Health begins at home [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • FEBRUARY-MARCH 1973 • UK 30p • USA $0.75 health begins at home 2 Front cover by Peter Davies Contents Health begins at home by Dr M. G. Candau 3 No man's home is a castle by Prof M. Schaefer Mental health and family life by Dr J. H. Kahn 8 Home cooking is best by Prof. G. Debry 16 India, blending old and new by Dr D. Anand 22 Beloved pets by Dr D. Cohen . 26 You and your doctor by G. M. Bovay 32 Family planning for better health by W. Porter 36 Too many accidents at home by F. J. Tomiche 40 Books 46 World Health appears in Arabic, English, French, German, Hindi, Portuguese, Russian, and Spanish. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland ,WORLD HEALTH World Health Day, 7 April 1973 HEALTH BEGINS AT HOME Message from Dr M.G. Candau DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION The World Health Organization ever since its inception in 1948 has con- centrated on health problems affecting mil- lions, hundreds of millions of people. Yet it seems to me fitting that on this World Health Day, WHO's twenty-fifth anniversary, we should concern ourselves with health in the little world of the family at home. Just as international health security depends on the level of health of each country in the world community, so the health of the city, the village, the hamlet depends on the state of health in the homes that make it up. There are innumerable ways of making the home a healthier place. Learning more about health, making the best use of avail- able foods, disposing properly of wastes dangerous to health, helping children to grow up strong and self-reliant, planning the family so that each child has a better, brighter chance of succeeding in life, taking some basic precautions against accidents, protecting the happiness of old people— these are but a few suggestions. In many such actions, the family needs service from the community. Water supply, vaccination against communicable diseases, and help to mothers in pregnancy and childbirth are obvious examples. Another reason why community services are impor- tant is that, in many a home today, the elders are living in conditions very different from those they knew when they were young. In the overcrowded city, for example, their time-tested ways are perhaps no longer appropriate. Community action can smooth the process of adaptation. Efforts to lead a healthier life may of course be foiled by one's neighbour's illness or by his bad habits; but if some diseases are communicable, so are good habits and healthy ways of living. Everybody can contribute to world health by making health begin at home. 3 NO MAN'S HOME IS A CASTLE by Morris Schaefer, D.P.A. PROFESSOR OF HEALTH ADMINISTRATION, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, UNITED STATES OF AMERICA No man's home is safer or more health- ful, ultimately, than the state of safety and healthfulness of the community of which it is a part. It is only through com- munity health action that each man's home can be a true shelter against the hazards of his environment. Along with food and clothing, shelter has long been regarded as a prime neces- sity for human life. Primitive man built physical barriers against the extremes of weather and against hostile creatures, in- cluding other men. As civilization pro- gressed, housing became more synthetic, sophisticated and secure. In most societies, the concept arose that "the home" was something more than mere housing, that it provided psychological as well as phys- ical shelter, and that it was a focal point for the orderly growth of the family. The home has also become a focal point for another requirement of living in orga- nized societies : privacy, with all that it connotes about the essential rights of families and individuals. The constitu- tions of many nations speak of the right to privacy, and the police services in many communities are concerned with main- taining the security and privacy of people in their homes. Perhaps the ultimate state- ment of the principle is found in the legal dictum: a man's home is his castle. What this idea suggests to the mind is the ability of the individual family to withdraw from the community into its own fortress, to pull up the bridges that link it with other people, to live in isola- tion from the sorrows and dangers that beset its neighbours. Perhaps a small num- ber of the extremely wealthy can purchase something like this degree of isolation and insulation, but for all other people it is an empty dream. Having conceded the individual's legal right to privacy (subject to compromise when balanced against the rights of the community and the government), one may fairly say that no man's home is a castle that can insulate him and protect him from the problems and hazards of life faced by the community. This idea is nowhere more true than in matters of health, for states of health and disease are constantly affected by the interaction between the home and the community. This interaction occurs in several ways. There are things for which most people have to depend on the world beyond the walls of their house; for example, earning a livelihood, obtaining food and clothing, finding recreation and emotional satisfac- tion, and taking part in community deci- sions and efforts that have a bearing on one's own interest. When people function in society in any of these ways, they expose themselves to certain risks. There may be hazards in the work environment itself, in the field, fac- tory, mine, river or sea; in the means and mode of travelling to work; in food and water contaminated by chemicals or disease organisms; in the wastes cast into the air and water from factory or farm; and in the stresses caused by crowding, noise and dirt. Besides, there are dangers to health generated in and by the home itself, in the form of biological and domestic wastes that can be sources of hazard to one's neighbours, as well as to one's own family. On the other hand, the family stands to gain from the impact of social activities introduced as safeguards against health hazards—activities that can be carried out only by community action and support. Community health services work when the people of the community support them with funds and by following healthful practices. There are the services that set up and maintain safeguards against the spread of disease through the contamina- tion of water and food. They seek to protect the worker on the job, the motorist and the pedestrian on the road, and anyone who may be exposed to breathing polluted air. They provide for proper and effective treatment of the sick besides taking mea- sures of sanitation and immunization to prevent the occurrence and spread of com- municable diseases. The extent of the interaction between the individual and society or between smaller and larger groups varies from country to country, but it is on the increase in all parts of the world as a corollary of social and economic development. In the developing countries, industrialization and urbanization are increasing, society is be- coming more complex, and there is a constant rise of new institutions—not the least of which are those devoted to the forms of mass communication. In the more developed countries, the unintended con- sequences of technological development have created intensive environmental prob- lems to be solved. The experience is having an impact on the developing countries, too, in that it points out the pitfalls to be avoided as the pace of economic develop- ment is accelerated. Are there men's homes that are immune to these problems, where the idea of isolated self-sufficiency still exists? To some extent, yes: in areas where population density and the level of technology are low—where homes are situated in rea- sonably ample plots of land farmed by 4 t The family circle in the privacy of the home (Colombia). -<— An isolated house near the village of Rincon Santo in Colombia and an English town- scape (Liverpool). Wherever one's home, from the health point of view there is no escaping the community. (Photos WHO/P. Almasy and E. Spooner) 5 ' • No man's home is a castle SIMIN1111111111•1■1111101111•111•1•111 _ -..„a ...'.....t ,i -- f14 . .., _ —4"- 1111.S.W ' " 2 . ,q-''''•■■• ■• ..._ ' ' : : ..,_"*.JAW ;abr., Z;rari7r....:+....1A V. 7; 10"1"-mgese A Colombian housewife doing her washing (above) and the waterworks at Cagua which supply the area. The home and the community depend on one another in many ways. The housewife constantly needs water and the community has the duty of pro- viding an uncontaminated supply in adequate quantities. (Photos WHO- P. Almasy) traditional methods—the community in- teractions that affect health are low, for there is a high degree of self-sufficiency almost by definition. The separation of homesteads by space, the capacity of sparsely settled land and water areas to absorb domestic wastes, and reliance upon home production of food and textile stuffs are the major factors in the relatively low level of interdependence. In so far as its insulating factors against disease are concerned, even this conven- tional picture of rural living seldom holds true. The idyllic image vanishes as soon as certain elements of cultural and socio- economic change appear: farmers, for practical reasons, live in hamlets or vil- lages and go out to work the surrounding fields; a hunting community decides to settle down in a village; land holdings shrink, in effect by rapid population in- creases, in fact by laws of inheritance; the introduction of agricultural chemicals without adequate safeguards leads to pol- lution of land and water; industries located nearby dispose of wastes in such a way as to contaminate the air and the streams of the region. All such changes strongly affect the rural condition, increase the interactions between the home and its environment, and require organized com- munity action to deal with threats to health and well-being. Even as life in village communities is modified by economic and social change, an ever increasing number of rural people move to the industrialized urban areas in search of a better life. Here there can be no pretence at self-sufficiency. The urban home is fully exposed to the physical and social environment. The factors of spatial separation, the capacity of land and water to absorb and dilute pollution, hardly apply. At the extreme end are the crowded, poor slum areas in the industrial sections of large cities, where the environmental impacts upon health are massive in every aspect. This is mainly because of low levels of food safety, air purity and cleanliness, lack of privacy, quiet and shelter, and inadequate water supply and waste dis- posal. Quite aside from the millions of people in the developing countries who are without housing and whose "home" is a place on a sidewalk or in a railway station, the city dweller is in no sense self- contained, and the degree of his exposure to physical and psychological hazards varies only with the levels of poverty and density in which he may live. Yet even the richest city family cannot shield itself from the industrial and traffic pollution of the air it breathes and is dependent, as all other families, on the availability and continuation of water, waste disposal and sanitation services. As urban areas have increased in size and density, so have the problems of health and disease. Cities become metro- politan areas or even "megalopoles" —thousands of square kilometres entirely urbanized, with the population bound together by production, pollution, trans- port and marketing—but seldom by co- ordinated or unified political organization that would permit them to solve shared problems on a regional basis. Because of their greater disease prob- lems and their density, cities have been pioneers in the development of organized health and sanitation services—as a matter of necessity for their survival. Unless cer- tain minimum conditions are met in mat- ters of water and food safety, waste dis- posal and pollution control, the threat of disease and poisoning exists for all, not only for those most directly and obviously exposed. Yet millions of city dwellers in today's world are without such minimum safeguards against physical hazards, much less against the psychological and social stress that are associated with mental illness, crime, functional disability and social alienation. Conditions are most acute in the poorer, developing countries where it is hard to find the economic means to achieve the minimum levels of sanitation, often in the face of rapid changes in population size and composition and of pell-mell urban- ization. The developed countries face many of the same problems and others engen- dered by the side-effects of technological sophistication and mass distribution of commodities that lead to pollution and aggravation of waste disposal problems. And in all communities there are enhanced needs and rising expectations for medical services to prevent, detect and treat disease and disability, and to rehabilitate the sur- vivors when necessary. Increasingly, governments in virtually all countries are being called upon to intervene more strongly to try to solve these problems. When solution of a health problem goes beyond the means available to individuals, singly or in groups, it has been the tradition in public health that the government legitimately steps in, a failure to do so being regarded as a failure to meet its mandate. Certainly the rise of new and more severe health problems that accompany changes in population composition and movement, and those resulting from technological development, calls for a more active role by the govern- ment. Only the government possesses or can harness the economic and scientific resources needed to solve these problems; only the government has been given the legal powers by the people to deal with them authoritatively. Today no government in the world can escape the challenge to use its resources and its powers in the interest of the public : to organize services, to extend basic safeguards and to find a balance between economic development needs and health needs—knowing that sooner or later the fact has to be faced that there can be a healthy economy only when there are healthy people, and vice versa. Yet the role of the government must reach beyond the regulation of enterprises and the provision of health and sanitation services out of pooled revenues. Necessary as these are, they must be joined with efforts to help people in their homes to act on their own behalf. Millions of parents now live in home situations radi- cally different from those in which they grew up and learned to function. Educa- tion and motivation are needed if these parents and their children are to use their homes in ways that promote their own health and create the least threat to the health of their neighbours. The home needs to be developed as a centre for health, whether the home is a mansion or a hut, whether it is set in the heart of a city, along the single street of a village or out in the country. Wherever there are human settlements, the prospects of people for better health are interlocked with the prospects of other people. For no man's home is safer or more healthful, ultimately, than the state of safety and healthfulness of the community of which it is a part. And it is only through community action on behalf of health—in its widest sense—that each man's home can be a true shelter against the hazards of his environment. Only through community health action can man check and regulate the hazards generated by urbanization, crowding, pollution and other rising sources of stress. Community health action, in turn, comes about when there is broad participation of the people, both as citizens and householders. ■ 7 MENTAL HEALTH AND FAMILY LIFE by Dr Jack H. Kahn CHILD GUIDANCE CLINIC, LONDON BOROUGH OF NEWHAM A family, like society, is something into which an individual is born. It exists in some form before he is born. He is moulded by it, contributes to it, and he may even in some ways alter its character. Human beings make society and are made by society. Society provides advantages and imposes conditions in order to protect its own existence. The family is the first society that any human being can become aware of. Sym- bolically it represents society in miniature, and in reality, particularly to the young, it acts as the declared representative of the community as a whole. Society, however, is not uniform and not coherent. There are different groups with overlapping boundaries, acting in co-or- dination or in conflict. The same individ- uals can, at different times