An ion-atom merged beams setup at the Cryogenic Storage Ring.

We describe a merged beams experiment to study ion-neutral collisions at the Cryogenic Storage Ring of the Max Planck Institute for Nuclear Physics in Heidelberg, Germany. We produce fast beams of neutral atoms in their ground term at kinetic energies between 10 and 300 keV by laser photodetachment of negative ions. The neutral atoms are injected along one of the straight sections of the storage ring, where they can react with stored molecular ions. Several dedicated detectors have been installed to detect charged reaction products of various product-to-reactant mass ranges. The relative collision energy can be tuned by changing the kinetic energy of the neutral beam in an independent drift tube. We give a detailed description of the setup and its capabilities, and present proof-of-principle measurements on the reaction of neutral C atoms with D2 + ions.

Vietnamese diabetic patients and their physicians: what ethnography can teach us.

OBJECTIVES: To describe the cultural context of type 2 diabetes mellitus among Vietnamese immigrants in the United States, including people's ideas about cause and proper treatment; and to suggest ways in which better control of the disease can be achieved in this population. DESIGN: The method was ethnographic. A native speaker used a structured interview guide to talk with 38 Vietnamese patients, and family members of 2 other patients, being treated for type 2 diabetes. In addition, 8 Vietnamese health providers--5 physicians, 2 nurses, and an herbalist--were interviewed. SETTING: A low-income area of southern California populated by a large number of Vietnamese. PARTICIPANTS: Forty patients being treated for type 2 diabetes and 8 health practitioners. RESULTS: Three quarters of the patients had not achieved good control of their diabetes. Ideas about the cause and proper treatment of the disease were culturally shaped. Many patients used eastern (herbal) medicine and described a strong aversion to insulin injections. Patients stopped taking their oral medications when using eastern medicine, and a quarter lowered their dose whenever they felt "out of balance." Almost two thirds had used traditional home remedies for diabetes. Two had received nonstandard medical care from neighborhood physicians trained in Viet Nam; 1 of these patients died during the study. CONCLUSION: The Vietnamese community and physicians serving that community need culturally appropriate education about type 2 diabetes and modern therapy for the disease.

Injury in children of low-income Mexican, Mexican American, and non-Hispanic white mothers in the USA: a focused ethnography.

Several studies indicate that rates of serious pediatric injury are higher among Hispanics than among non-Hispanic whites in the USA. To investigate possible contributory factors, we interviewed 50 Mexican, 30 Mexican American, and 30 non-Hispanic white mothers in their own homes in the same low-income neighborhoods of Southern California. Mothers were identified via door-to-door canvassing in areas with high rates of pediatric injury. We observed household conditions and behaviors and obtained a detailed family history, including accounts of any occurrence of serious injury in a child under 5 years old, the highest-risk age group for pediatric injury. Results show that Mexican families were poorer, less educated, and lived in more hazardous and crowded conditions than did families in the other two groups. Nevertheless, they benefited from strong family bonds and a cultural tradition in which responsible older children typically supervise younger siblings. In contrast, a number of Mexican American and white mothers had been abused as children and were estranged from their own mothers; hence they lacked support and models of good parenting. There was much less self-reported smoking, drug use, and mental dysfunction among the Mexican mothers and their male partners as well as much less excessively active and/or aggressive behavior among their children. The nature of the injuries reported by the various groups seemed to reflect these differences. Appropriate interventions for each group are discussed. The study illustrates the importance of using ethnographic methods to examine the context of pediatric injury at the household level.

Household poisoning exposure among children of Mexican-born mothers: an ethnographic study.

