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Archive for the ‘Historical’ Category

A history of alcohol

Hello all!

 

Many apologies for my long absence! Believe it or not- moving across the country and starting your intern year as a medical resident is incredibly time consuming! Add to that, my gnawing guilt about not completing an academic chapter (Aaron, forgive me, but I am working on it!), and writing for pleasure keeps getting postponed.

 

It’s a rainy day in Salt Lake City, so instead of getting out to explore I’m trying to buckle down to finish some academic writing. To refresh my memory I pulled up my PhD thesis to review a couple chapters and happened to glance at my chapter on the history of alcohol. While the majority of my thesis is rather dry, focusing on liver pathology and cell-signaling intricacies, this chapter might actually be interesting to those with an interest in history (and/or booze). For those interested, I’m posting it below!


 

History

Fermentation of foods and beverages is intricately woven into human history and culture, with archaeological evidence of intentional fermentation dating back almost 10,000 years. The biochemistry behind the process was finally elucidated by Louis Pasteur in the mid 1850s [1, 2].

Archeologists have discovered extensive evidence for the historic production of fermented beverages around the world, including in China, Egypt, Iran, Greece, and Georgia [3]. Ancient beverages were made from a variety of products, including rice (sake), honey (mead), fruit (wine), and cereal grains (beer) [4]. One of the earliest and most prevalent sources of sugar for fermentation was, and remains, grape juice (Vitis sp.), with the earliest evidence of large-scale wine production dating back to approximately 5400BC in the northern Zagros Mountains of Iran [5]. Indeed, it is likely that humans’ propensity for wine led to the domestication of Vitis vinifera and the global expansion of the species [6]. It has even been suggested that the earliest agrarian societies converted from their nomadic hunter-gatherer ways in order to increase their ability to produce alcohol [7]!

The first winemaking was probably a mistake, occurring when juice from stored grapes was exposed to natural yeasts that would have fermented in a matter of days [8]. Originally, fermentation was probably initiated by wild yeast, and it is not known when humans started to selectively add specific yeasts to their materials [3]. The success and popularity of the drink is evidenced by the vast and rapid expansion of viticulture throughout Mesopotamia and Europe [8]. It is currently believed that grapes were domesticated between the Black Sea and Iran between 7000-4000 BC [3, 5, 9]. From there, grape production and winemaking spread over the Mediterranean, reaching Greece in 5000BC, Italy in 900BC, France in 600BC and the Americas in 1500 AD [3]. The export of wine was a driving force behind the expansion of the Greek sea trade, and when Rome conquered Greece the Romans adopted winemaking. As the Roman Empire expanded, viniculture and viticulture spread with it. When the Roman Empire collapsed, wine’s place in Christian rituals helped to maintain production. While wineries in the Middle East and North Africa disappeared with the advent and spread of Islam, monasteries in Europe protected and refined the art of wine making. European expansion eventually carried wine production to the Americas, starting in Mexico and heading south into South America. European grapes could not survive in eastern North America, and native varietals were adopted and cultivated for wine production [8]. European cultivars thrived on the west coast of the US [10].

It is believed that the production and consumption of beer arose after the advent of wine, though like wine, the actual date when beer was first produced is unknown. The first beer may have been a result of a batch of porridge that was left to sit too long, and there is extensive archeological evidence of beer production and consumption dating from 4000 to 3500 BC. It is likely that the Sumerians were the first beer makers and it is believed that as much as 40% of their grain production was used to brew beer. While the Sumerians may have invented beer making, the process was quickly adopted by Egyptians [8]. Analysis of ceramics found in Egypt that date from 1500-1300 BC suggests that a combination of cooked and uncooked malt with water and an inoculation of yeast were used to make beer [3]. Most people drank beer daily, and it was used as an offering to the gods. Beer production spread from the Middle East to Europe and Africa, and also began spontaneously in other parts of the world. The Incas, for example, used corn, manioc, and peanuts as the starting material for fermentation in South America [8]. The introduction of hops increased the stability of beer and allowed for greater dissemination of the product because the phenolic compounds in the Hops prevents the growth of gram positive bacteria [11].

In addition to having social and religious implications, beer provided a valuable nutritional source to those that drank it. Only a small amount of the energy in grains is lost in fermentation and the growth of yeast provides a valuable source of B vitamins to an otherwise somewhat nutritionally barren substance. Additionally, in a time when drinking water was frequently contaminated by the products of civilization, brewing (and wine making) provided a valuable source of potable liquid [8].

Both beer and wine provide relatively low percentage alcoholic beverages because of the self-limiting nature of fermentation. As the alcohol concentration of the fermented substance increases, the yeast lose the ability to survive and continue fermentation, therefore, with a few exceptions, beers are generally 4-6% alcohol by volume (abv) and wines are generally 10-14% abv. Variations in alcohol content depend on the availability of substrate for the yeast to ferment and the type of yeast used for fermentation. The process of distillation, by which alcohol is physically separated from water by exploiting differences in the substances’ boiling points, allows for the production of liquids with dramatically increased alcohol contents. Distillation first appeared in Mesopotamia around 4000BC, and was primarily used for the production of perfumes. Sometime later, distillation was used to produce alcoholic beverages, and between 1000 and 1500 AD the distillation of wine in Europe led to the production of brandy [8].

Initially, liquor was perceived as a healthy tonic, even being referred to as ‘aqua vitae’, the water of life.   Distilled liquor had the advantage of decreasing the volume of the initial substance, and improving stability, increasing the ability to transport alcohol throughout Europe and North America. Many liquors are distinctly identified with a geographical location, such as bourbon in the US, tequila in Mexico, Scotch whisky in Scotland, Gin in England, and Rum with the Caribbean [8]. Unfortunately, the availability of relatively inexpensive high alcohol beverages led to abuse and societal problems, and began to be blamed for social and medical problems. Indeed, the English artist William Hogarth depicted the evils of the consumption of gin in his print ‘Gin Lane’, which he compared to the merits of drinking beer in his print ‘Beer Street’.

 

 

The production and consumption of alcohol has had significant cultural, religious, and social implications for millennia and it continues to be important around the globe today. In addition to its roles in social and religious events, alcohol is implicated in a number of facets of human health and disease. Moderate consumption of alcohol has been associated with a decreased risk of certain adverse health events in comparison to those who abstain from alcohol entirely, while the over consumption of alcohol is associated with a number of pathologies and death. The pathologies and benefits of alcohol consumption are varied, as are the mechanisms by which alcohol acts in the body. While some effects of alcohol are due to the direct action alcohol, the process and products of alcohol metabolism are hugely important and warrant significant examination.

