Ann V. Millard

The place of the clock in pediatric advice: Rationales, cultural themes, and impediments to breastfeeding

This analysis treats the U.S. medical literature as evidence concerning the formal system of knowledge in allopathic medicine. An examination of pediatric advice on breastfeeding reveals the logic of medical reasoning, the use of scientific rationales, and the intrusion of specific cultural themes. The corpus of data includes works of 18 authors published in 36 volumes from 1897 to 1987, 27 volumes being editions of two major pediatric textbooks. All sources advocate breastfeeding but the detailed advice on how to carry out the process actually tends to undermine it. Moreover, the clock has provided the main frame of reference, creating regimentation reminiscent of factory work, segmenting breastfeeding into a series of steps, and emphasizing efficiency in time and motion. Feeding schedules were advocated in former decades as a matter of discipline for the infant, but nowadays they are viewed as biologically innate to normal infants and to breast milk production. The literature manifests responses over the century to behavioral, biochemical and physiological studies; however, except possibly for one textbook, no thorough rethinking has occurred. Sources of the 1980s continue to focus on the tempo of feeding as a major concern. Cultural themes besides the factory model of breastfeeding include the extension of professional advice to family matters, the subordination of lay women to professional expertise, mistrust of womens bodily signals including the let-down reflex in determining the timing of feedings, mistrust of signals from infants as well, and a professional ideal of flexible advice coupled with rigid limits concerning schedules. The literature interweaves the cultural themes with rationales based on physiological studies in support of specific regimens in breastfeeding, and the relegation of control in breastfeeding to medical experts denies the validity of mutual bodily and emotional responses within the mother-infant dyad. Pediatric authorities thus participate in the selection of cultural themes emphasized in motherhood. Although the pediatric literature is not the only influence on physicians and women, it reinforces pressures on women regarding their orientations toward their infants and hence, may be expected to shape our views of infancy, motherhood, and humanity in general. The break from the bindings of schedules has been proclaimed at various points during the century; however, the clock ironically remains the major reference point in most pediatric sources today.

A causal model of high rates of child mortality

The distribution of child mortality has often been misunderstood because of insufficient attention to its context. High rates of child mortality in developing countries have variously been attributed to child neglect, cultural traditions of child care, population pressure, low maternal educational levels, lack of medical care, and insufficient basic resources. The model proposed in this article organizes factors leading to high child mortality rates onto three tiers to contextualize the medical causes of death and the debate over traditions of child care. The proximate tier includes the immediate biomedical conditions that result in death, typically involving interactions of malnutrition and infection. The intermediate tier includes child care practices and other behavior that increase the exposure of children to causes of death on the proximate tier. The ultimate tier encompasses the broad social, economic, and cultural processes and structures that lead to the differential distribution of basic necessities, especially food, shelter, and sanitation. The ultimate tier thus forms the context of causes located on the other tiers. Research from rural Mexico, Central America, and Africa supports various parts of the model, particularly concerning traditional parental behavior, which has often been interpreted as child neglect but appears in many cases to result ultimately from economic scarcity. Links from tier to tier in the model especially warrant further attention from both researchers and policy makers.

Principles that guide weaning in rural Mexico

Women in two Mexican villages use principles conveyed by oral tradition to guide their decisions about weaning. They do not blindly follow unarticulated beliefs, as implied by other studies. The principles that guide weaning inform a mother of the effect of continued lactation, under specific conditions, on the child at certain stages of biological and psychological development. Villagers and physicians have more similar views of weaning than previously understood; both make conscious weaning decisions based on maternal and child health. Villagers’ decisions are situational rather than determined by the childs chronological age. The outcome, according to lactation histories of 285 women, is a heterogeneous pattern of ages at stopping breastfeeding — mean ages ± s.d., 10.04 ± 5.79 months (N = 507 mestizo children) and 20.19 ± 7.75 (N = 282 Indian children).

Child mortality and economic variation among rural Mexican households

In two rural Mexican communities, rates of child mortality are significantly related to economic situations of households. Measured over the childbearing years of post-reproductive women, the rate of child mortality (ages 0-5 years) per mother is 163 per 1000 children in one village and 338 in the other. Significant economic correlates, which are defined ethnographically in each community, are housing quality, quality of farm land and marital status. Correlations of child mortality rates with economic variables range from -0.25 to -0.54, showing that poorer mothers lose significantly more children in the first 5 years of life. These results parallel those of urban, regional, national and international studies, but economic correlates of child mortality have not previously been found in rural Latin America. The methodological contributions of this study include a meld of ethnographic and survey techniques of data collection, the development of culturally appropriate variables to measure economic status, the use of child rather than infant mortality rates, and a household-related demographic measure, the rate of child mortality per mother.