OBJECTIVE: To explore reasons for high rates of unintentional poisoning among Latino children under 5 years old. DESIGN: Ethnographic interviews were carried out using a sample of mothers identified via door-to-door canvassing in an area with documented high injury rates among Latino children. Interviews included many open-ended and follow-up questions to elicit a detailed family history and emphasized observation of conditions and behaviors in the homes. SETTING: Low-income neighborhoods of Southern California. SUBJECTS: Fifty mothers born in Mexico with children under 5 years old. RESULTS: Children were exposed to potential poisoning agents in more than 80% of homes. Contributory factors related to culture included favorable attitudes toward iron as a healthful substance; extensive use of products that lack child-resistant packaging, such as rubbing alcohol and medicines from Mexico; high prevalence of shared housing; limited familiarity with toxic household chemicals not widely used in Mexico; and inability to read warning labels in English. CONCLUSION: Current Poison Control Center outreach efforts should be expanded. Clinicians are uniquely positioned to advise parents about the safe use and storage of toxic substances, including widely used products lacking child-resistant packaging. Medicines should be labeled in Spanish for those who do not know English.

Importance of complete system removal of infected cardioverter-defibrillators.

We describe a case of device infection after implantable cardioverter-defibrillator implantation managed by removal of all hardware except a portion of the epicardial sensing electrodes. Recurrent septic complications developed until all residual foreign material was eliminated. Despite anecdotal reports of successful management without device removal, extraction of all hardware components should be considered standard treatment for this complication.

Where there is no family doctor: the development of family practice around the world.

Family physicians are generalists trained at the postgraduate level to address the majority of primary care needs of patients of all ages in communities they serve. Throughout the world there is a need for family physicians to serve as cornerstones of comprehensive health care systems that provide high-quality, cost-effective medical and public health services to the entire population. To meet this need, each country must value and adequately finance essential medical and public health services and must provide family physicians with a thorough education focused on the relevant health care problems of the population being served. The authors present an overview of the status of this training throughout the world, outline challenges to the development of such training, and suggest strategies for successful development accompanied by illustrative case studies from South Korea, Venezuela, and Pakistan.

ARI concepts of mothers in Punjabi villages: a community-based study.

Pneumonia is a major child killer in the developing world; to prevent such deaths, mothers must be able to differentiate pneumonia from common cold. Local concepts regarding these illnesses were studied by interviewing 315 mothers of young children in their homes in Punjabi villages. Mothers described pneumonia differently from cough-and-cold but only a few volunteered fast breathing as a sign of pneumonia. Both illnesses were thought to be caused by "coldness," and were initially treated with "heat-producing" home remedies and feeding was continued in both. Spiritual healers were not consulted for cough-and-cold or pneumonia. Virtually all mothers said that allopathic medicines were necessary for both illnesses and 2/3rd said that if a child did not improve after 2 days of a given medicine, they would change the medicine and/or the doctor.

Insights from community-based research on child pneumonia in Pakistan.

Although pneumonia is a major cause of death in Pakistan, little is known about community beliefs and practices surrounding the disease. In this study, 35 mothers and four self-trained allopathic practitioners were interviewed in Karachi squatter settlements and rural Punjab. The findings indicate that maternal ideas about chest anatomy and the cause of pneumonia (principally "coldness") are very different from biomedical concepts. Further, mothers judge fast breathing impressionistically and tend to attribute it to fever alone. Nevertheless, they know that it is abnormal and most also link chest indrawing with pneumonia. Only mothers lacking other options take their children to government health facilities. Instead, most turn to private (frequently unlicensed) practitioners, although observation shows that such individuals are unable to diagnose pneumonia correctly and that they build their practices around the indiscriminate use of antibiotics. The study demonstrates that the target of ARI education in Pakistan should extend beyond government doctors to mothers and private practitioners as well.

PIP: In Karachi squatter settlements and in rural Punjab in Pakistan, in-depth interviews with 35 mothers and grandmothers of young children and 4 self-trained allopathic practitioners were conducted for a medical anthropology study of acute respiratory infections (ARIs), especially pneumonia. Most mothers were familiar with chest indrawing as a danger sign of pneumonia. Most regional languages distinguished between the upper and lower chest, which should make it easier to educate mothers about the seriousness of fast breathing and unusual movement of the lower ribs and the area right below the ribs during breathing (i.e., chest indrawing). Mothers tended to associate fast breathing with fever alone. Utilization rates of government health facilities was very low (e.g., 16% during 1982-1983). Mothers would take their children to government health facilities only if other practitioners failed to successfully treat pneumonia. Most mothers would seek medicine from private (mainly unlicensed) practitioners. Yet, some of these practitioners do not count the child's breathing rates or examine the chest for indrawing. They even consider a fast pulse more dangerous than fast breathing. They overprescribe antibiotics. These findings suggest that the Pakistani government should include mothers and licensed and unlicensed allopathic practitioners in addition to its physicians in ARI education.