 

 

  1. Pasteur, L., Mémoire sur la fermentation alcoolique. . Ann. Chim. Phys, 1860. 58: p. 323-426.
  2. Barnett, J.A., Beginnings of microbiology and biochemistry: the contribution of yeast research. Microbiology, 2003. 149(Pt 3): p. 557-67.
  3. Sicard, D. and J.L. Legras, Bread, beer and wine: yeast domestication in the Saccharomyces sensu stricto complex. C R Biol, 2011. 334(3): p. 229-36.
  4. McGovern, P.E., J. Zhang, J. Tang, Z. Zhang, G.R. Hall, R.A. Moreau, A. Nunez, E.D. Butrym, M.P. Richards, C.S. Wang, G. Cheng, Z. Zhao, and C. Wang, Fermented beverages of pre- and proto-historic China. Proc Natl Acad Sci U S A, 2004. 101(51): p. 17593-8.
  5. McGovern, P.E., D.L. Glusker, and L.J. Exner, Neolithic resinated wine. Nature, 1986. 381: p. 480-481.
  6. Cavalieri, D., P.E. McGovern, D.L. Hartl, R. Mortimer, and M. Polsinelli, Evidence for S. cerevisiae fermentation in ancient wine. J Mol Evol, 2003. 57 Suppl 1: p. S226-32.
  7. McGovern, P.E., Uncorking the Past: The Quest for Wine, Beer, and Other Alcoholic Beverages. 2009: University of California Press.
  8. Wolf, A., G.A. Bray, and B.M. Popkin, A short history of beverages and how our body treats them. Obesity Reviews, 2007. 9: p. 151-164.
  9. Arroyo-Garcia, R., L. Ruiz-Garcia, L. Bolling, R. Ocete, M.A. Lopez, C. Arnold, A. Ergul, G. Soylemezoglu, H.I. Uzun, F. Cabello, J. Ibanez, M.K. Aradhya, A. Atanassov, I. Atanassov, S. Balint, J.L. Cenis, L. Costantini, S. Goris-Lavets, M.S. Grando, B.Y. Klein, P.E. McGovern, D. Merdinoglu, I. Pejic, F. Pelsy, N. Primikirios, V. Risovannaya, K.A. Roubelakis-Angelakis, H. Snoussi, P. Sotiri, S. Tamhankar, P. This, L. Troshin, J.M. Malpica, F. Lefort, and J.M. Martinez-Zapater, Multiple origins of cultivated grapevine (Vitis vinifera L. ssp. sativa) based on chloroplast DNA polymorphisms. Mol Ecol, 2006. 15(12): p. 3707-14.
  10. Soleas, G.J., E.P. Diamandis, and D.M. Goldberg, Wine as a biological fluid: history, production, and role in disease prevention. J Clin Lab Anal, 1997. 11(5): p. 287-313.
  11. Sakamoto, K. and W.N. Konings, Beer spoilage bacteria and hop resistance. Int J Food Microbiol, 2003. 89(2-3): p. 105-24.

 


 

I will be back, with more posts on evolution, medicine, evolutionary medicine, travel, Utah, and life!  Until then…

 

Corolla, we're not in NJ anymore...

Corolla, we’re not in NJ anymore…

 

 

 

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I recently visited the Galapagos (more posts and pictures coming soon).  During that trip I brushed up on some of my Darwin knowledge- in a lecture on board, with some books in the ship’s library, and reading The Voyage of the Beagle on my Kindle. I just got back from a very different trip (visiting family in the UK), but again I managed to brush up on some Darwin, this time by visiting the place where he lived, worked, and died- Down House.

 

Down House, the home of Charles Robert Darwin (1809-1882) for the last 40 years of his life, is in the village of Downe in Kent.  Here Darwin conducted many experiments, and wrote most of his scientific work (On the Origin of Species by Means of Natural Selection (1859) being the most well known).  I am certainly a Darwin enthusiast (some might say a Darwin stalker…), but I expect that even those who have only a mild interest in Darwin, history, evolution, or science would enjoy a tour around this historic site.

 

Down House is located in the village of Downe (the Darwin’s kept the traditional spelling after an “e” was added to the village to distinguish it from the county Down in Ireland), and it has had a number of renovations since it’s initial construction in the early 1700s.  The Darwin’s acquired Down House in 1842, when Darwin and his wife (and first cousin) Emma (nee Wedgewood) wished to escape the hustle and bustle of London with their growing family (at the time they had two children and were expecting a third).  Darwin, in his characteristically frank style wrote, “It is a good, very ugly house, with 18 acres.”, though I think many today would disagree with this assessment!

 

Down House as it is today, with a very excited tourist.

Down House as it is today, with a very excited tourist.

 

Over the course of his 40 years at the house Darwin enlarged it not only for his growing family (he and Emma had ten children, though only 7 survived to adulthood), but also for the comfort of his servants.  Writing to family he said “It seemed so selfish to make the house so luxurious for ourselves and not comfortable for our servants “. One of Darwin’s many interesting (and noteworthy) traits was his humanism.  He was an avid abolitionist (a disagreement with Captain Fitzroy on this subject almost got him kicked off the Beagle), a kind “master” to his house staff, a loving and involved father (an anomaly in Victoria times), and supporter of the humane treatment of animals.

 

Today the name Charles Darwin calls up images of a great scientist, a deep thinker, and a major contributor to human knowledge.  However, this certainly wasn’t the future his family imagined when Charles was a youth.  As a boy he received a classical education at Shrewsbury School.  This was not an education that paired well with young Charles’ interests of beetle collecting (then a national craze), chemistry, and shooting.  His father, a respected physician, is reported to have said “You care for nothing but shooting, dogs, and rat-catching and you will be a disgrace to yourself and all your family.”.

 

After his mediocre performance at Shrewsbury School, Darwin was sent to Edinburgh to follow in his father’s footprints and become a physician.  Alas (or fortunately, for the future of science), Charles could not stomach the brutality of surgery in the era before anesthesia, and he returned home after less than two years.  He was next sent to Cambridge to earn a degree so that he could enter the clergy (entering the clergy was a common career path for men from good families with a penchant for natural history).

 

While Darwin did complete his degree at Cambridge, he never went on to study for the clergy, as he was recommended by a mentor to accompany Captain Robert Fitzroy on the Beagle. Darwin wasn’t the first young naturalist recommended for the job (he actually wasn’t on the boat as the naturalist, though he did later rise to this position, his “job” on the ship was to act as Fitzroy’s companion- a gentleman that a captain could talk to amongst a ship-full of burly sailors).  While his father did not support this decision he did eventually let young Darwin (he was 22 at the time) depart on this adventure at the recommendation of Charles’ uncle Josiah Wedgewood.

 

The expedition aboard the Beagle was meant to last two years, but it stretched into a five-year endeavor.  Darwin’s observations during this travel were instrumental in shaping his thinking and his future.  It is rather fascinating to realize that Darwin’s 5-year, around-the-world journey aboard the Beagle was the only travel he ever undertook.  He returned to England in October of 1836, married in January of 1838, and in September of 1842 took his growing family from the strictures of London to Down House where he would spend the rest of his life.