and for dif- ferent purposes, form themselves into groups that are occupational in origin, recreational, cultural, local, class, political, national and international. There are, likewise, although perhaps less obviously, different ways in which an individual might consider himself to be a member of a family group. In conventional descriptions, a family comes into being with the birth of a child. The child's parents are responsible for its progress and its care, and the family is the matrix in which the growth of the child takes place. It would, however, be just as true to say that the child gives birth to the mother and the father. The woman who has experienced motherhood has taken a further step in her own devel- opment. Fatherhood is no less a critical stage in the maturation of the male, but this aspect has received less attention in scientific writings and in the inter- pretations of dramatists and poets. Yet it remains true that fatherhood and motherhood alike are stages in human development that can only come into existence with the arrival of a new gen- eration. In an abstract sense, families also have an inner existence in the mind of each individual. Individual growth consists of a succession of roles which are given meaning within the family system. Infancy is succeeded by childhood, in which edu- cational influences are felt. During adoles- cence, puberty is reached and sexual rela- tionships become possible and, following the idealized progress into adulthood, the culturally approved state of marriage is held out as the goal, although in many instances it has already been anticipated. Procreation of the next generation brings a new family into being. The individual-centred study of the fam- ily assumes the existence of a purely notional individual who passes through separate stages of life in which his role and status are precisely defined. In reality, however, the role and status of an indi- vidual depends upon the particular place and time in which some interaction is occurring. A man might be a parent in one family and a child in another—a father to his son, a husband to his wife, a child to his parents, and a brother to a brother or a sister. Small wonder that he sometimes gets his roles confused ! He has wider ties of kinship, and family and social networks become intertwined. The boundaries of family structure change within the same group of people in different circumstances. We must be prepared, therefore, to find and to reconcile conflicts and inconsis- tencies. The professional worker who deals with families as an organized whole needs a scientific framework. The scientific student of family interaction is faced with the difficulty that his subject is the common experience of every member of the com- munity. Every individual is an expert in the thoughts and feelings of others. Each is prepared to predict what other people will do, and, not having to formulate his predictions in precise terms, he is unlikely to recall any failures. The scientist is lim- ited by his discipline, knowing that his results are applicable only to a specified setting. Moreover, in the field of human relationships he has to compete not only with popular generalizations; he is, in ad- dition, unable to separate himself com- pletely from the object of study as he would with the physical sciences. He re- mains, as a member of a family of his own, subject to the influences of family interaction past and present. He has to carry the burden of his personality and of the personal experiences which preceded and accompanied his professional training. It should be recalled that any professional worker, even when acting within his own professional field, brings, in his personal self, the scraps of knowledge gained from outside his own discipline. We must there- fore be prepared at any one time to ac- knowledge the authority, or lack of au- thority, by which we act. The study of the family is based upon an assumption that our thoughts, feelings and behaviour can make sense even when they are disordered. This is a special application of the act of faith which under- lies all scientific work—namely, that the universe is understandable. The assump- tion is unproveable and that is why I call it an act of faith. But without that belief, we would never make the first move to try to understand the physical and the living world. It was an innovation to apply the same assumption to the apparently irra- tional thoughts and the disturbed feelings and behaviour that are exhibited as what we have come to call mental illness. It needed some further assumptions before 8 Three generations: a man is often a parent in one family and a child in another. (Photo WHO/E. Schwab)

Mental health and family life meaning could actually be found in some of our mental experiences. We had to assume that mental life had unconscious as well as conscious aspects, and that unconscious components could be in con- flict with the mental processes of which we are aware, or which we are prepared to ac- knowledge as our own. The knowledge of existence of simultaneous and opposing drives is the key to the understanding of the mental life of the individual in health and in illness. Ambivalence, or the simul- taneous experience of love and hate for the same person or object, is the basic theme of emotional life. Tolerance of am- biguity, and of a love and hate that go together, become requisite for all profes- sional workers who deal with the emotional aspect of people's lives. There must be similar assumptions with regard to the living structure of family life. What applies to the individual can be applied, at least figuratively, to a group. The theme is parallel to that of the indi- vidual's ambivalence. It is the conflict of interaction; the opposition of the wish (and need) to be together and united, with the wish (and need) to be separate and individual. It is the clash of the wish to assert one's separate identity against the wish to be dependent and safe. The importance of this theme of the continued opposition of separation and dependence can be judged by the heat of any discussion, whether in scientific or popular fields, on any topic in which these processes are concerned. Should mothers of young babies go out to work? In what circumstances should children be taken "into care"? How should children "in care" be looked after by the social service depart- ments? Should we have day nurseries or nursery schools, and for which children? At what age should compulsory education begin? What are the causes of the type of failure of school attendance known as school phobia? Is it a good thing for children to go to boarding school? Should children be admitted alone to hospital? Less frequently do we hear of questions related to the father's absence from his home and from his children; what are their special problems when they take jobs that involve travelling long distances or living away? Separation has come to mean something that happens to a child, when his mother is absent through death, illness, desertion, inadequacy, or when the child himself is removed from the mother, either through illness or in order to provide him with more adequate care. But what are the results of this separation for the mother, the father and the other children in the home? In all these discussions, is "separation" looked upon as a single and perhaps once- and-for-all process? And are we looking at the effects on the child alone? Separation is but one part of a double process, and it does not happen once only in a lifetime, but is an essential ele- ment of every human relationship. To unite with another and yet to seek to become a separate identity is the two-sided process of living in a marital or family group. The family itself has no point of be- ginning. A child is born to parents who have pre-existing complicated family in- volvements to which is added the new relationship with each other and the child that they are going to have. The child is a fantasy—welcome or unwelcome—before it is a reality. Even in their own childhood, the parents had pictured themselves some- how in their own parents' roles. Both mother and father of a child have some kind of image of the child that they are going to have, and of the part they will play in his life. The image may have no relation to the real child, and the tragedy for some children—and some parents—is that it is hard to give up the image for the reality. Sometimes a real child moves more quickly towards a separate identity than the imaginary child, but in the case of a handicapped child, the dependent state may be retained at levels beyond those which the resources of the parents can support. There are stages in the development of each individual where there are alterations in the balance of relationship, and where new adjustments have to be made. Every child is born with his own capacities and limitations and receives, if he survives at all, some kind of nurturing. The capacities become performances. The limitations appear as defects. We can trace the pro- gress of each child against the scale of what is considered normal, recognizing that there are some standards which are regarded as universal in mankind, and other standards which are relative to a particular culture, and which differ in dif- ferent geographical areas, and in people of different race, religion and social class. Loneliness, isolation, deprivation, separa- tion and rejection are words that we can apply to some of the anomalies in human development. It will be our task to take these words and to examine the ways in which each child, with his unique potential, can receive the optimal provision, and it will also be necessary to note those cases where chil- dren suffer from deprivation of the neces- sary elements of nurture. Such knowledge as we have of the norms in human development has been accumu- lated as the result of the need to study what has been considered to be unsatis- factory, in the hope of making it more satisfactory. The study of the anatomy and physiology, i.e. the structure and func- tions, of the tissues of man was undertaken mainly in order to find standards with which to compare the pathological changes in physical disease. The study of mental and social life has now been added in order to have standards with which to compare thoughts, feelings and behaviour which are considered to be abnormal. The provisions for the development of children are usually offered within the child's own family, by the parents, but society has become organized in ways that supplement, and sometimes replace, the parental care. A family in which there are two parents can provide for the child's nurture, introduce the child to the restric- tions on social behaviour that will later be expected in the community in which the child will grow, and can also offer models of sexual roles of the adult male and female. The parents are not alone in this task. There are relatives in the extended family, neighbours in the immediate com- munity, teachers in the school, doctors, nurses, social workers and others who all attend in different ways to the needs of normal and anomalous development. Later there are all the pressures of the regula- tions imposed by law, and the access to 10 Separation. How does it affect the family at home? (Photo WHOIE. Mandelmann) -4- opportunities of employment, recreation and cultural activities. The best beginnings occur in the intact family, but there are children who are born of unmarried mothers, children whose parents die, fall ill, separate or are divorced. The intact family exists for the majority of children but there is a significant propor- tion who have no parents, only one parent, or, even amongst those with two parents, there are children who receive insufficient recognition of their needs. It is amongst all these that we should expect to find the greatest number of lonely children. Sir Alec Clegg and Barbara Megson estimated that 15 % of all school children suffer severe distress resulting from abnormal- ities or deficiencies in their family life, and they concluded that for most of these the only hope of alleviating their distress was what could be offered to them at school. By distress these authors mean, quite simply, "children who are wretchedly un- happy because of the strain put on them at home". It should be recognized that defects and relationships can exist in intact families and amongst those who are well endowed intellectually and materially. Clegg and Megson add that child distress is not con- fined to any one stratum of society. An important example of ill effects on the child is that of physical or mental illness in the mother which prevents her from responding to the needs of the child. If the mother is suffering from a mild depressive reaction following childbirth, the child will reach out in its first distress for the comfort which normally comes from the mother, but she will be unable to perceive it or respond properly. Severe forms of depression are likely to summon outside help for both the mother and the child, but the milder forms may be de- scribed as apathy, and receive a command to "snap out of it". The father is in some cases able to offer help, either directly to the child, or indirectly, through his under- standing and support of the mother in her apparently irrational sadness. During the vicissitudes of family life, both parents undergo further growth and development in relation to one another and in relation to the growth of their child. If the child should have to be separated 11 Mental health and family life from the parents, even if he is given suf- ficient care elsewhere, the parent is de- prived of that aspect of growth which occurs in taking part in the continually changing responses of the child to the adults' communication. Physical, sensory, or mental defects will prevent the child from perceiving some of the communications. They multiply their own ill-effects. For example, a mentally handicapped child starts with a lower po- tential for development. His handicap prevents him from receiving some of the personal interchange that is offered him, and he may not therefore develop even up to the level of his own potential. Next, his failure to reach the expected normal stages at appropriate times robs the mother of the rewards that come in the ordinary way from a child who benefits from her attention. Some of the mental illnesses, such as childhood autism, appear to be a with- drawal from the world of outer relation- ships, into an inner world of the child's own, largely unreachable through the ef- forts of parents and teachers in their everday setting, and only marginally acces- sible to the efforts of specialized treatment. It is difficult enough to communicate with parents about physical or mental handicap in their children. The parents cannot come to terms with the potential- ities and limitations of their handicapped child until they have mourned the loss of the perfect child (of their imagination) for whom the handicapped child is an inadequate substitute. The parents must be allowed to suffer the grief for their loss, and to make preparation in their minds for the burden that is going to be with them as long as they live. The doctor needs to be constantly aware of the par- ents' anxiety for the care of the handi- capped adult who may survive after their death. The handicapped child gets some image of himself from the apprehensions and hopes of the parent. There are popular and professional stereotypes of handicap. In some cases physical handicap is pre- ferred to mental handicap—it seems to carry less stigma. But even with physical handicap some members of the public look away in case the disability is "catch- ing". Popular stereotypes of mental handi- cap are often self-contradictory. These children may be thought of as perpetually helpless and dependent, or dangerously adventuresome and aggressive. Sexual ac- tivity for the mentally handicapped—whe- ther masturbatory, homosexual, or hetero- sexual—is abhorrent to some people, even though there is enlightened clamour for maintaining the mentally handicapped at home and in the community. It would be unreal to break down the walls of the closed institutions unless there can be tole- ration for expression of intellectual, occu- pational, and emotional fulfilment to the full extent of each handicapped person's capacity. Discussion of death seems to be the ultimate taboo, even in a society which has learnt some freedom of expression about sex. Most explanations of death assume that it occurs only in old age. Death in early adult life and in childhood is too painful to contemplate and yet it is part of ordinary experience. The doctor's special responsibility is to attend some of the illnesses in which appropriate diagnosis and treatment can avert death, but he is also expected to continue in attendance in those cases where, in the nature of the illness, death is inevitable. There are also the deaths by violence and by accident. Even in those cases where the circum- stances leading to the death can be scientifically understood, there is still the question, "why should it be this person, or that person, and not someone else?" Death after long illnesses releases com- plex emotions. Some anticipatory mourning has already taken place, and it is with a feeling of guilt that people feel some relief from the burden of care. One should be aware of the existence of emotion that is opposite to the one expressed. When it is relief that is spoken of a comment can be made, "but in some ways you will miss all the care that you have had to give". When the grief goes on being expressed, one should be aware of the anger that may be felt, against relatives, the doctor himself, and a universe which makes these things possible. Children are given insufficient credit for noticing the disturbances and misfortunes in the family. Deaths of grandparents and 12 Family harmony means a good start. (Photo WHO/P. Almasy)

