Sienna R. Craig

Having A “Safe Delivery”: Conflicting Views from Tibet

In the Tibetan Autonomous Region (TAR) of the Peoples Republic of China (PRC) maternal mortality ratios remain among the highest in the world. Although traditional Tibetan medical theory, practice, and pharmacology include information on maternal and child health care, Tibet is one of the few societies in the world that does not have traditional birth attendants or midwives. Using ethnographic methods, we gathered data from individual interviews with rural Tibetan women (N = 38) about their beliefs and behaviors surrounding pregnancy and childbirth. Additional data were gathered through interviews with prefecture, county, and township health care providers. These data were used to develop a culturally appropriate village birth attendant training program in rural Tibet. We describe Tibetan womens perspectives of “having a safe delivery” in relation to concepts about “safe delivery” according to evidence-based medicine in the West. Our work also provides an example of the benefits and challenges that arise when ethnographic research methods are used to design and implement health care interventions.

Maternal and neonatal outcomes of hospital vaginal deliveries in Tibet

Introduction: To determine the outcomes of vaginal deliveries in three study hospitals in Lhasa, Tibet Autonomous Region (TAR), Peoples Republic of China (PRC), at high altitude (3650 m). Methods: Prospective observational study of 1121 vaginal deliveries. Results: Pre‐eclampsia/gestational hypertension (PE/GH) was the most common maternal complication 18.9% (n = 212), followed by postpartum hemorrhage (blood loss ≥ 500 ml) 13.4%. There were no maternal deaths. Neonatal complications included: low birth weight (10.2%), small for gestational age (13.7%), pre‐term delivery (4.1%) and low Apgar (3.7%). There were 11 stillbirths (9.8/1000 live births) and 19 early neonatal deaths (17/1000 live births). Conclusion: This is the largest study of maternal and newborn outcomes in Tibet. It provides information on the outcomes of institutional vaginal births among women delivering infants at high altitude. There was a higher incidence of PE/GH and low birth weight; rates of PPH were not increased compared to those at lower altitudes.

Pediatric therapeutics and medicine administration in resource-poor settings: a review of barriers and an agenda for interdisciplinary approaches to improving outcomes.

The lack of affordable, available pediatric drug formulations presents serious global health challenges. This article argues that successful pharmacotherapy for children demands an interdisciplinary approach. There is a need to develop new medicines to address acute and chronic illnesses of children, but also to produce formulations of essential medicines to optimize stability, bioavailability, palatability, cost, accurate dosing and adherence. This, in turn, requires an understanding of the social ecologies in which treatment occurs. Understanding health worker, caregiver and patient practices, limitations, and expectations with regard to medicines is crucial to guiding effective drug development and administration. Using literature on pediatric tuberculosis as a reference, this review highlights sociocultural, pharmacological, and structural barriers that impede the delivery of medicines to children. It serves as a basis for the development of an intensive survey of patient, caregiver, and health care worker understandings of, and preferences for, pediatric formulations in three East African countries.

Children's medicines in Tanzania: a national survey of administration practices and preferences.

Objective The dearth of age-appropriate formulations of many medicines for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide. We provide information on current administration practices of pediatric medicines and describe key stakeholder preferences for new formulation characteristics. Patients and Methods We surveyed children aged 6–12 years, parents/caregivers over age 18 with children under age 12, and healthcare workers in 10 regions of Tanzania to determine current pediatric medicine prescription and administration practices as well as preferences for new formulations. Analyses were stratified by setting, pediatric age group, parent/caregiver education, and healthcare worker cadre. Results Complete data were available for 206 children, 202 parents/caregivers, and 202 healthcare workers. Swallowing oral solid dosage forms whole or crushing/dissolving them and mixing with water were the two most frequently reported methods of administration. Children frequently reported disliking medication taste, and many had vomited doses. Healthcare workers reported medicine availability most significantly influences prescribing practices. Most parents/caregivers and children prefer sweet-tasting medicine. Parents/caregivers and healthcare workers prefer oral liquid dosage forms for young children, and had similar thresholds for the maximum number of oral solid dosage forms children at different ages can take. Conclusions There are many impediments to acceptable and accurate administration of medicines to children. Current practices are associated with poor tolerability and the potential for under- or over-dosing. Children, parents/caregivers, and healthcare workers in Tanzania have clear preferences for tastes and formulations, which should inform the development, manufacturing, and marketing of pediatric medications for resource-limited settings.

Depopulating the himalayan highlands: Education and outmigration from ethnically tibetan communities of Nepal

Abstract Communities that have thrived for centuries in Nepals rugged mountain environments are facing rapid population declines caused by the outmigration of youths, both males and females in nearly equal numbers, who are sent by parents to distant boarding schools and monasteries for secular and religious education. This paper documents the magnitude of outmigration, migration destinations, migrations impact on the age–sex composition of sending communities, the effect of migration on fertility, and projected trends of population decline and aging. The authors conclude by discussing potential long-term threats to the viability of ethnically Tibetan communities in the Himalayan highlands, including outmigrations effect on agricultural production, the family-based care system for the elderly, socioeconomic inequalities, and human capital.