 

Once at Down House, Darwin preferred to correspond with friends rather than travel back and forth to London.  He was a prolific letter writer- spending the equivalent of thousands of pounds per year on stationary and postage.  While it does seem that Darwin was a bit of an introvert, this insular life was largely a result of ill health.  Once an active and lively young man with a penchant for exploring and shooting, he was plagued with illness after his return from the journey aboard the Beagle.  His symptoms, which were present in varying degrees for the rest of his life, included a number of GI problems, palpitations, and extreme fatigue.  There have been many theories about this illness, ranging from Chagas disease to Chronic Fatigue, including lactose intolerance, Crohn’s disease, and psychosomatic disorders.  Whatever the cause, this illness debilitated Darwin, and at Down House he developed a schedule around his symptoms- working when he could and resting when he must.

 

The Sandwalk at Down House, also sometimes known as the Thinking Path, was where Darwin would walk three times a day (health permitting).  There is a walk down around the property with a loop in the woods, and Darwin would walk laps on the circuit deep in thought.  He would kick rocks from one side to the other to keep track of his laps, as his mind was usually on matters other than his number of "reps".

The Sandwalk at Down House, also sometimes known as the Thinking Path, was where Darwin would walk three times a day (health permitting). There is a walk down around the property with a loop in the woods, and Darwin would walk laps on the circuit deep in thought. He would kick rocks from one side to the other to keep track of his laps, as his mind was usually on matters other than his number of “reps”.

 

Down house wasn’t only Darwin’s home, but also the place where he conducted many experiments – on pigeons, barnacles, orchids, and weeds- work that was instrumental in supporting his theory of natural selection.  Of course Darwin was not the first person to suggest that species were mutable, but he was the first to convincingly propose a cogent mechanistic theory and support it with various lines of evidence.  Both he and Alfred Russel Wallace appreciated the implication of Thomas Malthus’ commentary on populations- that sooner or later populations were checked by famine and disease- and both men independently came to the same theory of natural selection based upon the pressures exerted by nature.  However, it was Darwin who first wrote about the theory (though he did not publish it) and who collected extensive evidence to support the theory.

 

The Hot House at Down House.  A collection of orchids and carnivorous plants are maintained here.  This is where Darwin hypothesized that the orchid Angraecum sesquipeda was pollinated by moth with a long proboscis.  This was discovered to be true, 21 years after Darwin's death.

The Hot House at Down House. A collection of orchids and carnivorous plants are maintained here. This is where Darwin hypothesized that the orchid Angraecum sesquipeda was pollinated by moth with a long proboscis. This was discovered to be true, 21 years after Darwin’s death.

 

The Kitchen Gardens.  Not much going on this time of year, but in summer these beds are full.  This is where Darwin did experiments on pin-eyed and thrum-eyed primroses.

The Kitchen Gardens. Not much going on this time of year, but in summer these beds are full. This is where Darwin did experiments on pin-eyed and thrum-eyed primroses.

 

The remnants of some of Darwin’s experiments can still be seen at Down House.  His hot houses (heated by composting manure!), where he maintained large numbers of orchids and carnivorous plants, are still maintained, as are the large kitchen gardens where he studied primulas.  A reconstruction of “The Worm Stone” that Darwin and his son Horace used to study the action of worms is in the garden, and English Heritage, who maintains the house, continues to dig experimental weed plots similar to those that Darwin constructed to study the succession of plants.

A reconstruction of "The Wormstone".  I was being optimistic when I took this pic, and hoped that I wasn't actually taking a picture of the septic system...

A reconstruction of “The Wormstone”. I was being optimistic when I took this pic, and hoped that I wasn’t actually taking a picture of the septic system…

 

Throughout my visit to Down House I was overcome with a feeling of awe.  I grew up with a deep respect and affection for Darwin- my father is a huge fan, to the point where my brother’s middle name is Darwin.  Being the second born I received an equally nerdy though significantly less well known middle name- Lyell.

 

Charles Lyell was a geologist (I actually wrote about him briefly in my first blog post!) and a well-respected scientist.  He was a mentor for Darwin, though it took him a while to come around to Darwin’s theory of natural selection.  He eventually did, and it was Charles Lyell and Joseph Hooker who presented Darwin’s and Wallace’s papers On the Tendencies of Species to form Varieties and On the Perpetuation of Varieties and Species by Natural Means of Selection to the Linnean Society in 1858. It was a thrill to see Darwin’s portrait of Lyell in his study, as well as various volumes of Lyell’s books in locations throughout the house.

 

Visiting Down House certainly increased my understanding of this great man, and also increased my respect for him.  He was a humble man, a hard-working man, a loving father, and a great mind.  He was also a troubled man- plagued with illness, profoundly concerned by the implications of his theory, and deeply scarred by the loss of children he loved.

This is a picture of Downe Church (not mine) where Darwin would walk every Sunday.  Darwin lost faith in religion after the death of his first daughter, and while he would walk his family to church on Sunday he would not enter the church.  This is where his wife, Emma, is buried (Darwin is buried in Westminster Abbey).

This is a picture of Downe Church (courtesy of wikicommons) where Darwin would walk every Sunday. Darwin lost faith in religion after the death of his first daughter, and while he would walk his family to church on Sunday he did not enter. This is where his wife, Emma, is buried (Darwin is buried in Westminster Abbey).

 

Darwin’s work on natural selection is a classical example of the scientific method.  As a naturalist, especially during his time aboard the Beagle, he made a number of observations.  These observations led him to a hypothesis (natural selection) that he then researched extensively.  He was not purely a “great thinker”, who came up with a theory, but also a patient and meticulous experimentalist who painstakingly showed that species were mutable through pressures of nature.

 

Sometimes in science, medicine, and certainly in the paleosphere we get stuck on an idea or a theory.  We latch on to something that just “makes sense” or fits in nicely with our current way of thinking, and we start to accept it as fact.  Seeing how hard Darwin worked to build evidence to support a theory, which on an intellectual basis was so obvious, reminds me how important it is to not stand on theory alone, but to work diligently towards better understanding through rigorous science.

 

Though sometimes controversial in the US, Darwin is well loved in the UK.  He had a distinguished funeral at Westminster Abbey and is interred near the monument for Sir Isaac Newton.

Though sometimes controversial in the US, Darwin is well loved in the UK (and is featured on the ten pound note). He had a distinguished funeral at Westminster Abbey and is interred near the monument for Sir Isaac Newton.

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I’ve been fortunate to do some pretty amazing travel in the past, but the journey I just returned from has certainly stolen the show. 

 

As an evolution nerd, a Darwin enthusiast, and a lover of the natural world, a trip to the Galapagos was truly an experience I will never forget.  I’ve wanted to visit the Galapagos for a long time*, and while I had thought about visiting in my 6 months off between med school and residency I only booked the trip about a month ago.  My father (also an evolution nerd, Darwin enthusiast, and naturalist) and I travelled with National Geographic and Lindblad Expeditions on a trip to the Galapagos aboard The National Geographic Endeavour (named in honor of the first vessel that Captain Cook used in his explorations – the one that landed on the eastern coast of Australia; Cook never visited the Galapagos).  I’ll just start by saying the company, the experience, the ship, the crew, the staff, the naturalists, the whole package- were all first rate.  It’s a top of the line option for visiting the Galapagos, and it really shows.

