This is absolutely essential if the health sector is to promote good health rather than just control diseases.
poured. But in reality, of A Family health worker in Nigeria visits a mother and her child.
course, there are no empty vessels;
they are filled with popular health culture. Perhaps those who know their communities and their health culture best are the traditional heal- ers. These are available in significant numbers in many parts of the world and are unlikely to disappear, despite the spread of modem health services.
They have been found to be willing, effective and sustainable CHWs once they are given the necessary training and support. Traditional healers include people who may be known as herbalists, diviners, spiritual or faith healers, traditional birth attendants,
curanderos,shamans,bone- setters and by many other names.
Using available potential
There is often strong oppo- sition to traditional healers on the grounds that they are not "scientific". On the other hand there are those who argue that whether they are "scientific" or not, they are effective.
Furthermore, many people trust them, they are accessi- ble and affordable, and they are the only health services available to millions of people. In practice, argu- ments for and against traditional healers are not productive. It is more useful to start from the fact that they exist, they are accepted and used by their communities, and that in many cases they have the potential to be excellent CHWs.
World Health • 49th Yeor, No. 2, Morch-Aprill996
In Bangladesh, a community health worker gives nutrition and family planning advice to village women.
When a survey was made of projects that trained and used tradi- tional healers as community health workers, the findings were summa- rized as follows.
• Traditional healers are available and willing to work in community health.
• Traditional healers can be trained to perform a wide range of pri- mary health care tasks.
• Training has affected the atti- tudes, knowledge and practice of traditional healers in positive ways.
• Training the healers has proved to be cost-effective.
• The drop-out rate for traditional healers is much lower than that of otherCHWs.
On the other hand, there are also a number of difficulties to be over- come in using traditional healers as CHWs. The most important of these were found to be the following.
• There is a lack of supportive government policies to promote cooperation with and use of traditional healers in primary health care.
• This lack of clear policy has helped to foster a negative atti-
tu de on the part of health staff towards traditional healers.
• Many healers are illiterate or lack formal education, thus making it difficult for health staff to discuss ideas and approaches with them.
WHO followed up this survey with an in-depth field evaluation of the effectiveness of programmes in which traditional healers were trained to carry out primary health care services in rural communities.
Projects in Bangladesh, Ghana and Mexico were evaluated. As a result of this and other available informa- tion and experience, WHO has been able to produce guidelines whose aim is to assist individuals and orga- nizations to develop the right kind of training programmes. These will enable traditional healers to play a significant role in improving the health of their communities because they know the local traditions and culture, and can therefore build on them with the help of the modem health sector. •
Or Haile Mariam Kahssay is a Scientist with the District Health Systems Unit, Division of Strengthening of Health Services, World Health Organization, I 2 I I Geneva 27, Switzerland.
In Costa Rica, a health worker visits poor communities to control children's oral health.
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8 World Health • 49th Year, No. 2, Morch-Aprill996
Medicine for a small planet
Marc S. Micozzi
For 80% of the world's people, approaches that Western medicine might label
"alternative" or "complementary" constitute primary care. Far from being experimental, they have been "field-tested" by millions of people for thousands of years.
M
y experience as a physician and anthropologist has taught me that, in a world marked by complexity and diversity, no one system of health beliefs alone provides a formula that will allow us to offer effective medical care for the whole human family. Policy-makers and experts in the field of health would do well to adopt an attitude of open-minded respect towards the world's diversity of health beliefs and practices. What we need is an eclectic health model in which peo- ple can choose from a variety of health traditions. Here's why:Even gastronomy can promote health. Western medicine has stepped up its efforts to educate people on healthy eating so as to reduce the risks of cardiovascular diseases.
Western medicine has produced the finest system of emergency medical care the world has yet seen, but allopathic medicine (i.e. medi- cine which counteracts the effects of the disease being treated) is neither perfect nor always affordable.
During the last hundred years or so, Western physicians have embraced the science of medicine, and our initial success in dealing with a host of infectious diseases has encouraged us to believe that the future will always hold "miracle cures". Since the 1970s, scientists in the Western world have been searching for a cure for cancer. Many now suspect that neither this ongoing effort nor the international project to map the entire human genome will produce affordable magic bullets for heart disease, cancer or even arthritis.