Mental health and family life other relatives may be concealed from the child for a considerable time "in order not to upset them". Cases are known where a pet dies and an attempt is made to replace the pet before the child has been told of the loss. Concealments devalue the importance of the child's feelings and the importance of the identity of what has been lost. Children need their normal grief. No- one can value his own self unless he can grieve for the loss of someone else. The person who has to carry the information may be afraid of the emotional impact at the moment of communication and may shirk the job. With bereavement, as with information about illnesses and handicap, the comforter has to be aware of his own feelings and need not attempt to hide the tears that come to his eyes. Many of the children who are brought to child guidance clinics on account of difficulties in their personal relationships come from homes in which there are parents who, through no fault of their own, live in exceptional circumstances. There are those whose work takes them from town to town, or even from country to country, as the price of promotion. Their children have to tear up their roots that they have established in former districts, and put down new ones. Some- times the transplantation seems beneficial. In other cases there seems to be something that withers away. Many children seem able to respond by forming easy superficial relationships like the traveller who finds no lack of acquaintances in his temporary stopping places. There are the changes from district to district of those who are upwardly socially mobile, and whose children were envied in their former districts but are not yet acknowledged in their new ones. There are the social decliners who have to move to less desirable areas where they feel superior to their new neighbours yet feel at a disadvantage with them. There are the problems of immigrants from other countries who have to make individual adjustments against a back- ground in which they are fitted by others into a stereotyped role. The changing culture of today appears to lead to an increase in the varieties of family pattern. There is a tendency to the separation of young families from the families of origin. Factors such as family size, and the timing of the child-bearing years, have an effect on individual per- sonality as well as on family structure. Where child bearing is limited to the first few years or so of marriage, and where the family is isolated, relationships within the small family are close and intense. The extended family, with multiple children having a wide age range, and grandparents, uncles and aunts and cousins of all ages, provides for continuity of the generations and for auxiliary parentage when natural parents show temporary or long-standing inadequacy. Another feature of the short-term period of child bearing is the way that it allows a change in the feminine role. The woman is no longer tied down to the home by motherhood. After a few years she can begin a second kind of life outside the reproductive function. She can take up her old or a new occupation, join in recreational and social activities on an equality with the male—or almost on an equality. It needs just one of the family to be ill for her to be drawn back into the traditional feminine duty of carrying the main responsibility of nursing those who regress to childish needs. Sometimes, it would seem that there is a biological urge in a woman to fulfil these needs, and in many a family, the urge in the children to become separate and independent is a threat to the mother's feeling of personal fulfilment as a woman. It is usually assumed that, for adults, the normal state is expressed in married life. There are, however, a significant proportion of people who do not marry, and, of those who marry, some are separated, some divorced, and some suffer bereavement in the loss of the partner. In addition to those who marry and have no sexual fulfilment there are those who enjoy their sexual life and do not marry. There is marriage without children and there are children born outside marriage. Even if membership of a family is looked upon as being a criterion of statistical normality and a desirable state, the minority not in that state constitutes such a large number of individuals that we should hesitate to label them as abnormal. Most of them do not seek help and do not need help. Of the single who never marry, in some cases it is by choice and in some cases there is a problem of availability of suitable partners at the time when a particular individual is mature enough for marriage. The different aspects of personality re- quiring outlets for fulfilment grow at different rates. The intellectual aspect may be finding rich fulfilment in occupa- tional and social life, even to the exclusion of preoccupation with sexual activity. Some people, in times of social and occupational mobility, suffer the penalty of being in the van of progress. Rapid personal progress takes them away from the company of their former peers who could make close relationships with members of their family of origin. The need for close personal relationship of the kind found in marriage may make its appearance at a stage when it becomes a momentous individual decision, rather than one taken in the company of a group of young people who have been developing together. There is, however, a bi-sexuality in mankind which promotes some degree of satisfaction in sharing in imagination the experiences recorded in literature and available in some degree in various companionships. The balance of satisfactions is never complete for anyone; people build the structure of their personality, as a complete whole, out of the bricks that are available. The qualities within us that lead to our caring for the young extend to the caring for, and involvement with, mankind in general. The conflicting drives within the individual, and within and between groups, can be the source of adventure and creativity. Good and bad exist in their expression, but the underlying energy is neither good nor bad. We cannot improve our nature by seeking to eradicate that which might become bad. We must recognize the inevitability and the univer- sality of the conflicts that exist in ourselves and our societies, knowing that we have, at the same time, the urge to find a harmony within ourselves, with our neighbours, and with as much of the universe as we can comprehend. ■ No one can value his own self unless he can grieve for the loss of someone else. (Photo WHO/P. Almasy) 15 HOME COOKING IS BEST by Professor G. Debry UNIVERSITY OF NANCY, FRANCE Man must eat to live, and he works in order to obtain his food. This simple but fundamental truth manifests itself in a variety of ways, depending on the histor- ical, geographic, economic, social, reli- gious and cultural setting in which each of us is born, grows and dies. Nutrition is thus influenced by many closely related factors, while our freedom of choice in food habits varies according to the circumstances in which we are born and live. Perfection in dietary habits is not essen- tial; provided a person does not suffer from malnutrition or overnutrition, which may cause ill health or even death, his body is able to tolerate a wide range of diets without apparent harm. Indeed, the human body possesses an amazing capac- ity for adaptation to the most diverse con- ditions. Consequently, no precise estimate can be made of the normal requirements, which vary according to circumstances. In attempting to establish standards, the "reference man" can, in theory, be used, but in actual practice standards always correspond to the average values for a certain number of subjects who are recog- nized as being healthy and who satisfy all the other necessary criteria. A diagnosis of good health is usually made by exclusion, a person being judged healthy if no illness has been discovered and if his development is considered nor- mal when compared with that of other individuals who are already recognized as being healthy. This leads to the concept of "levels of good health". As a result of this concept, we naturally tend to aspire to the highest possible level of health for each individual, as can be illustrated by the following simple obser- vation. An individual may be large or small, and yet be in good health. However, it is a common observation that the average height of a healthy population increases in parallel with economic development and better nutrition. If reference values for a given population are taken from healthy subjects at different times, the average height will thus be found to vary from one time to another. The question arises whether, within a particular population, all individuals have the same potential for health and development, considering that they all have different constitutions and different needs. This question is difficult to answer, be- cause an individual's potential depends on many factors. For example, poverty tends to increase resistance, while affluence leads to greater vulnerability. Nutritional needs are by no means the only consideration with regard to human well-being. Indeed, the act of eating 16 Too many parents force their children to eat (left page). Above: traditional family meal in Morocco. (Photos WHO/E. Schwab and P. Almasy) cannot be considered in isolation but, as noted above, is related to many other factors. The individual is motivated to eat by a number of conscious and sub- conscious factors, some of which are deeply rooted in traditional social and religious customs, which have ensured the survival of the species. The process of taking food is also associated with various sensations, such as satisfaction or dissatisfaction, and feelings of security or insecurity. The insight man has gradually acquired concerning himself and his fellow-beings should caution us not to over-simplify the problem of nutrition. Indeed, bad plan- ning has often resulted from naively com- paring the human body to a machine that merely needs to have its energy require- ments satisfied. It is essential to avoid suddenly disrupt- ing the associations that have gradually evolved over the centuries between man's eating habits and his mode of living; such considerations should always be taken into account in giving advice on better nutri- tion. The act of eating arouses within us a multitude of emotional and sensory over- tones, and brings back forgotten memories, facts that are fully appreciated by those responsible for advertising food products. In addition to wide differences in behav- ioural patterns, economics are important. The changes that industrialization and urbanization have brought about in ways of life are universal, affecting both the developing and developed countries. The seriousness of this upheaval, especially in the developing countries, is due much more to the rapidity with which such changes have occurred than to their nature. Man is not well adapted to sudden changes in his way of life, and may need several generations to alter his behaviour without running serious risks. Sudden upheavals in the social and economic structure of rural life, disturbances in rhythms of living and working, and the knowledge of, hence a desire for, hitherto unknown goods, including food products, are changes that may have serious reper- cussions on the mental health of individuals as well as on family budgets. The feeling of isolation within urban communities, and the physical and emotional disinte- gration of families, create unsatisfaction and insecurity as compared with the tradi- tional atmosphere of family meals. Since there are as many possible solu- tions as there are problems, it would appear presumptuous to try to suggest generally valid solutions. The fact remains, however, that most people take their meals at home, while an increasing number eat both at home and in restaurants or can- teens. 17 Vs: \‘\ • .1ZVai;", AA% \4k\ NA iii u` MA, '• NA', • v A, IN • v . Communal eating places do not always provide a balanced diet. Unfortunately, those in charge of such establishments are still insufficiently aware of their respon- sibilities, and several years may pass before the situation improves. Adults, no less than children, often deny themselves a balanced diet by their choice of foods, which is based largely on personal habit. Numerous studies have shown that food habits are not always appropriate to re- quirements. In a developing country, the population may refuse new food products to which they are unaccustomed; in eco- nomically developed countries there is a trend towards the choice of more expensive foods, mainly those containing fats and animal proteins. While, in developing countries, canteens in schools and factories and various supple- mentary feeding programmes may serve to make good nutritional deficiencies arising from traditional diets, it is only by paying attention to nutrition in the home that all members of the family can be assured of a balanced diet; and yet the public is still largely lacking in elementary notions about food hygiene. For this rea- son, although the difficulties and dangers of trying to deal with home nutrition on a world-wide basis have been emphasized, some general remarks may help in finding solutions to individual problems. Improvement of nutrition depends on knowing how to obtain foods, how to prepare them, and how to use them in order to satisfy our needs. Food can be obtained by gathering or growing it, by purchase or barter, or by any combination of these means. At the family level, in countries where purchase or barter is difficult, the growing of only one type of food results in a monotonous and unbalanced diet; how- ever, this is an extreme situation. In most cases it is possible, by means of a minimal amount of agricultural training, to ensure a more diversified type of farming, such as the growing of different vegetables, fish-breeding, and cattle-raising, in order to provide the family with a balanced and relatively varied diet. However, this simple solution, namely, the provision of educa- tion, is impeded by a number of factors, some of which are unrelated to education but are by nature psychological (reluc- tance to change habits, fear of something new), socio-religious (permanent or tern- Home cooking is best For these children in Vietnam, rice is the basic food. Advice on better nutrition needs to take local customs and traditional beliefs into account. (Photo WHO/P. Almasy) porary food prohibitions or taboos, foods that are an integral part of social conven- tions), economic (initial investment of capital, feeding of animals, conflict between a desire to sell and the desire to feed one- self), or even related to health (spread of diseases, necessary vaccinations). It is also impeded, in many countries, by the inse- curity caused by climatic conditions (abun- dance or scarcity of rain), or by the urgent need for money, which can quickly cancel out any progress made towards diversifi- cation. As regards town dwellers, the only means of obtaining food is to buy it, yet here also the public needs to be edu- cated. For the same cost, some people eat well, others badly. Knowing how to buy is an art; but it is made increasingly difficult by advertising, which subtly arouses our desires and appeals to our unconscious wishes. In countries at all levels of eco- nomic development, people tend to buy what is expensive: the rich from a desire to have the best, those of limited means out of a desire for social advancement or to imitate the rich. In developing countries, therefore, ex- pensive imported foods, which are bought 18 Recommended daily intake Age Carbo- hydrates g (3) Fats g (4) Proteins g 5) Calories Kcal Calcium mg ( 5 ) Phos- phorus mg Iron mg Vitamins A (i.g (6) D Egg ( 6 ) C mg B1 mg B2 mg PP mg Boys 12-14 ± 402 90 50-90 2700 700-1100 1000 10 575 10 70 1.2 1.7 20.4 14-18 ± 445 100 60-100 3000 600-1100 1000 10 750 10 70 1.4 2.0 23.8 Adult males ( 1 ) ± 435 118 65-90 3200 500-800 1000 10 750 10 70 1.3 1.8 21.1 Girls 12-14 ± 355 80 50-90 2400 700-1100 1000 18 575 10 70 1.0 1.4 17.2 14-18 E 350 80 55-90 2400 600-1100 1000 18 750 10 70 1.0 1.3 15.8 Adult females (') ± 340 76 55-75 2300 500-800 1000 18 750 10 70 0.9 1.3 15.2 Pregnant mothers ± 374 86 65-100 2600 ( 2 ) 700-1350 2000 18 750 10 70 1.2 1.7 20.4 Lactating mothers ± 410 103 75-115 3100 1000-1920 2000 18 1200 10 70 1.3 1.8 21.1 Old people ± 320 73 60-70 2200 500-1000 1000 10 750 10 70 0.8 1.2 13.9 ' Average activity. 