 

In many people’s minds, the Galapagos are inexorably linked with Charles Darwin and his theory of Natural Selection.  Darwin visited the Galapagos, on HMS Beagle, in 1835. Darwin was aboard the Beagle for 5 years, but he only spent 5 weeks in the Galapagos of which only 19 days were on land!  Nonetheless, the observations he made there and the samples he collected were important ingredients for his future theory.

 

Tagus Cove- One evening we stopped in Tagus Cove- an area where Darwin landed.  There is graffiti in this cove, as it was traditional (until recently) to leave the name of your boat on the cliffs (some are amazingly high up).  The earliest inscription we saw was from 1836, the year after Darwin visited.

One evening we stopped in Tagus Cove- an area where Darwin landed. There is graffiti in this cove, as it was traditional (until recently) to leave the name of your boat on the cliffs (some are amazingly high up). The earliest inscription we saw was from 1836, the year after Darwin visited.

 

Most of the walks we took on this cruise were rather relaxed, but this evening’s hike was a change of pace, and we made good speed up a steep trail.  Looking back, we could see the Endeavour and a large pond that Darwin wrote about in The Voyage of the Beagle.  Alas, while he was hoping for a refreshing dip in some fresh water, he was frustrated to find that this pond is brackish.

 

A [disappointingly] brackish pond.

A [disappointingly, at least for Darwin] brackish pond.

I recommend the Galapagos chapter of The Voyage of the Beagle (Chapter 17).  It is a delightful and quick read, and if you have an e-reader you can find it for free online.  The Voyage of the Beagle was a travel journal of sorts, and while Darwin was the naturalist aboard The Beagle (well he was eventually, he didn’t start that way but eventually replaced the original Naturalist) he first became famous as a travel writer (his theory of evolution didn’t make him famous until quite late in life, and strangely his book on Barnacles wasn’t a big seller…).

 

Over the years, the Galapagos became a popular stopping point for ships.  While there is very limited fresh water, it was a good place to replenish food.  Early visitors introduced goats (a species that quickly flourished on the islands, wreaking havoc on endemic creatures) and the Galapagonian tortoises were particularly popular as well.

 

There are a number of species that are uniquely Galapagonian- the tortoise being a prime example.  These giant creatures at one time roamed the islands in great numbers, but their populations were decimated by humans in ~150 years.  The tortoise had two great misfortunes- first, they apparently taste pretty good (Darwin wrote of roasted tortoise breast “Gaucho style” being quite tasty, and was complimentary of tortoise soup (from medium sized animals), though he found nothing remarkable in the rest of the animal).  Perhaps the greater misfortune for these giants is that they can survive for ~2 years without food or water.  In a time before refrigeration, when fresh meat was almost an impossibility on long sea voyages, tortoises could be stashed on boats for ages until they were finally consumed.  I admit to being rather bad about anthropomorphizing animals, but I can only imagine that being kept in the hold of a ship for over a year before being killed and eaten was a rather unpleasant end.

 

A Medium Sized Tortoise- Perhaps this is a good soup-sized tortoise?

A Medium Sized Tortoise- Perhaps this is a good soup-sized tortoise?

 

These giants are believed to live over 200 years, though it is hard to be sure since we haven’t been studying them that long.

These giants are believed to live over 200 years, though it is hard to be sure since we haven’t been studying them that long.

 

The tortoises on different islands are considered different sub-species (though where you draw the line at species vs. subspecies or variety was a common quandary during our tour of the Galapagos) and some have gone extinct due to human harvesting, competition (with things such as introduced goats), and decreased hatching (because of damage to nests due to introduced species).  One of the most famous Galapagos Tortoises was “Lonesome George”, the last of his kind- a subspecies of tortoise that inhabited Pinta Island.  While a number of attempts were made to breed George and “save” his kind, none were successful, and he died- the last of his kind- in 2012.

 

Lonesome George had been living at the Charles Darwin Research Station on Santa Cruz Island since his discovery in 1971, and for many years was the center’s most famous denizen.  We visited Santa Cruz, and the Charles Darwin Research Center, during our cruise, and we got to see the conservation efforts there.

 

The National Park manages 97% of the land of the Galapagos (only 3% is habited). The Charles Darwin Research Center does a lot of research, but only the national park can change policy and initiate change in the park.

The National Park manages 97% of the land of the Galapagos (only 3% is habited). The Charles Darwin Research Station does a lot of research, but only the national park can change policy and initiate change in the park.

 

Eggs from different subspecies are hatched and reared in captivity on Santa Cruz (and there are two other tortoise breeding centers elsewhere in the archipelago).  When they are large enough to be released they are tagged and released.  These efforts have generally been very successful and the tortoise population is recovering nicely.  While they claim the number painted on the babies backs are for identification purposes, I secretly hope there is some illicit tortoise racing going on after hours!

Eggs from different subspecies are hatched and reared in captivity on Santa Cruz (there are two other tortoise breeding centers elsewhere in the archipelago). When they are large enough to be released they are tagged and released. These efforts have generally been very successful and the tortoise population is recovering nicely. While they claim the number painted on the babies backs are for identification purposes, I secretly hope there is some illicit tortoise racing going on after hours!

 

After his death, Lonesome George was sent to NYC where he was preserved by experts at the Natural History Museum.  The current celebrity at the Charles Darwin Research Center is a much happier tale.  When conservation efforts were initiated, there were only 14 tortoises of the Española subspecies- 12 females and 2 males.  While conservationists hoped to build the population from these animals, the females were not interested in the males.  In an attempt to save the subspecies, a global search for a male of their kind was initiated- seeking out giant tortoises in zoos and private collections around the world.  Eventually a male was found in the San Diego zoo, and after some negotiating “Diego” made his way back to the Galapagos.  Now, having fathered over 1000 offspring, Diego is known as “Super Diego”, and the subspecies is doing well!

 

The conservation of the Galapagos Tortoises seems to be on the road to success, which is wonderful.  The Charles Darwin Research Station has also had good success breeding and reintroducing some subspecies of Land Iguanas.  In fact, the breeding program at the research center has now been closed because the efforts were so successful.

 

These cuddly guys (land iguanas) have had a hard time on some islands, but with restoration and conservation efforts they are now dong well.

These cuddly guys (land iguanas) have had a hard time on some islands, but with restoration and conservation efforts they are now dong well.

 

There were slim pickings for the Land Iguanas on North Seymour. These guys like to eat prickly pear cactus, but were taking to the trees to find some greenery in this sparse environment.  One of the naturalists we were with said he had never seen Land Iguanas so high in trees before.