Our contemporary focus on science and technology has led us to construct a medical system founded
on expensive machines, powerful drugs and invasive procedures. It has also created therapeutic expectations which encourage people to believe that they can escape the conse- quences of risky health behaviour.
Patients, physicians and governments need a wellness-based medical sys- tem in which the goal is to keep the patient out of the hospital in the first place.
Spiritual component
Our reliance on scientific biomedi- cine as the ultimate "gold standard"
causes concern to many because this system does not accord a central place for the potential of the body to heal itself. It often detaches the health of people from their place in the natural world, and does not easily incorporate a spiritual component in
healing. However, these important aspects of healing have long been recognized by the traditional health belief systems of Asia and Africa and of indigenous American peoples. In these approaches, the healer attempts to restore a sense of balance by focusing on the individual's relation to the community and to nature.
Few traditional healers would attempt to restore a person to health without involving the body's natural abilities. Western health experts acknowledge that such abilities exist but often are not able to incorporate them in healing; much effort has gone into exporting biomedicine to the developing world, but many have concluded that developing nations
simply cannot afford it. Indeed, there
are now doubts about how much longer the West itself can afford the cost of Western medicine, given our current "health care crisis".
World Health • 49th Yeor, No. 2, Morch-April1996
A traditional healer at work in Congo. Relating the patient to his natural world will boost the potential of the body to heal itself.
In my view, traditional health care systems have yet to achieve the respect they deserve in the West because of misinformation. Many people are put off by the phrase
"alternative medicine." It might be helpful to point out that, for 80% of the world's people, approaches that we might label "alternative" or
"complementary" constitute primary care. Some physicians refer to these traditions as if they were experimen- tal, or a new, untested discovery without a sound intellectual basis and history, whereas in reality they have been "field-tested" by millions of people for thousands of years. While it is hard to make valid generaliza- tions about human behaviour, it is probably fair to say that human cultures are unlikely to continue to invest their time and energy in ap- proaches which don't work. The fact that these health belief systems have been passed down from one genera- tion to another for so long is worthy of serious attention.
Inner resources
ing. Anyone who has cut a finger or bruised a knee has seen this principle at work. A medical treatment simply mobilizes the body's own resources to respond.
A key component of these tradi- tions is respect for nutrition and natural products in maintaining good health. As a component of the nat- ural world, humans were "designed"
to eat certain foods. This also ex- plains why we obtain the best nutri- ents not from vitamin pills but from nature itself. It is no coincidence that plants do not only provide the oxy- gen we breathe, but serve as the source of many foods and pharma- ceuticals that people have come to depend on. In the United States, for example, two-thirds of the drugs currently available on the market are originally based on medicinal plants.
Since cost has become an essential factor in shaping the kind of health care people have access to, it is worth noting that one reason for herbal medicines being relatively inexpensive is that they cannot be patented. The international commu- nity has begun to recognize the importance of protecting the world's flora, but equally important is the indigenous knowledge of how these plants can be used for medicinal purposes.
9
During the last decade, efforts to export Western medicine to the developing world have been com- plemented by a kind of "reverse technology transfer". Medical approaches and techniques originat- ing in China, India and elsewhere have achieved strong footholds in Europe and the United States.
Doctors are healers first; they will use any acceptable treatment that has been shown to work. While main- taining safety we need to work towards a truly integrated medical model in which different systems can coexist. •
Or Marc S. Micozzi is Executive Director of the College of Physicians of Philadelphia,
19 South 22nd Street, Philadelphia, PA 191 03·3097. USA
These traditions are important be- cause they recognize that health is not a gift that some outside person or process can bestow on a patient.
Wellness results from a balance of inner resources with the physical and social environment. Many of these belief systems also understand that self-healing is the basis of all heal-
A Chinese woman feeds her child in the street. Wellness results from a balance between inner resources and the physical and social environment.