Mothers' perceptions of severe pneumonia in their own children: a controlled study in Pakistan.

In 1992, 320 mothers were interviewed in a Rawalpindi hospital to identify which of the signs and symptoms they saw in their own children were most consistently linked with a clinical diagnosis of pneumonia as opposed to common cold. A related goal was to determine whether mothers could correctly judge the actual presence or absence of two major pneumonia signs--fast breathing and chest indrawing. The mothers were predominantly poor and 43% were illiterate. The study sample was composed of four matched groups: (1) mothers of 80 children with pneumonia, most with severe disease, interviewed after the child was referred to the ward; (2) mothers of 80 such children interviewed in the outpatient clinic prior to any discussion of the pneumonia diagnosis; (3) mothers of 80 children with common cold; and (4) mothers of 80 'well' children. Results showed that when mothers were interviewed in the clinic, their perception that a child had fast breathing and/or chest indrawing was highly correlated with pneumonia (sensitivity 64%, specificity 90%). Mothers were even more likely to say that a child had these signs after the pneumonia diagnosis had been conveyed, suggesting that interaction with doctors influenced their views. Fast breathing was better recognized than chest indrawing, and accurate diagnosis of both signs was better among mothers having prior experience with childhood pneumonia. The data suggest that even in the absence of formal ARI education, a majority of Pakistani mothers attending hospitals in indigent areas can recognize these two signs in their own children. However, the seriousness of the signs and their connection with pneumonia should be stressed in education campaigns since a high percentage of children had chest indrawing (a late sign of severe disease) by the time they were brought to the hospital.

A Spanish-language prenatal family health evaluation questionnaire: Construction and pilot implementation.

The Family Planning Council of America has constructed and implemented a genetic history questionnaire, the Family Health Evaluation, to elicit risk factors, to increase clients' knowledge about reproductive choices, and to improve access to genetic services. The objective of the present study was to develop and implement a Spanish-language version of the Family Health Evaluation for data collection and risk assessment. The content of the Family Health Evaluation was modified to more clearly reflect the risks, exposures, and medical needs of an Hispanic, largely Mexican-American, population. In the present study, the questionnaire was administered to women presenting for prenatal care. The data collected in this pilot study indicate that the questionnaire is effective in identifying individuals and families who would benefit from receiving additional information about a medical condition in their families, from genetic counseling or from a referral for high-resolution ultrasound or other diagnostic procedures.

Maternal perceptions of pneumonia and pneumonia signs in Pakistani children.

Fifty mothers of children attending a hospital outpatient clinic with non-severe pneumonia (fast breathing but no chest indrawing) were interviewed in depth. Maternal perceptions and practices with clinical significance were documented. Results showed that most mothers initially tried "heat-producing" home remedies designed to counter the "coldness" of the disease, allowed only 2 days for any particular allopathic medicine to work, and did not go to the same practitioner twice. When mothers were asked what had alarmed them enough to come to the hospital, the symptoms named most frequently were persistent severe cough and high fever, inability to sleep and excessive crying. Fast breathing was spontaneously mentioned by only a few, although when questioned, 32/50 said that they had noticed it. The mothers who had prior experience with child pneumonia were more likely to notice fast breathing and also came to the hospital earlier than those who were inexperienced. Relatively higher levels of maternal education and income were suggestively associated with bringing a female child rather than a male child for pneumonia treatment. Fewer than half of the mothers knew where air goes when a person breathes in and where the lungs are located. Most held treatment preferences at odds with the protocols proposed for the national ARI program currently being initiated in Pakistan, e.g. they said that a doctor should use a stethoscope, should prescribe suspensions rather than tablets and should give injections. This study provides baseline data on attitudes and behaviors that can either be built on in that program or addressed through public education campaigns.