There were slim pickings for the Land Iguanas on North Seymour. These guys like to eat prickly pear cactus, but were taking to the trees to find some greenery in this sparse environment. One of the naturalists we were with said he has never seen Land Iguanas so high in trees before.

 

Lusher pastures for this land iguana near Urvina Bay.

Lusher pastures for this land iguana near Urvina Bay.

 

You may not know it, but about 30,000 people live in the Galapagos.  While 97% of the island is National Park (for which you need a permit and a naturalist to visit- no more than 16 tourists per naturalist), there are a number of inhabited areas.  At the end of our cruise we visited Santa Cruz, where the Darwin Center is, and San Cristobal, from where we flew back to the mainland.  In Santa Cruz we took a walk through town, and it was fun to stop at the fish market and see the catch of the day.  Humans weren’t the only interested customers!

 

Pelicans at the self-serve bar

Pelicans at the self-serve bar

 

A bit more anthropomorphizing... I imagined this Sea lion waiting for his number to be called at the deli counter.

A bit more anthropomorphizing… I imagined this Sea lion waiting for his number to be called at the deli counter.

 

The Sea Lion was given a hunk of fish and the fishmonger kept the pelicans back with a fly swatter so he could enjoy it!

The Sea Lion was given a hunk of fish and the fishwife kept the pelicans back with a fly swatter so he could enjoy it!

 

The Galapagos are part of Ecuador, and until fairly recently were not inhabited.  Initially, colonists were “gifted” land, as encouragement to come and live in the Galapagos, but now there are significant efforts to curb immigration.  When we were in Santa Cruz we headed up into the highlands to see tortoise in the wild (they much prefer to be in the highlands with lush vegetation and more water, but the females come out of the highlands to lay eggs- an unfortunate habit, since the smaller females were more desirable fodder for hungry sailors, and were much closer to the ocean than the large males who stayed in the highlands).

The tortoises in the highlands like to relax in ponds such as this one.  They will drink gallons of water when they visit, but can go years without water in hard times.

The tortoises in the highlands like to relax in ponds such as this one. They will drink gallons of water when they visit, but can go years without water in hard times.

 

At first I was confused by the shrubbery this tortoise had acquired, but after seeing them wallowing in the weed-covered pond all became clear.

At first I was confused by the shrubbery this tortoise had acquired, but after seeing them wallowing in the weed-covered pond all became clear.

 

Unfortunately, this method of hiding didn't save tortoise from hungry sailors.  Darwin writes how sailors would flip these hiding beasts over and carry them off to the ships for storage. Darwin also wrote about his attempts to ride these massive creatures!

Unfortunately, this method of hiding didn’t save tortoise from hungry sailors. Darwin writes how sailors would flip these hiding beasts over and carry them off to the ships for storage. 

 

While we were in the highlands we visited a plantation where a family grows coffee and sugar cane.  Both grow well in the Galapagos, and while we visited we learned how people traditionally processed sugar (into molasses and alcohol) and coffee.

 

Sugar Cane processing- This isn’t how the family processes sugar today, but this is the traditional method.  Sugar cane is fed into the press and juice comes out the bottom.  On this plantation half of the sugar cane juice is made into molasses and half is made into alcohol!

Sugar Cane processing- This isn’t how the family processes sugar today, but this is the traditional method. Sugar cane is fed into the press and juice comes out the bottom. On this plantation half of the sugar cane juice is made into molasses and half is made into alcohol!

 

Diabetic Warbler?- This Yellow Warbler really liked to hang out on the sugar cane press!

Diabetic Warbler?- This Yellow Warbler really liked to hang out on the sugar cane press!

 

Hooch- this was the open vat where the sugar cane juice was fermenting.  The final product, after it was passed through a still, was… rough.  There's a reason people age rum!

Hooch- this was the open vat where the sugar cane juice was fermenting. The final product, after it was passed through a still, was… rough. There’s a reason people age rum!

 

Coffee- Having had an introduction to traditional coffee processing methods in Belize, I got a review in The Galapagos.  Here you can see the unroasted cleaned and uncleaned beans.

Having had an introduction to traditional coffee processing methods in Belize, I got a review in The Galapagos. Here you can see the unroasted uncleaned and cleaned beans.

 

I took a new camera with me on this trip and certainly had some fun with shots like this...

I took a new camera with me on this trip and certainly had some fun with shots like this…

 

We got to try coffee beans, sugar, coffee, sugar juice (delicious with a squeeze of lime), and hooch (ditto).  While I certainly took lots of pictures in the Galapagos thing, the only physical product I’m coming home with is some Galapagonian Coffee.

 

Admission time- Label something “Evolutionary” and I am 27% more likely to purchase it.

Admission time- Label something “Evolutionary” and I am 27% more likely to purchase it.

 

I have a lot more to write about, and many more pictures to share, but this seems like a good stopping point for now.  I’ll get the next post up ASAP, but it may be a bit of a wait since I head to the UK tomorrow for a quick visit with family.

 

Me and my old new-friend. Unlike Darwin, I didn't try and catch a ride (though you can see why he tried!)

Me and my old new-friend. Unlike Darwin, I didn’t try and catch a ride (though you can see why he tried!)

 

*While I have always been keen to visit the Galapagos, I have also been somewhat wary.  There is no doubt that humans have done a lot of damage in the Galapagos.  While the bulk of this damage was done by early visitors who purposefully introduced a number of hardy species, tourists certainly have the potential to damage the environment, spread seeds, and introduce species or disease.  That being said, done correctly, tourism can be an incredible force for good in the Galapagos.  A lot of damage has been done in the past 200 yrs by sailors, settlers, and visitors.  Progress is being made to repair these damages, with money coming largely from tourists.  If humans were to now abandon the Galapagos, the endemic species would be pushed out by species that have already been introduced. Well-regulated tourism, appropriate management of the land, and conservation efforts can help preserve the Galapagos. They are certainly a wonder worth saving.

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I’ve previously written about the benefits of squatting for ailments of the gastrointestinal tract, specifically diverticulitis and hemorrhoids.  Some argue that squatting to defecate can prevent all manner of illness and while there are some clinical conditions I’d like to explore further in the squatting-in-the-bathroom paradigm, today I want to write about something quite different.

 

I finished my Obstetrics and Gynecology clerkship 5 weeks ago. I did my clerkship at a large, and rather posh, private hospital that is affiliated with my medical school.  There are some great doctors there, but I was sometimes aghast at the rather aggressive approach to delivery that many took.  The cesarean section rate for the last year was 47%, well above the national average of 33%, and most labors were artificially augmented.  I did not witness a single VBAC (Vaginal Birth After Cesarean), and was told that only one of the house attendings would perform them.

 

On the first day of my clerkship, I asked the clerkship director if women delivered in a variety of positions or if they were restricted to delivering in lithotomy (what many today think of as the “traditional” birthing position with the mother on her back with her feet in stirrups).  The director seems to be a rather progressive woman (she is the driving force pushing the hospital to become a “baby-friendly hospital”) and she gave me a rather knowing look and said “I know what you’re getting at, but unfortunately everyone here delivers lying down”.