10 World Health • 49th Year, No. 2, Morch-Aprill996
Food beliefs and taboos
Mohammed Abdussalam & Fritz Kiiferstein
T
he primary function of food is to provide nourishment.Nevertheless, in every society there are dietary customs which play sociocultural and symbolic roles that go far beyond the mere nourishment of the body. So it is extremely important for health workers to understand these roles and their implications when seeking solutions for a community's nutritional and food safety problems.
The natural environments and trade channels of all human groups provide a variety of nutrients or the potential to produce them. But the nutrients do not automatically be- come food until they are so defined and are culturally accepted as fit for human consumption. Because of aesthetic preferences, religious taboos, health beliefs and the like, some nutritionally valuable foods are often excluded from the diet.
Although people in Western commu- nities have plenty of scientific knowledge about nutrition and di- etetics, they generally avoid eating horse or dog flesh, the eyes and lungs of cattle and sheep, snakes and igua- nas, mare's and ewe's milk, dolphins, locusts, grubs, scorpions and sea- weed. Yet all these items are freely consumed in other cultures and are biologically valuable foods.
A recent survey of a South Asian population showed a general correla- tion between income and nutritional status, the rich being better nourished than the poor. Yet the poorest mem- bers of the community were as well nourished as the middle-income groups, simply because they were uninhibited in their choice of nutri- ents and supplemented their diet with
Certain nutritionally valuable food items may be excluded from the diet for aesthetic, religious or other reasons.
Food can also be mishandled, unwisely prepared or
inadequately cooked. Health education must be carefully designed to correct such practices i n socially and culturally appropriate ways.
Cultural taboos
The avoidance of specific types of food is a widespread phenomenon and applies more commonly to food of animal origin. Religious and other beliefs often call for this avoid-
ance, but other cultural factors are involved as well; some foods are regarded as being of low prestige, for example.
Most people avoid the meat of animals that have died of natural causes, especially if they were dis- eased. This natural trait is strength- ened by injunctions of the major religions. However, beliefs can differ sharply. One of the writers once saw migrant workers in the western Himalayas carrying away meat from a calf that had died of anthrax, a deadly disease, and was told that such meat had a special
"sweetish" taste which they highly
appreciated. The meat was later confiscated and incinerated by the authorities.
In most societies, cannibalism would be imaginable only in desper- ate circumstances. Yet in a number of cultural environments it has been
snake and rat meat. A fish market. Food preferences are closely linked with cultural factors.
World Health • 49th Year, No. 2, Morch-Aprill996
Cooking outdoors in Thailand. Culinary practices have usually evolved in such a way as to ensure safe food even in an unhygienic environment.
practised as a ritual. In some tribes, eating the brain of dead ancestors was thought to be a way of obtaining their wisdom, but scientists have seen it as a possible mode of trans- mission of kuru, an infection en- demic in some parts of the highlands of eastern Papua New Guinea. The tribes themselves consider kuru to be the result of sorcery.
Important examples of food avoidance are pork among Jews, Muslims and Ethiopian Christians;
beef among Hindus, some Buddhists and Jains; chicken and eggs in some African communities; dog meat in the West; fish in Mongolia and other parts of central Asia; milk and milk products in Polynesia and parts of China. Some communities avoid all food derived from animals.
Folk wisdom
Through trial and error over genera- tions, traditional societies have developed culinary practices which enable them to prepare and eat safe food even in unhygienic environ- ments. Some examples are: thor- ough boiling of milk, cooking meat in small pieces to facilitate heat penetration, using proper fermenta- tion processes, and eating freshly cooked food.
But folk wisdom is not an infalli-
safe culinary practices. For example, it is a widely held belief that raw food of animal origin is more invigo- rating and strengthening than cooked food. Raw fish and meat dishes such as sashimi in the East, steak tartar in Europe and ceviche in Latin America are well known and are now avail- able in special restaurants world- wide. There are many other raw dishes consumed locally in different parts of the world which encourage transmission of food-borne diseases and parasites.
Many folk beliefs require preg- nant and lactating women to avoid eating meat and eggs, or in some
ble guide to healthy food habits and A family eating supper in Bangladesh.
societies even to cut out fruit and vegetables. Scientifically, these are precisely the foods they need.