2 During the second half of pregnancy. 3 ± depending on the amount of carbohydrate chosen. On the basis of 30 % of the calories being derived from fats. Extreme values from tables published by FAO/WHO, the Food and Nutrition Board (USA) and the National Institute for Health and Medical Research (France). 6 1./..g: microgram = 1 millionth of a gram. Source: Dr Debry. by the rich, are often preferred to the local product, though the latter may be more nutritious. Tinned milk products, for example, compete with weaning foods made from locally grown cereals and vegetables. In economically developed countries, different foods are bought at the beginning and the end of the month. The constant appeals of the consumer society lead to money being squandered on unnecessary foods to the detriment of health. Without entering into details of food contamination control, it may be useful to mention a number of ways in which harm can be avoided. The control of flies and other insects, the meticulous cleansing of foods such as fruit, the cleanliness of kitchen utensils, the protection against contamination of food waiting to be eaten, and the personal cleanliness of those pre- paring food are elementary rules of hy- giene, but they must be constantly empha- sized in order to prevent a lowering of standards during the daily routine. The fact that suitable foods are avail- able does not ensure adequate nutrition, since nutritive substances may be lost during the preparation of meals. The nutri- tive value of whole rice is superior to that of polished rice, because only 30 % of the weight is lost in milling and most of the husk, which contains vitamin B 1, is preserved. Likewise, cassava contains more protein and vitamins if it is peeled after steeping, rather than before. If it is peeled before steeping, the cassava flour, when baked, may contain even more thiamine (vitamin B1) than the raw root, since the vitamin is synthesized during fermen- tation. In order to prevent the loss of vitamins from vegetables, they should be soaked in water for a short time only, and cooked in their skins with the smallest possible amount of water for the least amount of time that is necessary. Food is often kept warm after being cooked, to enable the various members of the family to take their meals at different times. This is bad practice, because the loss of certain vita- mins may be doubled if the vegetables are kept at 70° rather than being cooled and then re-heated. The prejudice against canned foods is no longer valid in view of the improve- ments that have taken place in conserva- tion techniques. The level of vitamins in such foods is similar to that of bought vegetables, because they lose no more in the process of purification and heating than do fresh vegetables as a result of exposure to the air and sun in the market place, and during soaking and cooking at home. The same is true for other methods of conservation, such as dehydration or freezing of fruits and vegetables, provided that the necessary technical precautions are taken during storage and distribution. Satisfaction of nutritional needs depends on evaluating them and ensuring a balanced diet. The evaluation of needs amounts to knowing how to keep accounts. In fact, the body is an excellent accountant; if overnourished it becomes fat, if under- nourished it becomes thin, and if mal- nourished it becomes susceptible to disease. We ourselves are both pupil and master; the master indicates his needs, while the pupil suggests and recommends levels, quantities, and standards. As explained at the beginning of this article, standards are not laws but indications that need to be adapted to each case; the above table shows levels of recommended dietary intakes. In composing a diet, provision can easily be made for variations in calorie require- 19 Home cooking is best ments, which depend on the amount of work performed, by providing 12 to 15 % of the calories from proteins, 30 % from fats, and 55 to 58 % from carbo- hydrates. On the other hand, when the body needs fewer calories than the recom- mended amounts, in order to keep the weight normal, either the energy expendi- ture can be increased by physical exercise or the intake reduced. Most of such a reduction will be in fats and carbohydrates, so that proteins will then account for over 15 % of the calories. To ensure adequate development and for normal activity, man needs not only nutritive substances but also an adequate fluid intake. This is more evident in a hot climate, but is true also in temperate regions. Urbanization leads to a reduction in fluid intake, and the average diuresis of city dwellers is less than 0.7 litres per day. The normal requirement for an infant is 100 to 150 g of water per kilogram body weight per day, and for an adult at rest it is 30 to 40 g; an infant should thus drink between 0.7 and 1.5 litres per day, and an average adult 2.5 to 3 litres. In fact, since the water contained in foods and produced by their metabolism amounts to some 1.6 litres per day, the minimum daily fluid intake for an adult is about one litre. In a warm climate, or when working under hot conditions, the supplementary fluid loss may vary from 5 to 10 litres per day. It is difficult to compensate for this loss, because of the long time necessary to absorb corresponding amounts of fluid (10 to 20 minutes for 0.75 to 1 litre of water). This fact, which is often over- looked, must be taken into consideration in planning work schedules; it should also be understood that the time required to compensate for losses can be reduced by taking frequent drinks while working, provided that the intake does not exceed 0.25 litres at a time. The addition of salt in a hot climate is at present under much discussion. Recent studies have shown that the taking of extra salt is not only useless but often badly tolerated by subjects who are already acclimatized. It should thus be given only to people who have just arrived in a hot climate, and always given with a drink (non-alcoholic), in the pro- portion of 250 ml of water per gram of salt, the latter being provided as tablets or in packets. A more palatable way of giving extra sodium chloride is in the form of salted vegetable broth. The danger of alcoholic drinks cannot be overemphasized; in addition to its toxic effects, alcohol acts as a diuretic and thus increases dehydration. In any climate and whatever the type of work, therefore, alcohol consumption should not exceed the equivalent of 700 calories, or about one litre of wine, per day. The satisfaction of our requirements depends on achieving a balanced diet both in the short term and over a somewhat longer period. In fact, the body does not utilize all the various nutrients in the same way. Some are absorbed almost completely (e.g. carbohydrates, fats, and proteins) at rates depending on the composition of the meal. Others only cross the digestive barrier when they reach levels that vary according to the body's needs (e.g. calcium and iron). Carbohydrate, fat, and protein require- ments are of the order of dozens, or maybe hundreds, of grams per day, whereas only a few grams of minerals and a few milli- grams of vitamins are sufficient. The body is capable of storing, in differing amounts, carbohydrates, fats, calcium, iron, vita- mins A, D, and B12, etc. It can also convert fats and amino acids into glucose, and excess dietary carbohydrates into fats, which are stored. Some constituents of the food, together with waste products of metabolism, are eliminated in the urine, faeces, and sweat (e.g. urea, calcium, iron, and phosphorus), while other substances, such as iron, are conserved. If too much fat is eaten, or if the fat is of poor quality, the digestion is impaired, while an excess of carbohydrates, which are absorbed rapidly, puts too much strain on the pan- creas, with consequent ill effects on the digestion, well-being and work capacity. In warm climates an excess of proteins raises the body temperature, owing to the large amount of heat produced by protein metabolism. These facts of nutritional physiology explain why both short-term and relatively long-term aspects must be taken into consideration. A balanced diet is achieved by adjusting the number and composition of our daily meals. The custom of alternating between high and low levels of food intake for short periods, due to difficulty in finding food or to religious observances, is not harmful and does not reduce physical performance. However, the recovery time after exertion and the return to a normal weight take longer when the food intake has been inadequate. The practice of reducing the number of meals to one a day modifies the way in which the body utilizes various nutrients, and may lead to obesity if the total amount of food available is not restricted. On the other hand, increasing the number of meals to between 3 and 6 per day, provided the daily calorie require- ment is not exceeded, predisposes to muscular development, protects against obesity, diabetes, hyperlipaemia, and atherosclerosis, increases work capacity, and reduces fatigue and accidents at work as a result of the more frequent meal breaks and the prevention of hypo- glycaemia. In this case, the greater part of the daily calorie requirement is not provided by the midday or evening meal, but can be divided more logically through- out the course of the day according to energy expenditure. For example, an individual working from 8 am to 12 noon and from 2 pm to 6 pm could divide his calorie intake as follows : breakfast 20 %, snack 5 %, lunch 35 %, snack 5 %, dinner 35 %. The rhythm of meals is often upset by hours of work, especially by rotating eight-hour shifts, while the alternate shift system produces both physiological dis- turbances, including effects on biological rhythms such as sleep, hormone secre- tions, and metabolic activities, and changes in the composition of meals, social condi- tions, and family life. A balanced diet can be ensured, in the short term, by dividing up the carbo- hydrate, fat, and protein intake into several meals each day. In the long term the achievement of a balanced diet is more complicated, as it is necessary to ensure the correct proportions of certain dietary 20 In Somalia, maize, the staple food, is ground at home. (Photo WHO/E. Schwab) constituents, for example animal and vege- table proteins, saturated and unsaturated fatty acids, calcium, phosphorus, calories, vitamins, carbohydrates, and vitamin B 1 . Obviously, it is impossible to calculate most of these proportions from the com- position of the daily food intake. Rather, a balanced diet can only be ensured by controlling the entire weekly food intake; for this, a few simple rules are necessary in making up menus. The more varied a diet, the greater the likelihood that it will be balanced. It is often easiest to plan the week's menu and to modify it as necessary from day to day, according to prices and what foods are available. These weekly menus should be adapted to working conditions. Details of all meals provided in factories and schools should therefore be made known a week in advance, so that the family can buy its food supplies in accordance with the meals provided outside the home. Knowing how to evaluate needs, to ensure a balanced diet, and to make up menus are merely the material conditions that enable us to satisfy our nutritional requirements. We have already laid empha- sis, at the beginning of this article, on the close relationship between food require- ments and those of an emotional and social nature. That is to say, even an excellent and well balanced diet can really satisfy our needs only if the emotional and social atmosphere of the meal is preserved. It is clear that the conditions of modern indus- trial life, and the accompanying social changes, form an increasing obstacle to the preservation of the family atmosphere. It is impossible to foresee the conse- quences of this new situation, since it is difficult to determine whether human nature will succeed, equally quickly and without harmful effects, in dispelling the emotional overtones associated with food. Whatever uncertainties may exist about the subject, it is nevertheless true that, at the present time, correct attention to feeding in the home is the best means of ensuring adequate nutrition. ■ 21 INDIA, BLENDING OLD AND NEW by Dr D. Anand PROFESSOR OF PREVENTIVE AND SOCIAL MEDICINE, JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION AND RESEARCH, PONDICHERRY, INDIA t.4 if A *ra SAT 4:1 m-IrAt iturg vIgratreq*-- ,kta 1.4 ft-mmtrytRi, In the cultural tradition of India, the family occupies a pivotal place. Conscious always of its lineal heritage, the family sets the norms of conduct for the individual and gives him a sense of belonging. It concerns itself with him before birth, during his lifetime and even in the here- after. It is at home, under the influence of parents and other elders, that the child grows to maturity, gaining physically and mentally. The concept that health begins at home is well in accord with the Indian view of life. It has been fully taken into account by the planners of India's health strategy. As the rural health services reach out to remote rural areas, seeking to intro- duce modern health care in tradition-bound communities, the conventional role of the family is being reinforced by the new con- cept of family health and of public parti- cipation in health activities. Tradition sets a high score on the selec- tion of a healthy spouse and recognizes the biological facts of conception, preg- nancy and birth as social events to draw attention to the nutritional and other health needs of the expectant and nursing mother and the infant. Some communities still observe the age-old samskaras or religious rites, 16 in all, to mark such events as conception, birth, the baby's first intake of solid food, cutting of hair, learning to read and write, leaving home for higher studies, marriage and death. The avowed role of the samskaras is to promote the physical, mental and spiritual health of the individual. A number of ceremonies performed during the ante-natal period glorify motherhood and are intended to make the expectant mother feel happy and important. The process starts with the selection of the bride, or daughter-in-law of the family Marriage within the clan or between blood relations is not permitted but for few a exceptions in certain cultural groups. In many rural communities in north India, the bride or groom may not be selected in the same village. Marrying into the clan of the mother or into that of the father's mother is also forbidden. 