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Archive for November, 2012

As an evolutionarily minded medical student, you can sometimes feel a bit alone in the crowd of conventionally minded medical practitioners and students.  I’ll admit that I’ve been repeatedly impressed with the interest that many of my fellow med students (as well as residents and even some attendings) show the ancestral/evolutionary ideas that I sometimes talk about, but most generally find an evolutionary approach to health and wellness interesting, rather than integral, in the consideration of health, wellness, and disease. 

 

I am not, however, alone.  There are a number of MDs and DOs who are interested in bridging the gap between ancestral health and western medicine.  There is a budding new organization of Physicians and Ancestral Health (with a winter meeting in February that I hope to attend), and there are other medical students who share a passion for thinking about modern medicine in the context of ancestral health. One such medical student is Angela Arbach, a student at Cornell Medical School currently doing research during a year long sabbatical between her third and fourth years of medical school, who I had the pleasure of meeting at the Ancestral Health Symposium in Boston in August.  There we had a long chat about our shared interest in evolutionary and ancestral medicine, as well as our specific areas of focus (she is passionate about women’s health and infectious disease).  I didn’t know it at the time, but Angela would soon be winging her way to Africa, where she would be involved in an international nutrition research project. When we recently caught up over e-mail I asked if she’d be interested in sharing her experience on my blog.  Her travels and observations are something that so few get to experience but so many could benefit from pondering. 

 

With out further ado: an ancestrally minded med student abroad.

Fresh from the Ancestral Health Symposium (AHS), after several days home in NYC and then a national boards exam in Philly, I was on a 4-hour bus trip to upstate New York to finalize plans for a research project in international nutrition.  A month later, I was on a plane to Northern Uganda: a nation in the global south, devastatingly resource poor, with an uncomfortably recent history of conflict.  [Check out the doc Uganda Rising, on youtube, for more history and a quick but imperative summary of colonialism in Africa].  It’s also a beautiful place.  From polychromatic garb to the giant layered sky underscored by the surrounding savannah, there is no shortage of images to appreciate.  The Acholi people, the dominant ethnic group of Northern Uganda, are still close to their traditional roots despite colonization and the recent influx of modern technologies.  When the English arrived, they left their development plans out of the north, making it easier to forcibly enlist Acholi men in the security forces.  And then, after independence (50 years, last month!), the north remained isolated and underdeveloped due to the LRA insurgency.  The Nile River, separating Acholiland from the rest of the country, only aids in this political and cultural divide.  For these reasons, an AHS-primed brain finds many cultural practices as fodder for rumination, along with prompts for contemplating our role in a global context.  Below, I will describe some of my earliest observations in this complicated milieu.

First, of course, the food.  It starts with starchy staples, mostly sweet potatoes, millet, rice, maize, sorghum, cassava, squash, and plantains.  These starches are used to scoop up, usually by hand, some combination of beans, peas, sesame seed paste, and, if you’re not incredibly food insecure, goat, fish, chicken, beef, or offal. The modicum of nonstarchy vegetables is nearly always cooked: the beans and meat stews are boiled with small pieces of tomato, green pepper, and onion, and a common side dish is boiled leafy greens.  I recently read an account of a Ugandan grandmother’s reaction to Western salads, laughing and asking how people can be healthy eating these raw foods since humans are not goats or cows.  The author explained how cooking all vegetables is a protective tradition, as soil and water is often contaminated by waste, but I wonder if there is more to it.  Fruit is eaten raw, however, and the most common fruits I see are bananas, oranges, jackfruit, mangos, avocado, passion fruit, and watermelons.  In terms of ferments, I’ve only heard of bongo (fermented milk) and the various alcoholic homebrews, usually from banana, maize, sorghum, or millet.

Example meals:  a plate of sweet potato and posho (stiff maize porridge) with a bowl of beans in a sesame paste sauce; kwan kal (stiff millet porridge) with boiled greens, tahini mixed in the green water; rice with a bowl of smoked goat meat stew.

fresh fish, sesame pasted greens, stiff millet porridge, sweet potatoes

One of my favorite meals, also an Acholi staple, is sesame paste mixed with mashed, cooked pigeon peas (dek ngoo) drizzled with dark shea nut oil (moo yaa).  Eat this by dipping in pieces of sweet potato or kwan kal.  These are typical lunches and dinners.

dek gnoo and moo yaa, with stiff maize porridge rice on the right

Breakfast is varied.  Some skip it, especially if they live in poverty and work all day (sure, call it a “feeding window, or just malnutrition).  Milk tea and milk instant coffee are very popular, with a milk-to-water ratio of 1:1 loaded up with table sugar.  The milk here is delicious– largely local and grassfed, it tastes so rich and sweet (a Ugandan colleague’s wife, who lived in the US for a year, told me “American milk doesn’t taste like milk”).  Millet porridge is served in some schools for breakfast.  A popular drink for children is milk, fermented or fresh, mixed with some kind of grain (I’ve heard millet or corn).  More common outside of the north, but still present here, is katogo:  stewed plantain or banana with offal or groundnuts.  Groundnuts are very similar to peanuts, and people buy them roasted for breakfast or snacking.  Groundnut stew (similar to a mild peanut sauce) is common elsewhere, but sesame paste stews are more common here.  Overall, the food variety is less than other places I’ve traveled, and the dishes are quite plain with little spice or herb additions– low food reward, perhaps.