Food processing
11
In recent years, remarkable progress has been made in developing rela- tively inexpensive technologies to make food safe for human consump- tion without reducing its nutritive value. Unfortunately, prejudice and cultural resistance to some of the most useful of these technologies, such as irradiation and microwave cooking, prevents their full exploita- tion.
Heat treatment (such as pasteur- ization, frying, grilling or roasting) destroys most of the disease-produc- ing organisms in food, if properly carried out. But people may not cook their food adequately either because they prefer a raw taste or because they cannot pay for fuel. In either case they expose themselves to serious risks of food borne disease.
Lack of adequate cooking facili- ties was highlighted some years ago by an outbreak of the pig tapeworm (Taenia solium) infection and a serious disease with its larval form (cysticercosis) among inhabitants of the lrian Jaya Highlands (Indonesia).
These people live in close contact with their pigs, but "cooking" merely
12 World Health • 49th Yeor, No. 2, Morch-Aprill996
means placing slices of pork, alter- nated with vegetables, among hot stones. Apparently, the tapeworms were introduced by migrants coming from a neighbouring region. Very soon a large percentage of pigs as well as people were infected, and cysticercosis produced epileptic fits, coma and death. The outbreak is now reported to be under control.
also their sociocultural basis, includ- ing tradition and beliefs. Recent development of the Hazard Analysis Critical Control Point (HACCP) approach has provided a simple and relatively inexpensive method of identifying safety hazards in food habits and in culinary practices.
secondly, it should be able to bear any economic and social costs it may involve. •
It is clearly desirable to change food-related behaviour which leads to malnutrition or to the transmission of agents of disease. Before deciding on intervention strategies, it is neces- sary to obtain full information about the practices to be changed -not only their health implications but
Once the hazards as well as the critical points for their control have been identified, health education can be designed to induce the community and individuals to correct hazardous practices. Two important principles have to be observed to assure the desired changes: firstly, the commu- nity should perceive the advantage of
Professor Mohammed Abdussalam is a former staff member of WHO; his address is 48 chemin des Coudriers, 1209 Geneva, Switzerland. Or Fritz Kaferstein is Chief of the Food Safety Unit, Division of Food and Nutrition, World Health Organization, 1 2 1 1 Geneva 27, Switzerland.
the change and,
Our common nutritional heritage
James Akre
According to a traditional Cameroonian saying, the stomach is blind. The implication is that all that matters to the stomach is that it remain full. Of course, the eye and the palate are considerably more discriminating about what in fact goes into the stomach. Nevertheless, choice in the matter is determined to a large extent by culture and geography.
From the universal need for every one of the earth's estimated 4237 mammalian species to obtain nourishment, the focus for the individual is on the specific foods that are actually available and eaten. Apart from one exception, then, it is probably not an exaggeration to say that there is no single universal food. And what is this exception? Why, breast milk of course!
Breast milk is the contemporary universal nutritional link par excellence for the entire human species - north, east, south and west, all 5700 million of us. Historically, it is also a vital nutritional link in the human family's unending chain; it helps to define our place in the parade of generations, as much in terms of those who came before us as of those who will come after.
No substitute, not even the most sophisticated and nutritionally balanced infant formula, can
Mother's milk, the common heritage of humanity.
possibly compete with the multiple wonders of breast milk. But then, how could it? After 60 million or so years of mammalian evolution - or what many attribute to the perfect hand of the Creator - a synthetic product that is usually based on the milk of another species could hardly be expected to measure up. Nor can artificial feeding do more than approximate the act of breast-feeding, in physiological and emotional significance, for babies and mothers alike.
•
And so, no matter how important it is to provide a nutritionally balanced substitute when babies are not breast-fed, giving them something else in place of breast milk will always be a deviation from the biological norm for our speci~s. Indeed, breast milk transcends culture and geography, uniting us all through our common nutritional heritage.
Mr James Akre is with the Nutrition Unit of the Division of Food and Nutrition, World Health Organization, 1 2 11 Geneva 27, Switzerland.
World Health • 49th Year, No. 2, March-Aprill996 13
Ritual and culture
Helmut L. Sell
Social and cultural factors underly the abuse of different substances. There is even a
"caste system" among illicit drug users in certain parts of the world.