4- Marriage in India is a family affair with deep cultural roots. The ceremony brings together not only two individuals but two families. Expectant mothers arrive at a primary health centre for advice on health care, nutrition and family planning. (Photos WHOIE. Schwab) The age at marriage continues to be low in India, especially in rural areas, but con- summation of marriage may be delayed from a few months to a couple of years on account of the traditional practice of gauna which requires the newly-wed girl to spend some time in her father's house before her husband arrives again to take her home. An increase in the age at con- summation of marriage is known to reduce frequency of pregnancy and the fertility rate. This observation in certain parts of India has encouraged the movement demanding raising of the legal age of marriage, from 18 to 21 years for men and from 15 to 18 years for women. In a country where more than 50 per cent of the babies are born at home, the traditional practices of natal care assume much importance. While the need to teach modern methods of hygiene to the village midwife cannot be overemphasized, it is interesting to observe that the traditional home delivery practices, with their empha- sis on cleanliness and segregation of the area of confinement, help to reduce the chances of illness of the mother and child. The room where the delivery is to take place is swept, cleaned and aired in advance and the person or persons expected to attend on the mother at the time of delivery must wash and bathe regularly. No others, including members of the family, may touch or go too close to the mother and child for the first few days. This segregation may have its origin in the desire to protect the delicate infant from unknown supernatural forces or the "evil eye", but its value in reducing the chances of infection by restricting the number of visitors is considerable. The mother is also given a special diet and post-natal care until she is fit to resume her normal house- hold functions. The diet of the expectant and nursing mothers is a matter for particular atten- tion even in the poorest homes. Some studies have in fact suggested that the extra attention and diet given during pregnancy may play a part in inducing some women to have frequent pregnancies. A wide range of taboos and practices are observed all over the country on the nature of food, the beneficial or baneful effects of various articles in the diet, and the time and manner of feeding the infant. Some foods are credited with properties that cleanse the gastro-intestinal system; others are believed to build general resis- tance against disease or to prevent such ail- ments as common cold, sun-stroke and diarrhoea. Some foods are described as "hot" and some as "cold", and believed to affect the system accordingly. Certain foods are forbidden in pregnancy because they are believed to increase the weight of the foetus, a large foetus being associated with complications at the time of delivery. Recent studies in child-rearing practices in India indicate the need for a study of these age-old practices and beliefs to identify those that have a positive bearing on health care. For instance, the attention given to the ceremony of annaprasan (giving the first solid food to the infant) acquires much significance in the light of Carl Taylor's statement about "growing evidence to show that the greatest cause of death may be the weaning syndrome". Late weaning can result in undernutrition of the child but is practised widely because it is stated to help in prevention of preg- nancy. In considering the question of high fertility, too, it is necessary to understand the cultural bias and traditional beliefs of the Indian family. The pastoral back- ground of the Aryans who came and settled in India, and their need for agricultural labour and generally for numbers in a foreign land, provide the clue to the many cultural practices and attitudes which survive to this day, such as fertility rites, pre-natal religious ceremonies, prestigious position of the woman bearing many sons, and the importance attached to the male child. For the small family norm to be established, it is being felt necessary to bring about a change in certain social values. A number of studies have shown that the pregnancy rate can be lowered if there is a change in certain traditional attitudes and values held high by husbands and elders in the family. Of course, the chances of survival of the children born will also have a bearing on whether family planning advice is accepted. The importance of the family as a basic unit of society is fully recognized by the state-operated health services of India, which reach more than 560,000 villages through 5,183 rural health centres and 32,157 sub-centres. The goal of the field staff, comprising doctors, public health nurses, lady health visitors, extension health educators and health auxiliaries, is to take some of the basic health services to every doorstep, and interest the family in measures for promotion of health and prevention of disease. Besides providing the needed services at home, the visit of the health worker becomes an educational experience which is of value not only to the members of the family but also to the staff of the health centre. A public health nurse knocking at the door is received by the housewife and other members of the family in their own environment where problems can be discussed with an ease and informality hard to achieve in insti- tutional surroundings. The public health nurse, too, can make her advice more realistic and meaningful by relating it to the living conditions and culture patterns of the family. The image of the health centre is chang- ing gradually from that of a hospital, where one goes only when sick, to a place meant mainly for the care of the healthy, specially the vulnerable groups. While the increasing attendance at the ante-natal and well-baby clinic is a sign that families are beginning to acquire the new outlook, the process is much too slow. The speed with which this change will occur is dependent not only on medicaments and equipment made available to a health centre but also on the professional health workers run- ning it. The major responsibility for bringing about this change rests on the auxiliary nurse midwife who spearheads the rural health service. She keeps in touch with the village people by frequent visits to the homes of pregnant and nursing mothers. She examines them, gives them advice on diet, health care and family planning. Besides providing the care that can be given on the spot, she encourages the mothers to come to the health centre for pre- and post-natal care. She gives post- natal care to mothers who have been delivered either by her or by the village dai (traditional midwife) and to the newly- born. She continues her supervision of the infants until they reach their first birthday, and gives them the primary vaccination against smallpox and two doses of the triple antigen against diphtheria, whoop- ing-cough and tetanus. There is at present one auxiliary nurse midwife for 10,000 population which may include 2,000 women of child-bearing age. The coverage is not sufficiently dense to bring about a radical change in the family's acceptance of health care provided through the health centre. However, better training of the auxiliary and adequate supervision can help bring about the desired change. Reducing the number of infant deaths is among the priority tasks of the Indian health services. At present, 20 per cent of all deaths occur among infants and 10 per cent of babies born die before completing their first year. One of the important reasons for this loss is the high risk to infants of mothers who have had repeated pregnancies. Out of every 100 babies dying in their first year, 33 are born to mothers who have had more than five pregnancies. This is a field in which a great deal of initiative rests with the family itself. By accepting family planning, parents at the reproductive age can help reduce the risk to the health of the mother and of the child. The widespread undernutrition and malnutrition among growing children is another important health problem of India, and has a strong bearing on the role of the family in promoting health. In the last decade there has been a dramatic increase in food production but no com- mensurate sharp decline in the prevalence of malnutrition. It is estimated that ap- proximately 50 per cent of the country's 100 million children (1-6 years) still suffer from some degree of protein calorie mal- nutrition. Studies have shown that the remedy is not merely a question of pro- viding more food but also of nutrition education that would enable the parents to select the right kind of food for the family table. Mass campaigns against diseases like tuberculosis, malaria and smallpox have helped the people to appreciate the benefits of the services given at their doors. Pre- ventive health measures are accepted more readily when the people understand their true value, and are enabled to observe the efficacy of the measures offered. It is within reach of almost all families in India today to demand protection against the major diseases or to obtain guidance on improved nutrition. These facilities will be in increasing demand as the network of health services, with its health education component, expands in the countryside, forging a strong bond between the home and the health service. ■ 24 4- A public health nurse demonstrates how locally available foods can best be used as a nutritious diet for infants. (Photo D. Anand/ WHO) The home visit establishes a close link between the people and the health services. (Photo WHO/E. Schwab) 4, India, blending old and new 1 BELOVED PETS by Dr D. Cohen DIVISION OF COMMUNICABLE DISEASES, WHO -1- 1111111111Pmmillirmq1111111111111k "The deviation of man from the state in which he was placed by nature seems to have proven to him a prolific source of diseases. From the love of splendour, from the indulgences of luxury, and from his fondness for amusement, he has familiar- ized himself with a great number of animals which may not, originally, have been intended for his associates. The wolf, disarmed of ferocity, is now pillowed in the lady's lap. The cat, the little tiger of our island, whose natural home is the forest, is equally domesticated and caressed." (Edward Jenner, London, 1796). Man, the compassionate creature, has always had a dichotomic attitude towards the animals with which he shares his planet. As a source of food and of physical danger he has been locked in mortal conflict with other animal species since his first days on earth. On the other hand, man, the human animal, has often looked to other beasts as a source of companion- ship and an outlet for the expression of kindness and love. This latter attitude contributed to the early domestication of wildlife and their introduction into the household as pets. However, the close presence of these other species in his home has always posed for man certain health risks. Some of these risks he has accepted knowingly, some he has been unaware of. We will try to review these risks, but it should be understood at the outset that the benefits of the association have been judged worthy of the risks and in most cases the risks can be minimized by ade- quate veterinary medical care and public health measures and the responsible behaviour of informed pet owners. What is the magnitude of the problem? In the developing, chiefly agricultural areas of the world, the close association between man and his animals is well established. In some parts of the world the farm animals share the same living quarters with farm families. This is especially true in some of the colder climates where the animals are brought into the house in winter as a source of heat as well as for protection. However, even in the developed world of urbanized societies, man has still maintained a close association with domesticated animals. In Britain it is estimated that there are well over twenty million household pets, with over five million pet dogs and four million pet cats. In the United States there is an estimated pet dog population of over 34 million animals and a similar number of cats. Britain reports over five million cage birds and the United States over 22 million cage birds, over three million turtles, hundreds of thousands of pet monkeys and thousands of pet skunks and other exotic pets (including fish). The total estimated household pets for the United States today is over 700 million. These figures are typical for the affluent developed societies of Europe and the Americas, but in the less developed areas of the world there are large numbers of pet animals as well. What are some of the health problems posed for man by these pets? One of the most prevalent and important is the problem of wounds produced by animal bites. In the United States, over 600,000 persons were reported in 1957 to have been bitten by dogs. In 1965, two and a half million persons in the U.S. were estimated to have been bitten by either dogs, cats or other animals with 200,000 requiring medical attention and 10,000 requiring treatment. The wounds so caused may produce severe physical and psy- chological trauma resulting in disfigure- ment and occasionally death. In a five- year study of hospital emergencies in the United States, 1.84 % were due to animal bites, 90.1 % of which were from dogs. Seventy-six per cent of animal bites occur on the arms and legs but 16 % occur in the face, head and neck and may result in a serious injury or disfigurement. Apart from the trauma they produce, animal bites can also prove a hazard to health because of the danger of wound infection. Although there is always the possibility of tetanus and the more com- mon wound-infecting agents, animal bites are also important as a source of three 26 , = r.:4=gkz = rather specific zoonotic diseases (diseases naturally transmitted between animals and man)—pasteurellosis, cat-scratch fever and rabies. The most serious illness to be trans- mitted by animal bite is rabies. This disease, once clinical signs appear, is considered to be inevitably fatal in man, although there are one or two reports of humans who have apparently survived the illness. The symptoms associated with this disease in man are particularly terrible—the manic, painful hydrophobia (fear of water due to the pain of swal- lowing) with the patient fully aware of what is going on although unable to control his actions because of his diseased brain. Although rabies can be produced under very unusual circumstances by exposure to heavily contaminated aerosols such as exist in certain very specific bat caves, the usual source of infection is by infected saliva transmitted through a bite wound. For all practical purposes we have no treatment for rabies once signs appear. We must therefore resort to preventing the onset of disease by cleaning the wound and using vaccine to prevent the infection from taking place. We still rely on one of the peculiar characteristics of the disease, a long incubation period, to allow us the time needed to abort the clinical illness. This incubation period may on occasion be short and all preven- tive measures may fail. The seriousness with which the possibility of exposure to this disease must be considered is reflected in the large number of Pasteur treatments taken each year in countries where the actual incidence of the disease in man is extremely low. In the United States, for example, about 30-40,000 persons receive Pasteur treatment each year although there are only one or two rabies cases per year for a population of over 200 million. A number of other diseases occur which are acquired by man by direct contact with his pets. Chief amongst these is leptospirosis, a bacterial disease usually spread by the urine of infected animals. Apparently healthy-looking animals may serve as carriers and shedders of the leptospira. The organism may enter man through the mucous membranes of the mouth, nose, eyes or through breaks in his skin which has become softened through contact with water. It chiefly affects his liver and kidneys but may also produce signs of meningitis. The disease is fairly widespread in dogs and is fre- quently under-reported in man where it may be confused with a number of other diseases. While the main culprit in leptospirosis is the dog, the cat is the one most fre- quently involved in ringworm of animal origin. In the United States, animal ringworm may account for as many as 70 % of the rural cases and 10 % of the urban cases. Of the urban cases, the most frequent animal reservoir is the cat. In a given urban area, cats may cause up to two-thirds of all the human cases reported. This disease is frequently un- diagnosed in the cat, where easily visible lesions may be absent. Psittacosis or parrot fever is a disease which first appeared on the world medical scene with an epidemic in 1929 that produced 750 cases of which 143 were fatal. This is a disease of pet cage birds, primarily of the psittacine family (parrots and parakeets), the prevalence of which has waxed and waned with the popularity of the birds and the degree of international trade. The disease produces an atypical pneumonia in man which fortunately responds to antibiotics. The disease has been controlled by the widespread use of antibiotic feeds on the part of commercial Beloved pets Close contact with animals favours disease transmission. Right, a country cottage in Crete. (Photos WHO/E. Mandelmann and P. Almasy) breeders and dealers of cage birds, and a variety of quarantine procedures imposed on imported birds. The disease produces