That all sounds wonderful, but I left out a big part of the common diet:  wheat, vegetable oils, and soft drinks.  All new additions to the food tradition, sometimes supplanting old foods.  Indian influence means chapati and samosas are common street foods, cooked in vegetable oils, of course.  Loaves of bread are becoming a staple, as well, and some people eat it with a schmear of sesame seed butter for breakfast.  I was happy to discover how common eggs are, but if I eat out, they are always fried brown in veg oil.  So it goes.  Within the ubiquity of food insufficiency in a context of very limited healthcare, I fear the implications of substituting already meager dietary items with these industrial foods.

Modern staples: vegetable oils, toilet paper, and soda

Walking around, I see people in positions that could be in Gokhale’s book.  The women work hard– constantly bent over to cook, wash dishes, do laundry, and clean floors (brooms are 2-3 feet long and made from reeds, mops are rags that you move with your arms).  They stay bent at the waist with perfectly straight backs, motivating me to keep stretching the hammies…

Women at work

 Some of these chores are done squatting, too.  Otherwise, the women can be seen transporting heavy objects on their heads, from 5 gallon jugs of water to sacks of grain.  This is all done with a baby wrapped to their backs.

I could be wrong, but perhaps these practices are the reason I see less postural kyphosis in the elderly ladies.  Also, I should mention that gyms are nearly nonexistent, and the only time I see running is when people get caught in the rain, are playing football (soccer), or are white people doing aid work or research (that’s me! But my research involves too much time at a desk).  Strenuous jobs are the norm, and most people don’t have cars.  Walking and bicycling are the rule.  Most of the footwear I see are thin sandals (minimalist), and it’s common to see barefooted people walking around, especially outside the towns (poverty).

About 100 years old, but I’m told these are still made in some villages

The lack of street lamps, along with daily power outages, and the fact that the vast majority of homes don’t have access to electricity, means that people generally experience natural darkness as the sun sets.  I’ve been heading to bed much earlier, especially since I cannot sleep past 5 or 6 am due to the roosters.  If I go to bed early enough, I often wake up in the middle of the night for an hour or so before a “second sleep”.  One of my colleagues (a Ugandan) does this, too, but I cannot generalize beyond us.  He and his family sometimes take a little siesta after lunch, too, which I can certainly get behind.  I can also check off items from the recent MDA post on hormesis.  I already mentioned the exercise and calorie restriction, and sunlight exposure is a given in a country on the equator.  Also, without modern conveniences such as electricity and hot water heaters, all showers are cold showers!

Another topic I want to touch on is Acholiland’s continued tribal culture.  Traditional dance and music is at the heart of this.  I frequently hear drums in the distance as I walk, and I’ve seen groups of students in universities meet up for dances in the grass.  For more on the healing power of traditional music and dance, track down the 2007 film War Dance, an incredibly beautiful but heartbreaking story about school children in Northern Uganda.  I have yet to read my book on the history of the Acholi tribes, so the majority of my info is from conversations with Ugandan friends, one of whom is the designated leader of his clan.  The presence of tribal culture is strong, the sense of belonging is crucial, and excommunication from your clan is considered a punishment worse than death.  Clan leaders are still called upon to resolve disputes or offer advice.  [See the Al Jazeera documentary, Bitter Root, for how these traditional practices lead to reconciliation, rather than retribution, for former abducted-children-turned-rebel-soldiers, taking the justice system from the hands of the government to the realm of tradition].  Distant relatives are sometimes described using nuclear family nouns– the son of your grandpa’s cousin’s kid is your brother– and everyone feels a sense of responsibility and goodwill towards other members of their clan.  This sounds like ubuntu, the topic of Frank Forencich’s talk (Africa reference?) at AHS, which I missed because I had to run back to New York that day.  I should mention that everyone here was thrilled when Obama won, and they often cite that sense of brotherhood they get from him, along with his more skillful way of taking care of the poor.