Mother's milk and pseudoscientific breastmilk testing in Pakistan.

In urban squatter settlements and rural villages of Pakistan, human breastmilk is regarded as a potential source of destruction as well as of nurturance. Though it is highly valued as crucial for infant survival, it is also thought susceptible to becoming tainted in many ways: by a 'shadow' from the spirit world; by 'evil eye' or black magic due to others' envy; by the effects of a new pregnancy; by the mother's illness or 'weakness'; by her exposure to excessive cold or heat; by her dietary indiscretions. In any of these circumstances, women may stop breastfeeding to prevent illness in the nursing child. Sometimes the stoppage is temporary, brief, and has no serious consequences. When the mother is pregnant, however, it is permanent. Further, if a child is sickly, cries a great deal, has prolonged diarrhea, or seems reluctant to suck, mothers frequently become alarmed and suspect irreversible breastmilk 'poisoning'. In the latter case, a folk healer has traditionally been consulted to test the milk's quality, but in recent years pathology laboratories have increasingly taken on this function in all of the major cities in Pakistan. Not only does the mother stop breastfeeding while the milk is being tested, but often she is unable or unwilling to resume nursing even if the milk is eventually pronounced safe to drink. This manifestation of inappropriate, child-endangering technology has gained acceptance partly because of maternal anxieties heightened by commercially-driven pressures to be 'modern' and partly because of its congruence with traditional ideas surrounding breastmilk, many of which have classical antecedents.

Traditional perceptions of marasmus in Pakistan.

One hundred and fifty mothers of under-5 children clinically identified as malnourished were interviewed in their homes in katchi abadis (squatter settlements) of Karachi. A variety of ethnic and religious groups were represented. Mothers were shown a photograph of a child with third-degree malnutrition (marasmus) and were asked what might be wrong with the child. Virtually of the mothers said that they had seen the condition, typically identifying it as sukhay ki bimari (Urdu: 'the disease of dryness and thinness'). The majority said that diarrhea predisposed to sukhay ki bimari, and vice versa, but only 3 of the 150 mothers said that diarrhea and/or lack of food could, in themselves, cause the condition. Instead, most said that the usual cause was contact with a woman who had a marasmic child or was otherwise in a state of ritual impurity. The mediating factor was said to be a saya ('shadow, influence') emanating from such a person and ultimately linked with the spirit world. Although the condition was judged to have a very poor prognosis, mothers described various magico-religious therapies that could be tried. Treatment by physicians or by giving more food was considered ineffective or even detrimental, and hiding of such children was reportedly common because of social stigma. Subsequent inquiries carried out by the author in Chitral in northwestern Pakistan produced similar findings except that there, the condition was known as moordasip and was more overtly associated with fright and spirit possession. In Karachi, 45 of the 150 mothers interviewed had children with third-degree malnutrition according to weight-for-age criteria, 15 of whom died in the course of the study. In these 45 families especially, early bottlefeeding had occurred, sometimes reportedly because of fear that the mother was a carrier of a saya and could pass it on through her milk. Most mothers had only sketchy knowledge of suitable weaning foods and an appropriate timetable for introducing such foods, and many showed little awareness of what their children were eating once they reached the toddler stage. Implications for the identification and treatment of marasmic children are discussed. A brief summary of crosscultural beliefs surrounding marasmus and the 'hard to raise' child is included.

Cow dung, rock salt, and medical innovation in the Hindu Kush of Pakistan: the cultural transformation of neonatal tetanus and iodine deficiency.