a diarrhoea in the affected birds and is transmitted to man by an aerosol created by the birds flapping their wings and causing the spread of the virus-contaminated faeces as a fine dust. Salmonellosis of pet animal origin is a disease of man which only periodically receives the attention it deserves. Most recently, attention has been focused upon pet turtles which become infected in their breeding ponds from contaminated feedstuffs and freely infect each other under the crowded holding conditions practised by dealers. They periodically cause outbreaks of salmonellosis in the children who handle these pets and then place their unwashed hands in their mouths or on their food. Salmonellosis has also been reported to originate from a wide variety of other pet animals, pro- ducing diarrhoea and occasionally death in man. Studies have shown that pet dogs, cats, chicks and ducks (particularly at Easter time), parakeets, monkeys and a variety of other exotic pets have pro- duced gastro-intestinal infections in children. In a survey of normal households in Florida, up to 15 % of normal dogs were shown to excrete Salmonella in their stools. A similar study of household cats yielded 12 % excretors. In Japan, a study of 220 dogs showed an infection rate of 9.5 % by faecal cultures. Pet foods are frequently contaminated with Salmonella through the food of animal origin contained therein. Salmonellosis and shigellosis are com- monly found in pet monkeys and have been a source of gastrointestinal infections in man. In 1931 an outbreak of 17 cases of Shigella dysentery was reported from Germany with three deaths in children. They obtained their infection from African guenons imported as pets. Other enteric bacteria may also occasionally play a role in human infection. In a more indirect route of exposure certain parasitic infections are found in which pet animals, primarily dogs, play an important reservoir role. They include the so-called larvae migrans syndrome, in which the larval forms of various round- worms migrate either through the skin, causing skin lesions, or through the route of the digestive organs, causing serious diseases of the liver and eyes or any organ into which the worm may enter. The cutaneous form is generally caused by the larvae of dog hookworms which are a problem found wherever people walk barefoot or where their skin comes in contact with soil contaminated with dog faeces. This includes beaches as well as the areas around the house, under porches and in the garden. The visceral form of larvae migrans is produced when the worm eggs are ingested, chiefly by children who eat dirt or who play in contaminated playground and garden areas. The indiscriminate defeca- tion of dogs in urban areas, particularly in parks and playgrounds where children congregate, is becoming more and more unacceptable as a result of the pet animal population explosion. No provision exists for the disposal of the tremendous volumes of pet animal wastes which affect our urban and suburban centres. These are a potential source of human infection, that can have tragic consequences. For example, the ocular form of visceral larvae migrans, which can be treated, was for some time mistaken for a type of highly malignant tumour and the eyes of many children were removed in the mistaken belief that this was necessary to preserve their lives. An extremely serious parasitic disease in many parts of the world is "hydatid disease" in which the dog is the chief animal source for man. This disease is caused by a tapeworm which is primarily found as a bladder-like cyst in sheep and is transmitted to the dog by allowing him to feed on infected sheep offal. The cysts develop into mature tapeworms in dogs which in turn pass infective eggs in their stools which become attached to the haircoat of the dog. The dog is then handled by people who transfer the eggs to their mouths and swallow them. The eggs develop into cysts in man which grow over the years into giant bladders, sometimes the size of a large grapefruit or small melon. This process may take many years before its effects are noticed. The infection takes place during childhood and clinical signs do not appear until adult- hood, some twenty years later. The liver is the organ primarily affected by the cysts in both man and animals. The prevalence of the disease can be quite a problem as the experience of Uruguay shows. There, in a country of less than three million people, there have been as many as sixty deaths a year due to this disease and 600 surgical operations an- nually are performed. There are a number of infectious agents that pet animals (primarily dogs) may carry which are borne by insects and may be transmitted to man. Among these, perhaps the most outstanding is leishmaniasis, a protozoan infection, which appears both in a visceral form (kala-azar) affecting the internal organs, primarily the liver and spleen, and in a cutaneous form (oriental sore), an ulcer- ative lesion. The parasite is brought to man by the bite of sandflies. The dog (and more rarely the cat) is thought to be the reservoir animal of this disease in Asia, parts of the USSR, the eastern Mediter- ranean and Brazil, although a variety of small wild mammals are known also to carry the agent. In the dog and cat the disease is usually of the cutaneous type and appears as an ulcerating sore on the heads of the animals, but visceral forms producing severe emaciation and weakness have also been reported. Control of this disease in many parts of the world depends, in the first instance, on the breaking of the pet animal/sandfly/man cycle. Another example of a vector-borne disease in which the pet animal may play an important role are the so-called "spotted fevers" and "boutonneuse fever". These are rickettsial diseases, producing a characteristic fever and rash, which are brought to man by the bite usually of ticks and in which, in some cases, the dog may play a reservoir role. This is particularly true in the Mediterranean area and in Kenya, where dogs are the main reservoir of boutonneuse fever. In South America, the dog is an important reservoir of the Colombian and Brazilian spotted fevers. In North America the dog may be a factor in the transmission to man of Rocky Mountain spotted fever by bringing infected dog ticks into the home. There are a number of diseases that are less frequently found in pet animals but which may occasionally cause human disease. Pet birds with Newcastle disease virus may cause conjunctivitis and respiratory disease in man. Feline pneumonitis, a disease of cats caused by an agent similar to the one causing psittacosis in birds, has produced an acute follicular conjunctivitis in man. A similar agent in dogs has been shown to produce canine diarrhoea and pneumonia, and may be a potential hazard for man. There are a number of cases reported of human infection with Diro- filaria, a blood parasite (a filarid worm) which produces pulmonary infarcts and occasionally cardiovascular involvement. More frequently human dirofilariasis results in subcutaneous lesions, migratory nodules of the upper part of the body. This has been reported—mostly from the south-eastern United States, southern Europe and the eastern Mediterranean. The disease is transmitted by an infected mosquito, with the dog as the reservoir of infection. Cats have been recently implicated as a hazard in terms of toxoplasmosis. This disease, which may produce only a mild 'flu-like disease in adults, can infect unborn children causing severe skull defor- mities, as well as blindness and brain damage. About 500 babies are born each year in the United States with clinical toxoplasmosis. This disease of man and also of cats and dogs is primarily con- tracted through ingestion of raw meat. However, it has recently been shown that the protozoan agent can not only affect the cat but can multiply in the feline digestive tract and be expelled in viable form in the cat's faeces into the environ- ment to infect man. The list of diseases man can acquire from his pets is quite extensive, but we have presented only some of the more interesting and important examples. The fact is that the full extent of the number of diseases that can be transmitted from pets to man has not yet been established. Nor has the definition of the word "pet" as an "animal tamed and kept as favourite or treated with fondness" been of much help. How do you warn an owner that his "pet" python may give him a case of abdominal pain due to infestation with Armillifer armillatus, tongue worms, which are passed to man via the contaminated saliva or excreta of his snake? Furthermore, at the moment we do not have very good quantitative data on the extent of most of the diseases described on a global scale and we do not know the full degree of risk to man from many of these diseases in various parts of the world. One thing is certain, given the large numbers of animals, their intimate contact with man and the growing array of exotic species utilized as pets, the opportunity exists for an increasing risk in the home. A recent paper on Hong-Kong influenza indicated that dogs can become infected with this agent both experimentally and in nature. Can they also give it back to man? We do not know. A study performed on common enterovirus infections in animals and man in rural families in Central America indicated that there was a common infection in both man and his dog of polio and coxsackie viruses. The medical literature is already replete with cases of streptococcal infections and mumps infections which man gave to his pet dogs. Can they give them back to him? Do they? It may be too much to ask of man to regulate his pets, but a purely laissez-faire attitude towards this subject on the part of the guilty owner inflicts risks on the innocent. The failure to bar dogs from the children's sand-pit or the public beach exposes others to the risk of larvae migrans. The refusal to co-operate in the control of wandering dogs is paid for each year in a tremendous number of dog bites, medical bills, Pasteur treatments and the fear that goes with the possible exposure to rabies. The refusal to vaccinate dogs for rabies and leptospirosis and the failure to de-worm these animals on the part of irresponsible owners increases the risks for other members of the community. Adequate veterinary medical care, both preventive and therapeutic, collaboration between veterinary medical and human health agencies, the establishment of veterinary public health programmes at all effective levels of government and the education of the public are in the end the only measures that can ensure safety as far as pets in the home are concerned. Is the pet a threat? The answer is "no" if common sense, responsible behaviour and professional judgement are used to minimize the risks involved in the trans- mission of diseases between man and his pet animals. ■ 30 Child and pet—a strong bond. (Photo WHO/D. Whitney) —> Beloved pets A farm in France and five at table. In a number of countries, especially the United States, the horse is becoming a popular pet. (Photo WHO/P. Almasy) YOU AND YOUR DOCTOR by G. M. Bovay In some highly industrialized societies, private medicine and the doctor patient relationship are tending to become impersonal. This article discusses some of the difficulties that may arise between the general practitioner and his patient. "One night in winter, during a snow- storm, I was rung up by a 70-year-old patient who lived alone with her Alsatian in an isolated spot in the north of the town. She was complaining about rheu- matism in her right arm. I knew the woman. I knew that she had trouble with her blood circulation on account of her age. I also knew that she was tough and that if she was phoning me at that hour of the night it was not for nothing. I therefore went to see her. In fact, she was suffering from arterial occlusion. I immediately had her taken to the hospital. She underwent an operation and we were able to save her arm. If I had waited, gangrene would have set in . . . I remember another patient who opened the door to me and had a fracture of the thigh bone, at 80 years of age. But against those two cases, how many times I have been called out for supposedly dreadfully urgent cases, like for example a cold or influenza . . . Obviously, when there is danger of a heart attack, I would rather make one visit too many than not enough . . . Too many people still have a childish attitude towards the doctor. They regard him as an all-powerful father." The speaker is a general practitioner, a member of a profession the community seems to need more and more, for with the steady decline of infectious diseases, we are witnessing the development of the so-called diseases of civilization, or of the consumer society, i.e. chronic, degener- ative, metabolic and functional diseases, which require more thorough investiga- tion. They build up over the years, and have many hidden causes. The doctor of today therefore needs more time for his patients, for it is not enough to make a diagnosis; it is essential to go back to the origin of the symptoms and to determine their cause in order to remove not only the symptoms but also the disease itself. To uncover modern diseases the doctor must no longer consider his patient as an "isolated" case. To distinguish which of his patient's ailments arise from the body and which from the mind, the doctor must con- sider the full problem within the context of his family and community, and his economic and social environment. A patient comes to see his doctor with precise symptoms—a pain that is not at all imaginary, for example continuous intes- tinal cramps. The doctor finds nothing abnormal after examination. A recom- mendation to see a specialist would also probably turn up nothing. "There is nothing wrong with you; it's just psychological" never satisfied anyone. The patient's first reaction would no doubt be to look for another doctor, and the frustrating cycle would start all over again. If the doctor is content to relieve the pain and even to suppress it, he will not go to the root cause and it will prob- ably not be long before the pain returns. If he continues his investigation on the psychological level, which requires time and patience, he may end up by discovering that the intestinal cramps relate to the difficulty the patient experiences in har- monizing his relationships with his fellow- men, his wife, his children or his employer. This is one example of many. Once the psychological problem has been solved there is every chance that the cramps will go away without drugs or surgery. To achieve this, the doctor must know the living conditions of his patient, how much he earns, what his family responsibilities are, etc., all factors that help him to assess the structure of the patient's personality. The therapeutic intervention becomes an act of mutual confidence between the doctor and the patient. If you wish your doctor to lose as little time as possible in getting to know you, do not hide what he is trying to guess. His job is not easy, for each patient "makes" his illness and "sees" it in a different way. Illness is a score played by the patient and interpreted in his own way. The doctor must therefore be aware of much in the patient's environ- ment: the social and economic conditions in which he lives, how he adapts to them, his style of life, his habits, his relations with those around him, his tensions, his fatigue arising from routine or thankless work, his conditions of transport, sur- rounding noise, etc., for all these factors influence his state of health and condition his emotional state. Illness is for each per- son an opportunity to live his existential anxiety, this burden which has belonged to every man, from primitive societies up to our own times. The doctor can cure your anxiety only by making you aware of its origin, or by artificial means such as tranquilizers. Learn therefore first to dominate your anxiety, and not to burden him with it. What can a patient expect from his doctor and, first, what should he not expect? 