Diabetes Screening and Prevention in a High-Risk, Medically Isolated Border Community

Introduction A project in a Texas border community setting, Prevention Organized against Diabetes and Dialysis with Education and Resources (POD2ER), offered diabetes prevention information, screening, and medical referrals. The setting was a large, longstanding flea market that functions as a shopping mall for low-income people. The priority population included medically underserved urban and rural Mexican Americans. Components of the program addressed those with diabetes, prediabetes, and accompanying relatives and friends. Background People living in the Lower Rio Grande Valley (LRGV) face challenges of high rates of type 2 diabetes, lack of knowledge about prevention, and inadequate access to medical care. Recent statistics from actual community-wide screenings indicate a high diabetes prevalence, 30.7% among adults in the LRGV compared with 12.3% nationwide. Methods A diverse team composed of public health faculty, students, a physician, a community health worker, and community volunteers conceived and developed the project with a focus on cultural and economic congruence and a user-friendly atmosphere. The program provided screening for prediabetes and diabetes with a hemoglobin A1c test. Screening was offered to those who were at least 25 years of age and not pregnant. When results indicated diabetes, a test for kidney damage was offered (urinary albumin-to-creatinine ratio). A medical appointment at a community clinic within a week was provided to those who tested positive for diabetes and lacked a medical home. Health education modules addressed all family members. Discussion The project was successful in recruiting 2,332 high-risk people in 26 months in a community setting, providing clinic referrals to those without a doctor, introducing them to treatment, and providing diabetes prevention information to all project participants. Implications for research and practice are highlighted. Conclusion This study shows that a regular access point in a place frequented by large numbers of medically marginalized people in a program designed to eliminate cultural and economic barriers can succeed in providing a hard-to-reach community with diabetes prevention services. Aspects of this program can serve as a model for other service provision for similar populations and settings.

Sex ratio and natural selection at the human ABO locus.

Natural selective effects of ABO maternofetal incompatibility depend on age, sex and gene frequency. This study focuses on differences of fitness according to age and sex. Calculations of genotype frequencies weighted by fitness lead to the hypothesis that forces of natural selection would favor an association of excess males with type O. Studies of polymorphic populations and homogeneous O populations provide empirical support for the hypothesis.

Environmental Justice and Community-Based Research in Texas Borderland Colonias

OBJECTIVE An innovative academic-community partnership studied daily decisions in communities of mostly Spanish-speaking, low-income residents of colonias in Hidalgo County, TX, about risk of exposure to fish contaminated by PCBs at an Environmental Protection Agency (EPA) Superfund site. DESIGN AND SAMPLE The team used focus group interviews with colonia residents and content analysis to assess knowledge of risk related to the Superfund site, the Donna Reservoir and Canal System. RESULTS (1) many lacked knowledge of the Superfund site contamination; (2) a few participants fished at the lake, knew people who did so, and consumed the catch, but most participants feared going there; (3) some participants remember receiving messages saying not to fish at the site, although they recalled nothing about contamination, but most participants knew of no such messages; (4) many use cell phones to get local information through personal networks and several Spanish-language news sources, but they have no consistent, culturally tailored local information source. CONCLUSIONS The findings indicate the need for further efforts to design culturally tailored means of communication and messages to inform local communities widely about the dangers related to the Superfund site and thus decrease health disparities resulting from consuming fish from the site.

TB meets IE: contributions of ethnography

Ethnographic methods can broaden impact evaluation by adding to randomised control trials to assess the effects of international development programmes. This article uses ethnographic findings on tuberculosis (TB) in the Philippines to analyse results of quantitative research and to assess an evaluation of the United States Agency for International Development (USAID)/Philippines TB portfolio. Ladia’s ethnographic research explains critical aspects of TB patient and provider behaviour, often influenced by the stigma of TB, leading patients to adopt less effective care and ultimately sustaining the spread of the disease. Ethnography can provide information crucial to project success and to the evaluation of project effects.