That’s my account so far, but remember that some of this information came from people who may want to tell the foreigner something interesting, rather than common, and then that data is filtered through my biased brain.  And of course, I can’t talk about these things without sprinkling in some political, economic, and social issues facing the Acholi.  An ancestral health picture is nice, but it’s not complete.  Acholi tradition has been undermined by forced migration into internally displaced peoples camps for over a decade, ending merely a few years ago, preventing the practice of many cultural rituals.  They were without land, independence, and other means to continue traditional livelihoods.  On a few occasions, I’ve been able to informally talk with Acholi elders.  They never fail to remind me how the IDP camps destroyed their peoples’ culture and morals, as well as fostering drug abuse, rape, and disease.  And yes, the foodways and hormesis sound great, but people are starving here.  Naturally active livelihoods are awesome, but not when they are the result of extreme gender inequality where women have no choice.  It’s sweet and heartwarming that man-on-man handholding is so common– brotherhood, right?  But it’s scary that the same affection towards your wife is risqué, or that you could be killed or imprisoned if you engage in love outside the bounds of heteronormativity.  Blame it on the proximate lack of education, former colonialism, or widespread Christianity, but it’s happening.  And let’s not start on the infectious diseases, government corruption, illiteracy rates, motor vehicle accidents, and lack of good healthcare.

So what can we learn from these people, a group so geographically close to the Hadza, Batwa, and Karamojong, close to some of the earliest human remains in the archaeological record?  The answer seems largely irrelevant.  We have a lot of the answers we need about diet and lifestyle.  Perhaps this is a case where we should ask:  what can we give of ourselves?  The ancestral health community has gained a lot from the study of indigenous groups, so what can we do in return?  How will we enable empowerment and protect culture?  American health trends have a global effect, so how can we be the example of doing this in a positive way?  Why was the apropos panel on Reclaiming Latino Health so under-attended, compared to the lamentable, stale debate on… potatoes?  Were we fighting with the Pima to protect their water?  Has anyone heard of the Decolonizing Diet Project?  And for the egocentric: more preservation of cultural heritage means more research opportunities to figure out the perfect post-workout meal…  I mentioned missing Forencichs’ talk, but when I read how greatly he inspired people, I looked him up and found this relevant post.  Adele Hite, a speaker at the symposium, gave a list of ways to become more involved than just frequently-commenting-on-blogs.  Her examples largely involve the USA, but I don’t see why our scope cannot transcend self-created national borders.  This already happens in research and blogging, so why not in action?  Involvement in other cultures demands care and scrutiny (you want to avoid dead aid), but I think this community is smart and thoughtful enough to create a significantly net-positive effect.  We’re crafty people, and we’ve already accomplished so much.  Some organizations are doing exciting, ancestral-health-minded things, like this medical clinic in Burundi.  They started a native foods garden, along with the administration of agriculture education programs, to combat widespread food insecurity that took place after the civil war and genocide– a nice solution to what many food aid programs stick a bandaid on by creating relationships of dependency using their culturally inappropriate bags of wheat and jugs of vegetable oil.

I’m merely a student, so I cannot provide all the answers, but I hope the bulk of my career will work on these issues.  I think this community is also up for the challenge, as evidenced by the last symposium.  The blogging about micro/macronutrients is dying down, and our focus is getting bigger:  public policy, remarkable research projects, interventions, activism, creation of med student electives, and the introduction of evolutionary health into workplaces and grand rounds.  I’m not saying that global issues and cultural preservation need to supplant the other amazing endeavors born from the synergy in the ancestral community, but I look forward to more attention to these topics.  They are not tangential, but fundamental, to progress for us all.

Angela is a medical student at Cornell in NYC. If you’d like to read more of her observations (with less focus on ancestral health) you can check out her travel blog, I highly recommend it!  

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Sandy has come and gone (at least in my part of the country- last I heard she was still making her presence felt somewhere in the middle of the country), but for me (and many fellow New Jerseyans) power has gone and not yet come back.  I weathered the storm in my apartment near school, and stayed there for the following day. When word came that my school would be closed for the entire week (the associated hospitals have remained open throughout), I decided to pack up my freezer and head back to my parents’ place (also without power) where there was storm damage that needed to be handled.

All things considered, my family and I were very fortunate with this storm. We are not on the coast and as such were spared the coastal flooding that has damaged so much of our Jersey Shore. We faired much worse with Irene last year, where flooding led to serious damage at our house and at our farm.  While Irene brought us water, Sandy brought us wind.  The majority of the damage after this storm (at least in our area) is due to downed trees or direct wind.

Of course, with downed trees come downed power wires.  As I write this, we approach 100 hours without power*.  At my apartment, while I lacked power, I had water (and while it lasted, the bit of hot water that remained in the tank). My parents’ old farmhouse is on a well, and as such lacks running water when the power goes out.  Luckily there is a stream that can be accessed for water to flush the toilets and we stockpile water in tanks for occasions such as this. We have lots of firewood stashed (and a good old wood-burning stove), so while the temperatures continue to drop we are able to keep ourselves warm the old fashioned way.  The biggest concern with extended power cuts (for us at least) is the risk of our 2 big freezers defrosting. With hundreds of pounds of beef, lamb, pork, and fish (not to mention veggies and berries), an extended outage gets a bit concerning.  Fortunately we have very generous neighbors who have a generator, and after a couple days without power they bring their generator over so we can plug in and recharge our freezers for a bit (as I write this, we’re on round 2 of recharging- so far so good).