M
ind-altering substances have been used in many cultures for millennia. Their use was socially sanctioned and often formed part of social or religious rituals.Cannabis is still consumed at reli- gious festivals in some parts of Asia.
Where alcohol is widely used, it is an accepted part of adult social behaviour; in some families adoles- cents are introduced to alcohol con- sumption in a rite of passage and many kinds of celebration involve symbolic or social drinking.
The ritualistic and social nature of alcohol consumption is also obvious from the large number of customs surrounding it. For instance, differ- ent types of glasses must be used for different alcoholic drinks; it is seen as improper to offer champagne in a coffee mug or plastic cup, whereas water, coffee or soft drinks may be taken from any container. Certain drinks are to be consumed at specific times of the day; friendships are confirmed over a glass of wine, and so forth.
Culturally and socially accepted forms of drug use, including intoxi- cation on specified festive occasions, have been strongly defended when governments have tried to impose bans. In Thailand, for example, a civil war followed a ban on opium in 1811, leading finally to the opium franchise of 1851 permitting trading
Even though if tastes terrible of first, young people often go on smoking for fear of losing status among their peers. it is essential therefore that health education messages are aimed primarily of the very young.
under official control. The attempt to ban alcohol in the USA in the 1930s was notoriously unsuccessful.
There are even cultural differ- ences in the ways drugs affect peo- ple. The Chittagong Hills on the Bangladesh-Myanmar border are a sort of watershed for the effect of opiates: to the east the drugs are incapacitating, to the west they are invigorating. Landowners in India still sometimes give opium to their labourers to make them work harder;
and the Rajput warriors of north-west India took opium before going into battle in order to fight more fiercely.
One important issue often over- looked is that all substances of abuse have an unpleasant effect for the uninitiated, usually giddiness and nausea. Why do people work so hard to become smokers, for example?
Most commonly, it is probably be- cause youngsters feel that some special status is to be achieved by becoming a smoker.
If drug initiation is accompanied by fear of the unknown, the danger- ous and illegal, the anxiety-alleviat- ing effect of drugs may come as a pleasant surprise, with a feeling of relief. But the puzzling question
remains: why do people continue taking drugs if they have initially unpleasant effects?
A variety of factors influence people to switch from oral drug use to injecting. In many instances socio- cultural factors are particularly strong. This can be seen when the inconvenience and discomfort of using a syringe are apparently out- weighed by the attraction of joining the drug injectors' sub-culture.
There is even a kind of "caste system" among drug users in some societies. Those who inject do not normally mix with those who inhale drugs. Heroin inhalers sometimes look down upon cannabis smokers, and all of them despise alcohol abusers. •
Or Hefmuf L Sell is Regional Adviser on Health and Human Behaviour of the World Health Organization Regional OHice for South-East Asia, World Health House, lndraprastha Estate, Mahatma Gandhi Road, New De/hi-
ll 0002, India.
14 World Health • 49th Yeor, No. 2, Morch-Aprill996
Babies need their mothers beside them!
James J. McKenna
the infant re-
In close contact with its mother, the infant receives protection, warmth and emotional reassurance.
ceives protection, warmth, emo- tional reassur- ance and breast milk in just the forms and quanti- ties that nature intended. This sleeping arrange- ment permits mothers (and fathers) to re- spond quickly to the infant if it cries, chokes, or needs its nasal passages cleared, its body cooled, warmed, ca- ressed, rocked or held. It thus helps to regulate the infant's breathing, sleep state, arousal patterns, heart rates and body
lt is thoroughly misleading to suggestwffhoutquaHficanon
that the close proximity and contact between a mother and her infant during sleep causes cot death.
T
hroughout human history, breast-feeding and parents sleeping alongside their infants constituted a marvellously adaptive system in which both the mothers' and infants' sleep physiology and health were connected in beneficial ways. By sleeping next to its mother,temperature. The mother's proxim- ity also stimulates the infant to feed more frequently, thus receiving more antibodies to fight disease. The increased nipple contact also causes changes in the mother's hormone levels that help to prevent a new pregnancy before the infant is ready to be weaned. In this way the infant regulates its mother's biology, too;
increased breast-feeding blocks ovulation, which helps to ensure that pregnancies will not ordinarily occur until the mother's body is able to restore the fat and iron reserves needed for optimal maternal health.