 

Indeed, as I went through my rotation, all the vaginal deliveries I saw were done in the semi-reclined position that is common in western hospitals.  This is not universally true.  When I ask my family physician (who actually delivers babies- quite a rarity in this day and age) what position her patients delivered in, she immediately responded “whatever position they’re most comfortable in!”, a response I have heard from a few other MDs as well as many midwives and labor coaches.

 

Birth is, of course, a risky thing… Death in childbirth was historically a significant cause of mortality, and the rates are still high in some countries.  I think it’s important to recognize that birth is still a risky endeavor, and while pregnancy and labor is a normal human experience, it is one that comes with real dangers. Nonetheless, just because historic rates of maternal demise were much higher than they are today does not mean we should not cast an eye to historic practices when thinking about birth.  As I’ve argued before, I think modern medicine (in obstetrics and in most fields) could greatly benefit from casting an eye to evolution and our ancestors to further improve our current medical system by combining ancestral and evolutionary knowledge with modern technology and science.

 

I planned to write a significant argument for the consideration of “non-traditional” (though they are, in fact, traditional) positions for laboring, but then I came across a book from 1883 that said it all already. The book, entitled Labor Among Primitive Peoples (with the subtitle Showing the development of the obstetric science of today from the natural and instinctive customs of all races, civilized and savage, past and present.) by George Julius Engelmann MD, is available in it’s entirety thanks to the power of Google Books.

 

This book is fascinating, and at many times frightening (more on that later), but I found the “Posture in Labor” chapter of particular interest for this post.  There, the author divides the positions into 3 main categories: Perpendicular (including standing, partially suspended, and suspended), Inclined (including sitting erect, squatting “as in defecation”, kneeling, and semi-recumbent), and horizontal (on the back, side, or chest and stomach (!)). He also goes through the then common birthing practices of countries in Europe, Asia, Africa, North America, Central and South America, and Australia and the surrounding islands [1].

 

Curious?- here are some highlights from the book, but I highly recommend you take a scroll through the book to at least see the illustrations!

 




The squatting position of the Tonkowas- a Native American group indigenous to present-day Oklahoma and Texas.

The squatting position of the Tonkowas- a Native American group indigenous to present-day Oklahoma and Texas.

 

The squatting tradition of the Pawnee Native Americans- the laboring mother squats with her back to a female assistant while someone (in this case a shaman) assists with the delivery. This position (with an assistant acting as a back support) was apparently popular in many cultures around the world.

The squatting tradition of the Pawnee Native Americans- the laboring mother squats with her back to a female assistant while someone (in this case a shaman) assists with the delivery. This position (with an assistant acting as a back support) was apparently popular in many cultures around the world.

 

 

If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.

If you’re curious (as I was) about what a “suspended” birth looks like, here you go.

 

There is plenty to be said on each of the positions mentioned, but for the sake of this post I will focus on what the author says on squatting.  He states that squatting

 

is hardly to be defined with exactness, yet we may, in a general way, consider all postures as squatting which resemble that assumed in defecation. Though apparently inconvenient, and repugnant to the refined woman, this position is certainly the most natural one for expulsion from the abdominal or pelvic viscera, and will certainly, in many cases, facilitate labor. (72)

 

He documents the experience of another physicians, saying:

 

“… he tells me of attending a lady of good position in society in two labors. ‘In her first labor, delivery was retarded without apparent cause. There was nothing like impaction, or inertia, yet the head did not advance. At every pain she made violent efforts, and would bring her chest forward. I had determined to use the forceps, but just then, in one of the violent pains, she raised herself up in bed and assumed a squatting position, when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition, labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position as I had remembered her former labor, and she was delivered at once squatting.” (73)

 

Information on traditional birthing positions can also be wrought from the Old Testament. The King James translation of Exodus 1-16 says “When ye do the office of a midwife to the Hebrew women, and see them upon the stools…”. However there is some scholarly debate about the translation of the word “stools”, as a more accurate translation might actually be “stones”.  You might wonder what stones have to do with birthing, until you see this depiction of a popular Persian birthing position.

 

If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.

If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.

 

A friend recently shared a video of women delivering in the squatting position.  I post this video with the STRONGEST OF WARNINGS. I warn (only slightly jokingly) that that which is seen, cannot be unseen*. Proceed at your own risk! Birth is magical (though not mysterious), but some people find the imagery rather disturbing.

 

With that warning in place, I present the following video:

 

 

Those that have seen (or perhaps experienced) birth in the modern conventional position will probably agree that these women make labor look somewhat easy…

 

It’s also interesting to explore the delivery position of some of our closest living ancestors.  It appears that chimpanzees naturally deliver in a squatting position (with a similar “occiput anterior” presentation).

 

 

One of the most basic elements of obstetrics that we learn in medical school is the “7 cardinal movements” of delivery. Medical student must know these movements- engagement, descent, flexion, rotation, external rotation, and expulsion- and on the labor and delivery floors we are expected to participate in and assist with deliveries.  I remember watching many of my classmates “air-deliver” babies- going through the maneuvers of “catching” (a much more honest term than “delivering”) a baby, as we discussed these cardinal movements. While I understand that it is important to know these normal movements, the idea that a physician actually guides these movements is laughable. Truly, in most deliveries, our hands are there to catch and support. In fact, they are likely only necessary because of the position that we have developed for women to deliver.  In this youtube video explaining the 7 cardinal movements, the doctors hands only show up once the head is expulsed so that the baby’s head does not rest on the perineum. Indeed, “protect the perineum” is the mantra chanted to med students and novice doctors learning to deliver babies in a reclining position.  In the squatting position, gravity protects the perineum.

 

Support is needed because of maternal positioning, not intrinsic necessity.

Support is needed because of maternal positioning, not intrinsic necessity.

 

Gravity isn’t the only reason to consider delivering in a squatting position. I’ve heard it said (though haven’t found a reliable source) that squatting not only increases a woman’s ability to push (allowing her to better utilize her abdominal muscles), but also helps the pelvis open wider for delivery (due to the pull of abducting muscles).  In this position, and with the aid of gravity, it seems (and again I’ve heard it suggested) there is a lower risk of a perineal tear, something that I saw all too frequently during my Ob clerkship.

 

Squatting is by no means a perfect solution to birthing.  According to at least one study conducted in Nepal, squatting deliveries (along with multiparity and early age of first birth) are associated with an increased risk of pelvic organ prolapse later in life [2].  Also, opting for a squatting delivery removes the option of an epidural for pain control. An epidural causes a loss of sensation below the level of anesthesia, thus making walking (and squatting) impossible.

 

Squatting is not the only traditional (though now it would be classified as “non-traditional”) birthing position that women can consider.  I whole-heartedly appreciate my family physician who encourages women to find a position that is most-comfortable for them.  Hands-and-knees (exactly what it sounds like), has actually been studied in the first stage of labors for mothers whose babies are delivering in the occiput-posterior position.  While the study was small, the findings were encouraging [3].