At times such as this there are a number of things for which I’m very grateful .

1-    Health. If you aren’t physically well and physically able this manner of glorified camping could turn into hell.

2-    A gas stove. Seriously. The power may go out, but at least I can still cook. What do people with electric stoves do?

3-    Firewood. And after this storm we’ll be set with firewood for many more years to come

4-    Friends with generators (who not only recharge out freezers, but also offer warm showers… saints!)

5- Merino clothing. Cozy and  stink free… need I say more?

With a limited water supply and a desire to keep dirty dishes to a minimum, I keep my cooking simple. Dinners have been big one-pot numbers (I cooked up a good beef shin bone 2 nights ago and I have lamb shanks on the go at the moment), and breakfasts have been soft-boiled eggs.

“Eggs and soldiers” (soft-boiled eggs served with slivers of toast for dipping) was a regular breakfast when I was a child.  While I haven’t had toast in years, soft-boiled eggs remain a regular part of my diet.  They’re quick, they’re easy, they require no preparation or clean up, and despite this I’m not sure I’ve ever met another American that eats them (my parents are English).  Soft-boiled eggs seem to be quite popular in Europe.  Not only are they part of English culinary history (Go to work on an egg), but I’ve seen them at a number of breakfast buffets while traveling in Germany.

I have no intention of writing a food blog. There are much more capable chefs (with much fancier cameras) who cook and write about delicious and nutritious healthful food (here’s a good example), but I’ll take this opportunity to introduce this tasty treat to my readers (and if I’m completely wrong and Americans are eating soft-boiled eggs like mad, please let me know!).

If you can boil water, you can boil an egg. The difficulty with making soft-boil eggs is getting the timing right.  I’ve sometimes heard soft-boiled eggs referred to as “4-minute” eggs, as 4 minutes is about as long as it takes to cook.  Some variables interfere, such as altitude, size of the egg and freshness of the egg (there’s nothing worse than overcooking a beautiful fresh egg still warm from the chicken!), but 4 minutes is a good estimate.

I’ll admit I almost never time my eggs. I invested in one of these gadgets a few years ago, and can’t recommend them highly enough. If you’re lazy like me and sometimes cook tons of eggs at a time, this little device can tell you when they’ll all be done better than any timer.  Worth every penny (I get no kickbacks, I assure you)!

Once your egg is cooked you can stick it in cold water to stop it from cooking too much or just eat it right away. Soft-boiled eggs are best enjoyed warm and are most easily eaten using an eggcup.  Here’s my favorite:

This was the eggcup my Nan would give me as a child when I visited her in England. I reminisced about it and she kindly gave it to me!

The next step is cracking the egg. This too, is easily done!

Once whacked, you can get to work and open up the egg. If all went according to plan, you’ll have a perfect soft yolk!

Mmmm…. Brains

I like mine with a bit of salt (and sometimes some pepper).

I’d like to thank my hens for eating such a nutritious diet and for having such lovely yolks!

It seems as though Brits are pretty keen on soft-boiled eggs (or at least they have been in the past). Maybe it’s because soft-boiled eggs are delicious, or maybe it’s because eggcups are kind of fun. There are lots of options, from cute little pants sets to fine silver.

An antique silver eggcup set- also from my Nan (I can’t believe anyone ever used these!)

Soft-boiled eggs are not only quick to cook with minimal cleanup (usually just a spoon) but they’re also excellent emergency food.  They’re very nutritious, and they can be cooked in water that wouldn’t otherwise be potable (love that shell!). I remember my good friend Jamie Scott  making that point when he wrote about his experience with the earthquakes of Christchurch.

In college I toured Iceland, including a visit to the geysers. I remember hearing that you could cook a soft-boiled egg in the sulfurous hot springs if you were so inclined (talk about Waste not, want not!), and I tracked down a video of some guys doing just that.  The kitchen method might be easier- no hot spring required!

(As the pictures might suggest, I am going a but stir-crazy, though I have to admit that life without power is not without its charms. I’ve read a big book of EKG interpretation cover-to-cover, dismembered a fallen old maple, fixed a chicken house, and taken the dog for a number of walks over the last few days. I’m also rather enjoying the darkness-imposed early bedtimes (now that it no longer sounds like the wind will rip the roof off from over me!)  More science to come- I do plan to get back to liver and lipids shortly!)

 

*This post is up courtesy of the photons and electrons of a local coffee spot… Thanks Riverside Coffee!

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