It is a curious fact that in Western societies the practice of mothers, fathers and infants sleeping together has come to be thought of as strange, unhealthy and dangerous. Western
parents are taught that "eo-sleeping"
will make the infant too dependent on them, or risk accidental suffoca- tion. Such views are not supported by human experience worldwide, however, where for perhaps millions of years infants as a matter of course slept next to at least one caregiver, usually the mother, in order to sur- vtve.
At some point in recent history infant separateness with low parental contact during the night came to be advocated by child care specialists, while infant-parent interdependence with high parental contact came to be discouraged. In fact, the few psycho- logical studies which are available suggest that children who have "eo- slept" in a loving and safe environ- ment become better adjusted adults than those who were encouraged to sleep without parental contact or reassurance.
Complex history
The fear of suffocating infants has a long and complex cultural history.
Since before the middle ages "over- lying" or suffocating infants deliber- ately was common, particularly among the poor in crowded cities.
This form of infanticide led local church authorities to make laws forbidding parents to let infants sleep next to them. The practice of giving infants alcohol or opiates to get them to sleep also became common; under such conditions, babies often did not wake up and it was presumed that the mothers must have overlaid them.
Also, in smoke-filled, under-venti- lated rooms, infants can easily suc- cumb to asphyxia.
Unfortunately, health officials in some Western countries promote the message that sleep contact between the mother and infant increases the
World Health • 49th Year, No. 2, Morch-Aprill996
parents within a year, whereas humans take 14 to 17 years to be- come fully devel- oped physically, and usually longer than that to be fully indepen- dent.
Sleeping beside her child enables the mother to give it constant attention.
Apart from being a natural characteristic of our species, constant proxim- ity to the mother during infancy is also made neces- sary by the need to feed
frequently.
Human milk is composed of relatively low amounts of pro- tein and fat, and
chances of the infant dying from sudden infant death syndrome (SIDS). But the research on which this message is based only indicates that bed-sharing can be dangerous when it occurs in the context of extreme poverty or when the mother is a smoker. Some researchers have attempted to export this message to other cultures. However, in Japan, for example, where eo-sleeping is the norm, SIDS rates are among the lowest in the world, which suggests that this arrangement may actually help to prevent SIDS.
Human infants need constant attention and contact with other human beings because they are unable to look after themselves.
Unlike other mammals, they cannot keep themselves warm, move about or feed themselves until relatively late in life. It is their extreme neuro- logical immaturity at birth and slow maturation that make the mother- infant relationship so important. The human infant's brain is only about 25% of its adult weight at birth, whereas most other mammals are born with 60-90% of their adult brain size. The young of most other mam- mals become independent of their
high amounts of quickly absorbed and metabolized sugars. Therefore the infant's hunger cycle is short, as is the time spent in deep sleep. All of these factors seem to indicate that the custom of separat- ing infants from their parents during sleep time is more the result of cul- tural history than of fundamental physiological or psychological needs.
Sleep laboratory studies
Sleep laboratory studies have shown that bed-sharing instead of sleeping in separate rooms almost doubled the number of breast-feeding episodes and tripled the total nightly duration of breast-feeding. Infants cried much less frequently when sleeping next to their mothers, and spent less time awake. We think that the more frequently infants are breast-fed, the less likely they are to die from cot- death.
Our scientific studies of mothers and infants sleeping together have shown how tightly bound together the physiological and social aspects of the mother-infant relationship really are. Other studies have shown
IS
that separation of the mother and infant has adverse consequences.
Anthropological considerations also suggest that separation between the mother and infant should be minimal.
Western societies must consider carefully how far and under what circumstances they want to push infants away from the loving and protective eo-sleeping environment.
Infants' nutritional, emotional and social needs - as well as maternal responses to them- have evolved in this environment for millennia. •
Or james). McKenna is Professor of Anthropology and Edwin and Margaret Hahn Chair of the Social Sciences, Pomona College, and Senior Researcher (SIDS Pro;ect), University of California, /Nine School of Medicine, Departments of Neurology and Child Psychiatry. His address is 425 N. College Avenue, Claremont, CA 9171 1-6361, USA
Being breast-fed by its mother ensures that the infant has the best passible start in life.