 

Sometimes when I talk about evolutionary and ancestral medicine people assume that I am anti-modern medicine.  I am not. In childbirth in particular, modern advances in general health, pre-natal care, diagnostics, medicine, and surgery have saved countless lives. I am, however, in favor of assessing (and re-assessing) our beliefs (new and old) about how to best obtain and preserve health.

 

I find Dr. Engelmann’s book fascinating, and while there are elements that are rather disconcerting (the traditions of male and female circumcision, a surgery performed on men to decrease fertility, and the tradition in one culture of removing one testicle to prevent the conception of twins to name a few), I find his observations and his humble admissions (as well as his love of commas) lovely.  His conclusions are well worth reading (emphasis mine):

 

Abler obstetricians than myself have undoubtedly understood the movements of women, and the positions which they assumed in the agony of the expulsive pains. As regards myself, I must candidly confess this was not the case; and it was not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about and sought to quiet them; I bade them have patience and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for the parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis, more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.

 

The contractions of the previously inactive and rested abdominal muscles are a powerful adjunct to the tired uterine fibre, in the last prolonged and decisive expulsory effort, and in the dorsal decubitus they are somewhat hampered; they act to the best advantage in the inclined positions, semi-recumbent, kneeling, or squatting. We know that the squatting position is the one naturally assumed if an effort is required to expel the contents of the pelvic viscera; we, moreover, all know how difficult, even impossible, it is for many to perform those functions recumbent in bed, and mainly because they have-not sufficient control of the abdominal muscles in that position. Much more is this the case in the expulsion of the child; but the recumbent position is sanctioned by custom; it is pointed out as apparently convenient; it is imperatively demanded by prudery; and by a false modesty which hides from view the patient’s body beneath the bed clothes; and above all it is dictated by modern laws of obstetrics, the justice of which I have never dared question; we have all been taught their correctness, and we all thoughtlessly follow their dictates. There is no reason for assuming this position, though we are taught it; it is not reason, or obstetric science, but obstetric fashion which guides us,- guides us through our patients; and blindly do we, like all fashion’s votaries, follow in the wake. (140-141)

 

Obstetrics is a specialty where many do not want to question the norm. Indeed, fear of litigation generally pushes physicians to be overly aggressive in managing labor and quick to opt for cesarean delivery. Randomized controlled studies that push the boundaries of modern “obstetric fashion” are unlikely to be performed for fear of litigation, but observation of mothers who choose to deliver in various positions as well as consideration of ancestral practices can potentially help drive modern medicine to a higher standard.

 

 

The “progression” of the obstetrical chair. The first stool is not unlike some modern  birthing stools, while the final incarnation is not too far displaced from the modern delivery-room bed.

The “progression” of the obstetrical chair. The first stool is not unlike some modern birthing stools, while the final incarnation is not too far displaced from the modern delivery-room bed.

 

*A brief story from when I was on an Emergency Medical Services elective.  The ambulance I was on was called to back up another team that had gone to attend at precipitous delivery. When we arrived, it became apparent that we were not there to assist the patient (it was her fourteenth (!!!) delivery), but rather to make sure that the EMT who had just witnessed his first delivery did not pass out.  He had a very pale and shocked look to him, and he just stared at us blankly as we helped the mother with her new child. After a couple minutes, he looked at us and asked “does the mental image ever go away?”. He later admitted that he didn’t want to sleep with his girlfriend for at least two weeks… I believe this is what a good male friend of mine describes as figuring out the difference between “medical vagina and sexy vagina”. 

 

1.            Engelmann, G.J., Labor Among Primitive Peoples. Second ed. 1883, St Louis: J.H. Chambers and Co.

2.            Lien, Y.S., G.D. Chen, and S.C. Ng, Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal. Int J Gynaecol Obstet, 2012. 119(2): p. 185-8.

3.            Stremler, R., E. Hodnett, P. Petryshen, B. Stevens, J. Weston, and A.R. Willan, Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 2005. 32(4): p. 243-51.

 

And finally, for your viewing pleasure, this classic:

 

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When I tell people that I’m interested in evolutionary medicine, I sometimes get the response “Evolutionary medicine? Or the evolution of medicine?”.

 

I’ll admit, I’m actually interested in both, but my interest in Evolutionary Medicine is much stronger than my interest in the history and progression of medicine, though this subject can be rather fascinating.  I’ve listened to a course on the history of medicine, attended some extra lectures, and occasionally pick up a book to indulge this interest, but as a third (soon to be fourth, in 2 weeks!) year medical student, I generally have a hard enough time trying to make sense of our modern medical practices without spending too much time thinking about medical history.

 

Sometimes, however, the evolution of medicine plays out right in front of your eyes.

 

Today I took the end-of-clerkship exam for my obstetrics and gynecology rotation.  I actually enjoyed this clerkship a lot more than I had initially anticipated (a good thing, as I am increasingly thinking that I will pursue a residency in Family Medicine, which includes obstetrics).  I found myself a lot more enthusiastic to go to the OR to scrub in than I was during my surgical clerkship many months ago (it’s amazing what a year of clinical medical education will do to you).

 

This clerkship was split into a number of portions: labor and delivery (L&D), night float, women’s health clinic, maternal-fetal medicine (MFM), reproductive endocrinology and infertility (REI), gynecology, and gynecologic oncology… Quite the smorgasbord! On night float and L&D I would frequently end up in the OR to scrub in on a cesarean delivery, on gyn and gyn onc I was in the OR daily for a range of procedures from small biopsies to extensive tumor staging cases.

 

Major advancements in surgery include the discovery and utilization of anesthesia (Imagine being awake and able to feel everything in surgery! Better not, actually…), and the acceptance of germ theory (for which we should thank John Lister (1827-1912), namesake of Listerine!). Many other discoveries, techniques, and inventions have changed the practice of surgery, but these two are biggies.  The third, looming, problem that needs to be addressed is the perturbation of cytokines during and after surgery, but that is a story for another day!

 

An interesting progression of surgery is the way in which surgeons gain access to the abdomen and pelvis. Traditionally, as one might imagine, the easiest way to visualize and manipulate the internal organs was to do an open procedure, literally cutting a person open to directly access the area to be operated. In the 1980s, gynecologists started to train in a new technique- laparoscopic or “minimally invasive” surgery- in which a small camera is inserted into the abdomen (which has been inflated with an inert gas to create space*) so that surgeons can visualize the internal structures without opening the belly. Instruments can be introduced into the abdomen through small incisions, and organs and instruments can be manipulated inside the body** and visualized on a screen.

 

Initially this technique was used for only very small procedures (such as a tubal ligation, “having your tubes tied”), but as surgeons became more proficient, the complexity of the cases that could be performed in this manner increased.  The utility of this technique was recognized, and in the 1990s, general surgeons started to train in laparoscopic techniques.  Now, many surgeries, both gynecologic and general, are performed laparoscopically (somewhere along the way, urologists started using this technique as well).