Good Manufacturing by Whose Standards? Remaking Concepts of Quality, Safety, and Value in the Production of Tibetan Medicines

This essay analyzes the impacts of global and national pharmaceutical governance on the production of traditional medicines—specifically the making and marketing of Tibetan medicines in contemporary China. Based on research conducted in Tibetan medical factories and with practitioners, producers, and consumers of Tibetan medicines in the Tibet Autonomous Region (TAR) and Qinghai Province between 2002–2010, this article presents ethnographic evidence for the ways Tibetan knowledge systems and the value of medicines themselves are being transformed through interlinked engagements with science, technology, and the market. I focus on the implementation of Good Manufacturing Practices (GMP) and related regulations: state-mandated standards that govern the conditions under which raw materials are evaluated, medicines are made, and finished products are sold. This article responds to calls for an anthropology of pharmaceutical practice in the context of social transformation. I propose that ethnography of Tibetan pharmaceutical production provides an apt illustration of global governance in action because it shows how shifts in medical production practices are tied to much larger processes of political and economic change within China and beyond. Further, my examination of points of incommensurability and ambivalence with respect to GMP regulations contributes to an anthropological analysis of the constitutive role cultural politics plays in the construction of value and meaning with respect to traditional medicine.

Taking the MINI to Mustang, Nepal: methodological and epistemological translations of an illness narrative interview tool

Illness narratives and explanatory models have been a research focus for the discipline of medical anthropology for decades. In recent years, standardized qualitative research tools have been developed to elicit illness narratives as a means of conducting socio-cultural analysis and as a springboard for health-related interventions – particularly with reference to communities experiencing rapid socioeconomic transition or those in which trauma has been experienced. Nevertheless, gaps persist in terms of the latent methodological and epistemological challenges of translating and transplanting such research tools to new contexts. This paper chronicles the adaptation of the McGill Illness Narrative Interview (MINI) for use in the culturally Tibetan region of Mustang, Nepal. This analysis is based on 44 in-depth interviews using an adapted version of the MINI to elicit narratives about experiences of illness. The MINI proved to be a compelling research tool, particularly in terms of engaging research assistants in the field. Yet its deployment in a context where distinctions between individual and social suffering can be blurred, where the dichotomization of ‘religion’ and ‘medicine’ makes little sense, and where understandings of causality are rooted in the concept of karma, revealed the extent to which the MINI – and, by extension other such qualitative research tools – emerges from particular models of narrative construction and assumptions about the relationships between self and other, cause and effect. Concluding recommendations are made regarding the adaptation of this tool to other settings.

Effectiveness of a sports-based HIV prevention intervention in the Dominican Republic: a quasi-experimental study

Previous observational and quasi-experimental studies in sub-Saharan Africa have suggested the effectiveness of youth-targeted HIV prevention interventions using sport as an educational tool. No studies have yet assessed the effect of similar programs in the Caribbean. A quasi-experimental trial was conducted to assess the effectiveness of a sports-based intervention in six migrant settlements in the Puerto Plata Province of the Dominican Republic. A total of 397 structured interviews were conducted with 140 adolescents prior to, immediately following, and four months following 10-hour interventions using the Grassroot Soccer curriculum. Interview responses were coded, aggregated into composite scores, and analyzed using logistic regression, adjusting for baseline differences as well as age, sex, community, and descent. At post-intervention, significant differences were observed between groups in HIV-related knowledge (adjOR = 13.02, 95% CI = 8.26, 20.52), reported attitudes (adjOR = 12.01, 95% CI = 7.61, 18.94), and reported communication (adjOR = 3.13, 95% CI = 1.91, 5.12). These differences remained significant at four-month follow-up, though declines in post-intervention knowledge were observed in the Intervention group while gains in knowledge and reported attitudes were observed in the Control group. Results suggest that this sports-based intervention could play a valuable role in HIV prevention efforts in the Caribbean, particularly those targeting early adolescents. Further evaluation of sports-based interventions should include indicators assessing behavioral and biological outcomes, longer-term follow-up, a larger sample, randomization of study participants, and strenuous efforts to minimize loss-to-follow-up.

Pregnancy and Childbirth in Tibet: Knowledge, Perspectives, and Practices

To Tibetans life does not begin at birth, but rather at conception. After death, a being’s consciousness… wanders in an intermediate realm until impelled by the forces of its own karma to enter a womb at the instant of conception. Gestation is a hazardous time when women try to consume foods and seek spiritual means to prevent any harm coming to their growing baby. Once born, the child must fight for survival against daunting odds. Infancy is fraught with more hazards than any other stage of the life course, and the infant mortality rate in Nubri is frightfully high. Nearly one in every four children born alive does not live to see his or her first birthday. (Childs 2004: 38)

Conservation, Cultivation, and Commodification of Medicinal Plants in the Greater Himalayan-Tibetan Plateau

This special issue of Asian Medicine: Tradition and Modernity emerges from the Seventh International Congress of the International Association for the Study of Traditional Asian Medicine (IASTAM), which was held in Thimphu, Bhutan, from 7–11 September 2009. As readers of this journal may be aware, IASTAM’s unique vision aspires to bring academics and practitioners of Asian medical traditions into dialogue with each other, to promote the study and cross-cultural understanding of Asian medicines from a variety of disciplinary perspectives, and to do so in a way that honours and embraces the sometimes difficult task of reckoning the world of reflection and critique with that of engagement and practice. This Seventh Congress in Thimphu brought together scholars, practitioners and students of Himalayan, East Asian and South Asian healing systems, as well as social entrepreneurs, civil servants, and representatives of global businesses engaged in the commercial sale of Asia-derived medicinal products. This mélange of perspectives owed a lot to the theme of this Congress: Cultivating Traditions and the Challenges of Globalization.