32 Treatment is based on mutual confidence. (Photo WHO/J. Mohr) • You and your doctor 11111111•11■M. 1111111M■111111111111 The doctor needs more time for his patients. He must take into consideration the family background as well as the social, and eco- nomic setting. (Photo WHO/J. Mohr) "Send me some more of that green stuff, doctor, it's the one I like best." He should not automatically expect a prescription, that magic little piece of paper without which the patient is reluc- tant to leave the doctor's surgery. Physical pain and the symptom often conceal the origin of the illness, and to remove them does not solve the problem; on the con- trary. The patient who insists that the doctor give him a prescription is doing himself a disservice. Sick people more and more are refusing to take the time to look after themselves and believe it is enough to take a pill. They expect too much of modern medicaments and are abusing them. This is particularly marked with regard to psychotropic drugs, those medi- caments that can change mood and out- look. It is easier to swallow two or three pills a day (a stimulant in the morning, a tranquillizer during the day, and a sleep- ing tablet at night) than to make the effort of facing the real problem and doing something about it. Too often, the prescrip- tion is a lazy pillow to fall back on. Many people who demand medicaments are inclined to forget that the first remedy is the doctor himself. Modern man is trapped in such a vice of social demands, admin- istrative irritations, economic obligations, that it is hardly surprising his nerves crack and his health deteriorates. In the least serious of cases, he will not be able to overcome his (false) fatigue. In the most serious, he may develop functional symp- toms or even attempt suicide. In most cases, the medicament prescribed is not enough. Perhaps he will have to consider a new way of life, a change in his attitudes and habits. This can be decided only by means of a frank discussion between the doctor and the patient. And let us not forget that this type of patient represents up to 75 per cent of a general practitioner's practice. A patient must never expect a miracle, or leave the solution of all his problems to the doctor. The doctor is not the only depository of miracles. The miracle, or more simply the cure, can come only from an effective association, from a harmonious relationship between the patient and his doctor, the doctor not stopping at the diagnosis but going beyond it to seek out the underlying cause of the trouble This is possible only if there is a good under- standing with the patient. For his part, the patient must not expect too much of his doctor, but must contribute himself to his own cure. He will often be able to, once he has a better understanding of disease prevention and appreciates the old adage: "Know thyself". The complaints that trouble us more and more these days are for the most part those that take root in the human body and develop over the years (cancer, heart and blood vessel conditions, arteriosclero- sis, hypertension, rheumatism, diabetes, mental diseases, etc.). They are often the long-term results of continuous mistakes in our way of living (bad eating habits, too much tobacco and alcohol, physical inactivity, nervous tension, etc.) that may have a more or less conscious emotional element. The patient therefore should pay 34 as much attention to the smooth function- ing of his body as to the steady hum of his car engine. Medicaments that are supposed to be given only on medical prescription should in fact never be taken without a doctor's advice. Take nothing in excess, not even aspirin. Self-medication is an extremely dangerous habit. It is a sign of anxiety and a surrender to the publicity of drug com- panies (where such publicity is allowed: in many countries it is banned). Also, do not take in excess any of the drugs pre- scribed by your doctor. Do not exceed the prescribed dose, but do not take less and take it for the period advised. If not, your body may develop a resistance to the drug through getting accustomed to too small or insufficient doses. If you take tablets to reduce fever or try to relieve pain by swallowing drugs before the doctor arrives, you run the risk of mis- leading him by distorting the symptoms. Nor should you try to present him with a diagnosis cut-and-dried. Among the rules for establishing a good relationship between patient and doctor, the following may be mentioned : Do not constantly change doctors. A doctor needs to know his patients. If you jump from one to another, none of them will accumulate enough information to be able to give you effective treatment with full knowledge of the facts. When there are too many doctors involved, the patient is tossed from one to another, and none of them feels any real responsibility for him. The best doctor is the one who has known you and looked after you since childhood. Do not follow your friends' advice when they recommend their doctor. They will only do it if this doctor has cured them of their ills . . . which are not the same as yours ! The contrary advice may be mean- ingless also, for when treatment produces no results the responsibility is probably not only the doctor's but also the patient's. Equally, do not accept the advice of your friends, relatives or acquaintances on drugs which they have taken themselves and that "worked miracles". In medicine, each case may be different and what works for one person does not necessarily work for another. Parents should not refer to the doctor as a bogy, but should reassure their children and tell them that the doctor is their friend. Finally, the interest and sympathy shown by the doctor for your case does not authorize you to monopolize him with your personal problems and to eat away the precious time he owes to other people, perhaps more seriously ill than you. Any childish or egocentric attitude should be avoided. Between you and your doctor there should be built up a true under- standing based on mutual confidence. The patient should aid the doctor to get to the root of the trouble and should then follow his advice. The relief of pain, the improvement of health and in fact all treatments are a joint undertaking in which the doctor and his patient are equal partners. ■ 35 FAMILY PLANNING FOR BETTER HEALTH by William Porter The family is the basic unit of society. There is wide variation in countries throughout the world in the structure and functions of families, but the care and early training of dependent children re- mains primarily a family responsibility in most societies. The health of family members is sig- nificantly affected both directly and in- directly by the environment—whether nat- ural or man-made, physical, chemical, biological or social. If the family's environ- ment is grossly unhygienic, for example, children are exposed to a host of infectious agents. The material and physical environ- ment is largely determined by economic re- sources, in the broadest sense, and is itself an underlying determinant of many cultur- al, social and behavioural patterns. Family health, then, is mainly conditioned by the environment, and many family health problems can be solved only by the application of measures affecting the environment as a whole. Some family health problems, however, arise directly from the processes of human reproduction, growth and development, and affect mothers and children in particular. Family planning is thus a component of comprehensive health care for the family. Health care that focuses on the family unit combines activities that were formerly offered separately, provides continuity in the attention given to individual members during their lifespan, considers individuals as members of a family unit that needs to be seen as a whole, and necessarily unites preventive and curative services. Effective family planning can favour- ably influence the health, development and well-being of family members, as well as the family unit. It may also improve the quality of life through its impact on family health. For example, when children are born at optimum times, and are wanted, it is more likely that they will be well cared for and that their environment will be condu- cive to normal growth and development, while family members can more easily share an emotionally satisfying relation- ship that will promote family health. The health impact of family planning occurs primarily through the following effects on human reproduction: the avoidance of unwanted preg- nancies and births, and the occurrence of wanted births that might otherwise not have taken place; a change in the total number of children born to a mother; variation in the intervals between pregnancies; and changes in the time at which births occur, particularly the first and last, in relation to the age of the parents, especially the mother. Social, economic and cultural factors impinge on all aspects of human reproduc- tion. For example, high parity (a large number of births) is commonly associated with low socio-economic status, poor nutrition, poor hygiene, overcrowding, and poor education. These factors are all associated with each other and in turn tend to be linked with premature or difficult labour, low birth weight, trauma and infection, which makes it difficult to establish clear causal relations. Neverthe- less, there is little doubt that certain combinations of factors greatly increase the risk of certain results, and it is on the basis of this evidence that the health benefits of family planning are founded. The benefits are of course most striking in relation to the health of mothers and children. Family planning and the limitation of family size can lower maternal, perinatal, infant and child mortality and morbidity, especially if practised by women at high risk. For example, the risk of maternal and infant death increases below the age of 18 and above the age of 30-35 years. The avoidance of pregnancy in early adolescence and by older women, and the planning of pregnancies during the opti- mum period between the ages of 18 and 30 years could help improve maternal and child health. The effect of maternal age on morbidity and mortality is usually linked to the number of births (parity). When it is possible to dissociate the two factors, it is found that parity has a greater effect than maternal age, and that the risk of maternal and infant death rises with each pregnancy beyond the third and increases significantly after the fifth. Family planning to space pregnancies can also affect maternal and child health favourably. For example, mortality rates for unborn and newly-born babies are lowest when the interval from the termina- tion of one pregnancy to the beginning of the next is between two and three years. Diarrhoeal disease, the principal cause of death during the first two years of a child's life in developing countries, is clearly associated with poor weaning practices : early weaning and ensuing malnutrition often follow a short preg- nancy interval. Finally, pregnancy spacing can help improve maternal health in areas 36 In Costa Rica, a health visitor tells a mother about the advantages of family planning. (Photo WHO /P. Almasy)-÷ Y where a woman's fertility span is charac- terized by a continuous cycle of pregnancy and lactation, resulting in a serious drain on her nutritional reserves. Limitation of the number of pregnancies is also an important health measure for women with specific diseases such as cancer, cardiovascular and renal diseases, Rh-incompatibility, severe anaemia, dia- betes mellitus, and hypertensive diseases of pregnancy. Repeated pregnancy may also aggravate psychiatric and neurolog- ical conditions and exacerbate the damage resulting from certain obstetrical injuries. There are clearly many advantages— medical, as well as administrative and technical—in integrating family planning activities into the maternal and child health component of general health services. Permanent community health services that include maternal and child care are needed for the acceptance of family planning. As long as parents have no reasonable assurance that the children they already have will survive in good health, they may be reluctant to practise family planning. Since child mortality and morbidity are increased by a fast tempo of family-building, family planning coun- selling should be included in the advice given to parents on child care. Family planning is related to every phase of the maternity cycle, biologically as well as in service and educational aspects. If it is integrated into maternity care and related to the phases of the maternity cycle when women's needs are greatest, its potential availability and effectiveness are enhanced. The close contact that health workers have with families provides many oppor- tunities for family planning work. All the priority needs of mother, father, child and family can be considered at each contact with the health services. A health service worker who resides in the community will be helpful in overcoming initial lack of knowledge or interest in family planning, and will try to enlist local participation in health and related aspects of community development programmes. All types of health service personnel are needed to deliver maternal care, child care and family planning. Some forms of contraception require trained health 38 workers for the selection and introduc- tion of methods, for follow up, and for management of complications. Physicians, nurses, midwives and health educators and their auxiliaries can provide a broad range of related health services to the family and community. A rational use of existing resources and personnel for the delivery of all types of health care will help promote efficiency by preventing duplica- tion and avoiding fragmentation of pro- grammes. If resources for family planning are pooled with those for health services, the results may be the ultimate strength- ening of both and the provision of more care at lower cost to the community as a whole. Difficulties may arise if financial re- sources are made available on a restricted basis for a family-planning programme only, for the likelihood of the programme's success is considerably reduced if general health services are not properly developed. Many mass campaigns, including those for family planning, have met with initial success, but often the success is not maintained and in some instances has even been followed by negative counter- reactions. The relative success of mass campaigns against specific diseases is not in itself a justification for mass family planning campaigns. An attack against an infectious disease is not undertaken unless there is probability of rapid impact; it may mean changing some components of man's environment, or may require only a single injection per person. Family planning is a long-term process that requires couples to take repeated action of a personal nature. It is therefore not amenable to the mass-campaign approach. The objectives of family planning pro- grammes will be achieved only gradually over a long period of time. In summary, family planning is seen as both a preventive and promotive measure, since it can favourably influence the health, development and well-being of the family and has a strong impact on the health of mothers and children. Family planning care is an integral part of the health care of the family, and many aspects of that care require the personnel, skills, techniques and facilities of health services. It is therefore of immediate concern to medicine and public health. ■ Family planning for better health E-- In a hospital in India, a doctor ex- plains about IUDs. (Photo WHO/ E. Schwab) -3. Costa Rica—family planning begins before the first baby. (Photo WHO/ P. Almasy) At a clinic in Kingston, Jamaica, a group of women are instructed in the various methods of contraception. (Photo WHO/E. Rice) 4, TOO MANY ACCIDENTS AT HOME by F. J. Tomiche Accidents are one of the three leading causes of death in many countries, with accidents in the home accounting for a large proportion of accidental deaths. The figures, established by a WHO survey, still give only a partial picture of the actual situation, for data on fatal accidents give no information on the incidence of less serious accidents which require medical care or lead to temporary or permanent disability. The United States of America publish detailed accident statistics at regular intervals. The most recent figures show that, in 1968 alone, 20,000,000 people in the United States were injured in domestic accidents, five times more than the number injured on the roads. Of these 20,000,000 injured, 28,500 died within the year and 110,000 suffered permanent disabilities. The American statistics also give the most common causes of accident, as follows: falls (40 %), burns (24 %), poi- soning (6 %), firearms (5 %), gassing (4 %), asphyxia (8 %), others (electrocution, fall- ing objects, etc.) (13 %). The accident pattern will obviously vary from one country to another depending mainly on the standard of housing and the facilities available in the home. In developing countries, falls are often due to inadequate lighting or to poorly fenced balconies or terraces. In developed countries, slippery stairs, highly polished