16 World Health • 49th Yeor, No. 2, Morch-Aprill996
Sudden infant death syndrome
Hazel Brooke
Baby sleeps an its back and with its mother. The way Asian Families tend their infants may have a bearing on the low rate of Sudden Infant Death Syndrome.
B
abies have been dying suddenly and unexpectedly for centuries.In the First Book of Kings in the Old Testament, written about 500 BC, we read: "And this woman's child died in the night; because she overlaid it". For many centuries overlying by the mother (causing suffocation) was accepted as the cause of sudden unexpected infant deaths. It was not until the late 18th century that doctors began to explore other possible causes for such deaths, beginning with the hypothesis that these infants suffered from an en- larged thymus, leading to "internal suffocation". This was widely ac- cepted throughout the 19th century and indeed into the 1930s, when it became discredited.
In 1969, a definition of the term Sudden Infant Death Syndrome (SIDS) was agreed upon at an inter- national conference in the USA:
Commonly known as "cot deaths", the Sudden Infant Death Syndrome is
remarkable for its widely different rates between various ethnic groups. The baby's sleeping position and whether or not the mother smokes appear to have a direct bearing on those rates.
"The sudden death of any infant or young child, which is unexpected by history and in which a thorough postmortem examination fails to demonstrate an adequate cause for death".
The second half of the 20th cen- tury has seen many hypotheses proposed about the cause of these deaths. Millions of research dollars have been spent on efforts to identify the mechanism of death, and these efforts are continuing. The SIDS rate is now less than 1 per 1000 live births in most Western cultures. At the same time, medical science has been taking increasing interest in the differences that exist in the SIDS rates between various ethnic groups.
For example, studies have shown a low rate among Asian families, even if they are immigrants living in a Western society. Most researchers now feel that there are useful lessons to be learnt from different cultural practices in relation to child care.
Let us look at three widely accepted recommendations on reducing the risks of SIDS.
World Health • 49th Year, No. 2, March-Aprill996
1. Place your baby on its back to sleep.
Many studies have indicated a strong association between prone (front) sleeping and the occurrence of SIDS.
The practice of placing babies face downwards to sleep became popular in many Western countries in the 1970s and 1980s- a period marked by high SIDS figures. Prone sleep- ing is not favoured in Asian families, even those resident in Western soci- eties. Evidence from Hong Kong, where there are virtually no cases of SIDS, confirms this avoidance of prone sleeping. In countries where, over the past few years, a strong message has been conveyed to par- ents to avoid the prone sleeping position, there has been a marked reduction - in some cases of 60% - in the number of SIDS cases. This would strongly suggest that the Western practice of placing infants prone for sleep was actually harmful.
Smoking is harmful for the foetus. When the habit continues after the birth, the infant will be put at increased risk of Sudden Infant Death Syndrome.
2. Avoid smoking during pregnancy and around the baby during the first year of life.
Smoking, particularly among moth- ers, has emerged as a major risk factor for SIDS. Studies have shown that maternal cigarette smoking increases the risk of SIDS for a baby as much as sevenfold, with an even greater risk if the father smokes too.
In New Zealand, where a forceful campaign to reduce the risks of SIDS has been promoted since 1990, there has been a striking drop in the inci- dence of SIDS among non-Maori infants, but a far less marked reduc- tion among Maoris, whose infants are now four times as likely to be SIDS victims as non-Maori infants.
Researchers in that country are convinced that one of the reasons for this difference is that Maori women are twice as likely to smoke as non- Maori women. Smoking was intro- duced relatively recently in Maori society but has become a cultural norm. Conversely, smoking is un- common among Asian women, whose infants seem to be at very low risk of SIDS.
3. Avoid overwrapping your baby.
Studies have indicated that babies may be at increased risk of SIDS if they are too warm. A study of Welsh and Bangladeshi families in Cardiff, Wales, published in 1993, demon- strated that the Asian mothers were much more concerned about the danger of their infant overheating, and this was one of the explanations given for the practice of shaving babies' heads. Welsh mothers, on the other hand, were anxious to keep their infants warm.