In mountain villages of Chitral District in northwestern Pakistan, dried cow dung is used as Westerners would use talcum powder when babies are swaddled and rock salt is consumed in tea and other foods. Both substances are esteemed as conveying beneficial 'heat' and 'strength'. Unfortunately, however, cow dung sometimes contains a bacterium that causes neonatal tetanus, and the resulting toxin may enter through the baby's unhealed umbilical cord and cause death. Further, rock salt contains no iodine, and Chitral's soil is so iodine-deficient that goiter is very common. Thus local health workers advocate use of talcum powder rather than cow dung, immunization against tetanus, and replacement of rock salt by powdered iodized salt. The present report documents widespread community acceptance of these innovations despite the fact that the biomedical model of tetanus and goiter was not well understood and indigenous concepts of the causes of the diseases remained virtually undisturbed. Most of the villagers were Ismaili Muslim followers of the Aga Khan; their receptivity to such health messages was influenced by the high value that their religion places on advancement through 'education' and was correlated with their proximity to Ismaili health workers whom they trusted. A major implication of this research for primary health care programs is that when one is attempting to change existing health practices, explication of biomedical models should not be the only focus of concern. Attentiveness to the context in which behavior changes are introduced and interpreted is at least equally important. Further, the fact that new knowledge was added to the old without replacing it illustrates the complexity of human cognition and points to limitations in the KAP (knowledge-attitude-practice) model of health belief and behavior. This report adds to a small but important body of literature documenting the dynamic nature of medical pluralism in the developing world.

Culture and 'compliance' among leprosy patients in Pakistan.

In Pakistan approx. 30% of the 18,000 known leprosy patients have dropped out of their treatment programs. To investigate reasons for such widespread noncompliance, 128 diagnosed leprosy patients--59 outpatients and 69 inpatients--were interviewed in Karachi. More than half of the 'noncompliant' outpatients denied having the disease. Denial was found to be an understandable coping mechanism in view of the severe stigma associated with leprosy. The presence of close-knit extended families, in which joint decision-making was the norm and in which such a dread diagnosis could spell the end of job and marriage prospects for even distant relatives, contributed to the likelihood of denial. In such a setting, the very term 'noncompliant' appeared to be an oversimplification since it covered so many different types of culturally-constrained behavior. In addition, many of the patients who initially seemed most 'compliant' by virtue of being long-term hospital inpatients in fact owed their hospitalization to the fact that they had been markedly noncompliant in the past. Thus the usual view that adherence to a biomedical treatment regimen constitutes 'compliance' and that nonadherence to such a regimen constitutes 'noncompliance' proved inadequate for understanding the health behavior of these Third World leprosy victims. The study also showed that many patients had initially consulted traditional healers, inadequately-trained physicians, and/or untrained medical practitioners for treatment of their symptoms, which resulted in lengthy delays before they were correctly diagnosed. Further, even after the diagnosis was made and appropriate medications were prescribed by trained personnel, most patients were not told what had caused their leprosy and how the drug regimen worked to combat it: when questioned, only 4% of the 128 respondents attributed the disease to infectious organisms. In addition, patients were usually not warned in advance of the possibility of undesirable side effects from their leprosy medications, which led to further 'compliance' problems. The findings of this study emphasize the need for better training of physicians and other health care providers in early diagnosis of leprosy and better health education of diagnosed patients. To be truly effective, the treatment of leprosy must include counseling of extended families and education of the public at large as well as enhanced communication with the patients themselves.

Mothers' concepts of childhood diarrhea in rural Pakistan: what ORT program planners should know.

Diarrhea is the leading cause of infant and child death in Pakistan. Appropriately, the development of oral rehydration therapy (ORT) programs has become a major priority of the Pakistan Ministry of Health and of international funding agencies. Paradoxically, however, there is virtually no published anthropological literature on diarrhea-related traditional health beliefs and practices among the rural and illiterate people who make up 90% of the nation's population. The study reported on here focuses on these matters and suggests important implications for the multimillion-dollar ORT programs currently being launched. Mothers' ethnomedical models of diarrheal disease and concepts of appropriate treatment are discussed, as are practical problems relating to the effective implementation of ORT in such a setting. The results underline the need for anthropological studies as an adjunct to health interventions involving behavioral modification.