floors and unsteady ladders are generally to blame for falls. Overturned paraffin lamps are a frequent cause of burns in some developing countries; in cold coun- tries, defective stoves; and in countries rich and poor, old or badly maintained electrical installations. In a large number of countries it has been found that domestic accidents strike women more often than men and that some age groups are at greater risk than others. As the graph (page 43) shows, in eight of the ten European countries mentioned, more women than men were injured in the home. Furthermore, children under 4 years of age and people aged over 65 have more accidents than all other age groups taken together. Surprising as it may seem these days, rat bites are a fairly usual cause of injury. According to reliable estimates, 14,000 people in the United States and 20,000 people in Bombay, India, are bitten by rats each year. Technological progress and the use of paints, varnishes and medicinal drugs and many other chemical products in the home has brought in its wake an increase in cases of poisoning in the majority of industrial countries. In England and Wales in 1970 as many as 515 people died from poisoning following ingestion of various solids or liquids. In the United States, there were 2,400 fatal accidents in 1967 from this cause. The National Clearinghouse, the central agency through which all information on cases of poiso- ning in the United States is channelled, has compiled data showing that for every fatal case of poisoning there are 100 non-fatal cases. Nearly 90 % of cases of poisoning occur in children under five years of age, most frequently those in the age group 18-24 months. The product ingested varies with the age of the child. One-year-olds generally swallow pol- ishes, pesticides, petroleum products and dyes. With two-year-olds, ingestion of medicines (aspirin in 50 % of cases) is the main cause of poisoning. Toys and other articles for children are also a major cause of accidents. Two American experts on the subject, Dr Raymond Neutra and Mr Ross McFarland, have drawn attention to "minor epidemics of accidents" that could be avoided by fairly simple mea- sures. In 1963, for example, the United States Health Service noticed that about 100,000 people a year were cut and lacerated in injuries caused by glass doors and French windows. Some injuries were very serious as the broken glass severed nerves and arteries. An enquiry showed that 75 % of these accidents occurred when people hurrying out of a building came into violent contact with a door they thought was open. Forecasts indicated that sales of glass doors were growing so fast that the United States would have a million and a half of them by 1970. Swift action was thus needed to contain the epidemic. With the help of the glass industry, a new, more resistant product was developed that does not produce jagged edges when broken. Since then 40 Falling is the most frequent cause of home accidents. Young children and old people are at greatest risk. (Photos Novosti, M. JacotIWHO) --> El 11.►sur10 ....1•011110.•■ ••■••••■■ T Children are attracted by electric wiring. Protective covers on power outlets can help prevent accidents. (Photo WHO/E. Mandel- mann) /1 Children should be encouraged to handle various tools. A little explanation on how to use tools properly can go a long way in promoting creativity, safety, and dexterity. (Photo WHO/E. Mandelmann) 4- Candles and paraffin lamps cause a large number of burns. (Photo WHO/C. Huber) Number of deaths due to home accidents per 100,000 population by sex and selected external cause in 9 European countries Scotland 1966 Hungary 1965 England and Wales, 1966 Norway 1966 Ireland 1965-1966 Northern Ireland, 1966 Sweden 1966 Finland 1966 Bulgaria 1966 1 I I I I I 0 2 4 6 8 10 12 14 16 18 20 22 24 Source: WHO Regional Office for Europe, Copenhagen. 1 1 I 1 I I L I 1 1 1 11 II I Falls Poisonings Fire accidents Others 1 I I I 1 1 1 I 1 1 I I 1 1 1 1 1 M F M F M F M F M F M F M F M F M F there has been a sharp decline in accidents of this nature in the United States. In Ceylon, the bottle lamp has been the cause of countless cases of burns and often even of fires. It is used as a source of light and consists of a bottle of paraffin into which a cotton wick is dipped. The slightest tap is likely to break the bottle and send the paraffin lip in flames. A campaign to promote a safer cheap lamp was successful in cutting down this type of accident. These two examples show that some- thing can be done to prevent accidents. What are the means available for this purpose? Firstly, the public authorities can take legal measures. More stringent safety standards can be made enforceable by law, as has been done in industry. Build- ing materials and equipment for domes- 43 Too many accidents at home Falls, the leading cause of home accidents, are often brought about by unstable ladders. Badly lit rooms and staircases and slippery floors also exact their toll of life and limb. (Photo WHO/P. Almasy) Children and adults are often scalded by neglecting to take precautions when raising the lid of a boiling pot. (Photo WHO/ E. Mandelmann) Air-guns and fire-arms also cause a large number of accidents in many countries. (Photo WHO/D. Henrioud) 4, "1.S. • -1.4*"61.' ;.-.4.dosso"140 tic use ought to meet minimum safety criteria at all times. Next, the public itself has to understand the seriousness of the problem, and here the dissemination of information is of the greatest importance. All mass media should be brought into play to promote greater public awareness of the question. Through ignorance, parents often leave potentially dangerous articles such as knitting-needles, sharp objects and medi- cines lying about within reach of small children. Many accidents could be avoi- ded by the exercise of a little self-discipline. This does not mean, of course, that children, who must learn to come to terms with the world around them, should be forbidden everything, but they do need to be taught how to handle sharp objects and flammable materials. The better informed parents are, the better instructors they make. For older people, on the other hand, a ramp at the proper height, a hand grip in the bathroom, or better lighting will often prevent a serious accident. In this context, sanitary inspectors and health visitors can be of invaluable help by taking note of dangerous situations and seeing that they are remedied. For this purpose, a system of regular and syste- matic inspection is needed. Following the example of industry, research teams representing several disci- plines have been set up to design, on ergonomic principles, a safer and more functional habitat for all categories of occu- pants, including the groups most at risk. In addition to these measures, a WHO symposium has pointed out the need to obtain more detailed epidemiological data through additional surveys and statistics. The members of the symposium also recommended that national bodies for the prevention of accidents in the home be set up along the lines of those concerned with the prevention of road accidents. It is clear that the social and economic significance of an accident is similar whether it occurs on the road, in the kitchen or in the factory. The prevention of domestic accidents should therefore be included in a general programme for the prevention of accidents. ■ 45 BOOKS Maternal Deprivation Reassessed, by Michael Rutter, publ. Penguin Books, Harmondsworth, 1972. In his report to the World Health Organ- ization in 1951 on maternal care and mental illness, John Bowlby 1 reviewed the evidence that led him and others to conclude that the quality of parental care which a child receives in his earliest years is of vital importance for his future mental health. Bowlby maintained that a warm, intimate and continuous relationship be- tween mother (or permanent mother sub- stitute) and child underlies the develop- ment of character and mental health, and without it the child suffers "maternal deprivation". Bowlby was at pains to point out that this general term covered situations ranging from almost complete deprivation (when, for instance, the child is removed from home to a residential institution or hospital) to more subtle forms involving maternal rejection or unsatisfactory mother-child relationships. More specifically, Bowlby's work drew attention to deficiencies in the psycholo- gical development of children deprived of a normal home life, and led to improve- ments in the care provided in institutions. Writing 20 years later, Rutter acknowl- edges that the concept of maternal deprivation has gained widespread cur- rency, but he finds it of questionable scientific value since it may lead to un- justified assumptions that similar psycho- logical mechanisms underlie a variety of conditions loosely attributed to maternal deprivation, such as mental retardation, delinquency, depression, dwarfism, acute emotional distress and affectionless psy- chopathy. In his survey of recent research on humans and animals, Rutter sets out to analyse the key components of maternal deprivation, and their short- and long- term effects. He concludes that a crucial element of maternal care is the establish- ment of a bond of attachment between mother and child. Disruption of this bond rather than separation per se is responsible for the acute distress experienced as a short-term effect of separation, for exam- 1 Bowlby, J. Maternal Care & Mental Health, Monograph Series No 2, World Health Organiz- ation, Geneva, 1951. ple in hospital or nursery, but the effects may be modified by the age and tempera- ment of the child, by the previous mother- child relationship, or by the presence of some familiar figure other than mother. On the other hand, the lack of opportunity for developing affectional bonds through personal interaction may be responsible for the serious long-term effect of depri- vation called affectionless psychopathy. Yet other psychological mechanisms are involved in the intellectual retardation following deprivation. This is due most likely to the lack of perceptual, linguistic and social stimuli that are part of normal home life. The association between a "broken home" and subsequent social maladjust- ment has long been recognized, but research suggests that disturbed family relationships rather than parent-child se- paration are the more likely cause of antisocial behaviour attributed to maternal deprivation. Though his approach is that of a research worker rather than a clinician, Rutter's critical analysis of the evidence now available nevertheless supports the earlier, and then controversial views, of Bowlby. He concludes that the time has come to question not whether, but how and why children are affected by ad- verse early life experience. What in fact are the special qualities of "mothering" that are important to ensure normal psychological development? Is there some- thing special about the mother-child bond of attachment that distinguishes it from other bonds? Why are there individual differences in children's responses to "deprivation"? The pursuit of these and similar research issues could provide the basis for constructive development of Bowlby's pioneering work. Rutter's book is not only a useful progress report on attempts to explore some of the influences on children's psychological development which were first identified more than 20 years ago, but also charts the path for future studies. Dr A. R. May Malaria, l'e'popee du paludisme, by G. M. Bovay, publ. Denoel, Paris 1972 (in French). Malaria is the endemic disease most widely distributed throughout the world, a serious scourge in developing countries, and a popular account of the subject is given in this book. In the first part of the work the ravages of the disease are de- scribed and the tale told of the exploits that led to the discovery of the parasite, to the demonstration that the disease is transmitted by mosquitos and to the syn- thesis of DDT, which opened the way to the possible eradication of malaria. In the second part, following an account of the world malaria situation in the middle of the 20th century, the author summarizes the principles of the world malaria eradi- cation campaign and outlines the methods used to carry it out, discussing, among other things, the resistance of the mosquito to insecticides and of the parasite to drugs. Finally, the last chapter reviews the suc- cesses that have so far been recorded and lists the tasks that still remain to be tackled. The book is thus, in a narrow sense, just a factual chronological account of man's fight to control malaria, but it has been redeemed from pedestrianism by the author's craftsmanship and artistry. He has managed to bring out the epic quali- ties of the struggle with this disease. In Mr Bovay's hands, dry facts and figures are woven into a vivid account of one aspect of the heroic saga of mankind, with all its underlying anxieties and suffering. Two chapters placed on either side of the factual account give the book its human dimension : the opening chapter describes the tragedy of one poor family, one out of thousands of others, while the final chapter concludes on a note of hope. There is an extremely interesting account of a malariologist at his everyday tasks, a revealing and unhackneyed portrait of an expert at work in the field. In addition, extracts are given from the memoirs of Major Ronald Ross, the Indian Army physician who discovered the mechanism of malaria transmission. These diary pages are of great interest. Written in a vivid and lively manner, G. M. Bovay's book has the pace of a novel and, despite the abundance of factual information, reads very easily. Some sweeping generalizations and the occa- sional small error do not detract from its very many good qualities. This is popular- ization of a high order. Although it is primarily intended for the general public, it will also be a source of much useful information to those who, in various spheres such as health administration, economics or sociology, are concerned with the advancement of the developing countries. Dr. P. Bertagna 46 WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to World Health as follows: use* C .• Sw. fr. One Year 4 1.60 16 Two Years 7 2.80 28 Three Years 10 4 40 One year: Two years: I I Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country . • or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland The Future General Practitioner—Learning and Teaching, by a Working Party of the R,yal"'College of General Practi- tioners. Published for the Royal College of General Practitioners by The British Medical Journal, London, 1972. "Therinost pressing task before the writers of this book has been to make a detailed statement about the knowledge, skills and attitudes essential for general practice." This new look at an old-new subject begins with a business-like description of the job of a general practitioner. It con- tinues by presenting, with exceptional orderliness and sensitive clarity, the educa- tional process by which doctors may be prepared for their varied career. For those concerned with teaching health workers of any kind, this stimulating section will be particularly welcome. Vocational educa- tion involves defining objectives, creating a syllabus, providing learning experiences and passing judgment on the results. The authors have discussed the process stage by stage as it relates to general practice with a breadth of insight gained from long experience. What is particularly interesting in their approach is the impor- tance given to preparing general practi- tioners for the personal, social and educa- tional role so important to patients and so neglected in the burgeoning technology to which modern medical students are subjected. The subjects dealt with include the consultation, clinical practice in health and disease, human development, human behaviour, medicine and society, and the organization of medical practice. This last section goes some way towards countering the argument that general practitioners do not have the time to do a good job. It is only when the teacher has real experience of his subject and the ability to communicate that he is able to convey to the learner the distinction between the wood and the trees, and discuss simply and directly the aspects that matter. The working party of the Royal College of General Practitioners has followed its own educational precepts in preparing a rare book which sets high but realistic standards and should be of the greatest value not only to students but also to practising doctors who want to do a better job. Dr J. Burton Health protection for the family is all-important (see page 4).