Is stimulation desirable?
Over the past three years, consider- able interest has also focused on the possibility that stimulation may play a role in reducing the risk of SIDS.
Asian families, with their low SIDS incidence, often live in an extended- family situation, with aunts, uncles, cousins and grandparents forming part of the household. The baby is kept in the heart of the family during the day, subject to the noise and bustle and accustomed to a busy social and tactile environment.
Western babies are much more likely to be placed "somewhere quiet" for sleep periods; the suggestion has been made that this lack of both supervision and stimulation may not be advantageous.
Be careful not to leave your baby alone for too long.
17
At night the Asian infant sleeps either in bed with the mother or in a cot next to her. The fact that this practice is associated with a low incidence of SIDS has led some researchers to think that bed-sharing may be desirable for all infants.
However, research from New Zealand has indicated a significantly increased risk of SIDS for infants sharing a bed with a mother who smokes. Maori mothers are twice as likely as non-Maoris to both smoke and bed-share.
Bed-sharing is a traditional infant care practice for the Maori, while smoking is an introduced practice.
Educators in New Zealand are there- fore trying to discourage smoking, while encouraging the treasured tradition of bed-sharing. The low incidence of SIDS among bed-shar- ing Asian infants may reflect the fact that few Asian mothers smoke.
Cultural differences may well suggest valid ways of reducing the risks of SIDS, but it is important to see these differences as interdepen- dent parts of rich and varied cultures, rather than in isolation. In addition, we may have to face, in all our cul- tures, a rise in SIDS rates caused by the use of illegal substances. •
Mrs Hazel Brooke is Chairman of SIDS International. Her address is Scottish Cot Death Trust, Royal Hospital for Sick Children, Yorkhi/1, Glasgow G3 8Sj, Scotland.
18
Psychotherapy and
culture in Africa
Karl Pelzer
A healing ritual related to pregnancy in Ghana.
C
haracteristically, most of the traditional healing methods in Africa have not been recorded and written down. This orally trans- mitted healing knowledge is usually only known to initiated healers themselves. People are understood to obtain this knowledge either from initiated healers or from ancestral spirits. Most of the literature on traditional and faith healing in Africa concerns mental disorders. Although in a traditional context mental and physical disorders cannot be sepa- rated, most healing methods focus on psychosocial problems and disorders.Most psychosocial problems and disorders can be classified in the following way:
• social disorders (economic and occupational problems, family problems, sorcery, witchcraft, theft, security and legal problems);
• psychoneurotic disorders (hyste- ria, depressive neurosis, anxiety neurosis);
• functional psychotic disorders;
• psychosomatic disorders (men- strual problems, impotence, asthma);
alcohol, cannabis and other sub- stances;
• psychosocial problems in patients with infertility, epilepsy, sterility, organic psychosis, mental handi- cap and development disabilities;
• terminal or chronic diseases requiring psychosocial rehabilita- tion.
Outpatient setting for traditional healing
The typical outpatient setting is at the healer's own house, but sometimes the healer con-
ducts home visits. More rarely, witchcraft is deemed to be affecting a whole community, such as a village or a school. In such cases, the group concerned may be "cleansed"
from witches and wizards by a witchfinder, in
World Health • 49th Year, No. 2, Morch-Aprill996
Faith healers may succeed in offering positive support for their urban clients, but they are not usually well versed in the nature of modem
psychosocial disorders . As a result, more and more
patients, especially in urban Africa, feel the need for psychotherapy.
called a "public health approach".
Cleansing ceremonies of this kind seem to be on the decrease, while there is an increasing trend to join
"born-again" Christian movements which seek to have a long-term effect by changing ways of living and personality traits that are judged harmful to health.
Treatment in possession cults usually takes place in an outpatient setting. A potentially good spirit is thought to express itself through the patient while he or she is in a "pos- session trance" during which the patient may be initiated into the cult.
• disorders related to the use of what might be Traditional healers can treat a whole range of psychosocial disorders.