 

To be a good laparoscopic surgeon takes a lot of time and training. Cut yourself a 31 or 42 cm stick and imagine trying to do small and precise tasks with the end, which you can only visualize on a screen. Now imagine you have to dissect out delicate pieces of anatomy, correctly identify them, preserve or remove tissue accordingly. As a student on the gynecology service, there was really no reason to scrub into “lap” cases (though they were generally good cases to observe, since the screens make the procedure easy to follow), but on surgery I would sometimes scrub in and occasionally be allowed to steer the camera or “bag” a specimen for removal (really, the resident would drop the sample into the endocatch bag, but they would generally act like it was a great triumph for the student!). It all looks fairly easy until you actually have your hands on the instruments and have to find your way around the belly (or if you’re the med student with the camera, make sure the surgeon is seeing what she wants to see!).

 

Once you are proficient with laparoscopic techniques, there is a lot you can do. One of the fellows on the Trauma service was a specialist with laparoscopic techniques, and he could “run the bowel” (visualize it from end to end) more rapidly laparoscopically than many surgeons could do open.  Getting proficient, however, takes a lot of time, especially if one is to master skills such as laparoscopic suturing.

 

Many gynecological and general procedures are now done using laparoscopic techniques. If you have your gallbladder or appendix removed, it’s likely you will have a “lap-chole” or a “lap-appy”, and the offending part will be removed with only a few small incisions visible.

 

In the last 10 years (I think), there was been “the next step” in laparoscopic surgery… the invention and utilization of a laparoscopic robot.  I should be clear that surgery is still under the control of a surgeon, and no one has “robot surgery”, but the “latest and greatest” (though is it really?) advancement in surgery is “robot assisted laparoscopic surgery”.

 

In robot cases, the abdomen is accessed similar to a traditional laparoscopic case, except the various instruments are subsequently attached to a robot, instead of being wielded by surgeons (though an assistant was needed at the patients side in the cases I saw to swap out instruments and to suction).  Using “the robot” allows surgeons a lot more precision and accuracy, and according to one of the surgeons I observed, you become proficient much more quickly on the robot than you do with traditional laparoscopic techniques.

 

Is it progress? 

 

On my week of gynecology, I witnessed the same surgery (supracervical hysterectomy) done open, laparoscopically, and with a robot-assist.  Some cases, due to the underlying pathology or anatomy, must be done open.   If the uterus is too adherent to other structures or if there might be malignancy that could spread if not removed in one piece, open surgery is probably the best option.  All things being equal, recovery from an open procedure is much longer than for the other options.

 

When it comes to laparoscopic surgery, robotic surgeries can potentially accomplish much finer tasks than general laparoscopy with significantly less blood loss (the robotic hysterectomy that I observed had an estimated blood loss of 20cc- they probably take more at your annual physical).  The laparoscopic case I saw also had minimal blood loss and was accomplished very quickly- the surgeon has decades of practice under his belt.

 

So- is this the evolution of medicine? Will robots fill every OR, and will the best surgeons be those who spent many hours as a child (or as an adult, as often is the case) playing video games? (I had to have a quick google, which resulted in this.).

 

Who am I to say? I’m just a MS3.97 (yes I calculated), with no great knowledge of surgery.  All I can say is that the progression of medicine is amazing.  We (generalists, specialists, surgeons, and other health care practitioners) have amazing technology at our fingertips. We have access to impressive diagnostics, powerful drugs, and amazing technology that allow us to diagnose, treat, and definitively fix disease.  But we must be judicious. Diagnostics and treatments (pharmacologic and surgical) have consequences- some big and some small.

 

Sometimes the question shouldn’t be “what type of surgery”, or “which drug”, but rather “is surgery necessary?” or “how will treatment help” (I don’t think the cases I described above were unnecessary, but Obstetricians/gynecologists, because of the horrible state of medical-legal affairs, often seem to err on the side of doing too much and/or acting very quickly).  We can do amazing things with medicine. Contrary to how this may sound, I’m not acquiring medical knowledge with no intent of using it. Rather, I think that those with medical knowledge have a responsibility to help patients decide what is the best option for them– physically and personally. At least that’s the kind of doctor I want to be…

 

But hey- we have some pretty cool tools out there to help us when we need them!

 

courtesy of wikicommons

A surgical robot- Courtesy of wikicommons

 

*It’s amazing how laparoscopy can pervert your perception of anatomy. When the abdomen is pumped full of gas it looks like organs are flopping around with lots of space, when in reality everything is rather tightly packed during day-to-day living.

** I write abdomen or “belly”, but I generally mean abdomen and/or pelvis.

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Happy New Year!

2012 was a whirlwind year for me. I defended my PhD at the beginning of 2012 and am now almost finished with all the required clerkships of third-year medical school. Phew!

I spent my winter holiday visiting my brother in Dubai, exploring many sites of the United Arab Emirates (UAE). I got to see a lot during my stay, and I’ve been writing a post on some of the interesting things I saw there.  As I was writing about the traditional dietary staples of the Middle East, I took a foray through a lot of literature that is available on camel milk.  It’s interesting stuff, and I found myself heading off on a tangent that I thought I should post as a stand-alone article.

So here we go…

Ship of the desert
Camels were (and still are, but for different reasons) an important part of life in the Middle East. The Arabian camel (the dromedary Camelus dromedarius) is a one-humped beast, and should not be confused with the 2-humped Bactrian camel (Camelus bactrianus) of central Asia.  Dromedaries were the only mode of transportation in the desert before motorized vehicles (walking any substantial distance on foot is out of the question and horses need too much water), and they also were an important form of wealth and source of food. Camel meat was a rare delicacy, while camel milk was a staple of the Bedouin diet. Camel hair was also used to make household necessities and camel dung was often used as fuel (a nice argument against the calories in calories out argument- if biological creatures were bomb calorimeters there wouldn’t be anything worth burning coming out the other end…).

Camel meat was not a staple of the Bedouin diet.  In fact, most nomadic people are reluctant to kill their subsistence animals for meat. Female camels were used for dairy and some males were kept for breeding purposes, but extra young male camels would be slaughtered and eaten for special occasions.

Though definitely not a traditional dish- this seems to be the #1 way to eat camel meat today

Though definitely not a traditional dish, this seems to be the most popular way to eat camel meat today

Camels are uniquely able to provide sustenance for humans in an environment that is generally rather inhospitable. Camels are able to not only survive, but thrive, on the limited and harsh forages that are available in the desert. She-camels can produce enough milk to nurse their offspring and provide liters of milk per day for their owner.

Camel in its native environment. These beasts thrive on the course and sparse forage of the desert.

Camel in its native environment. These beasts thrive on the coarse and sparse forage of the desert.

Camels’ milk is interesting stuff. Unlike the milk of cows, goats, and sheep, it cannot be easily made into cheese.  It doesn’t coagulate with bovine rennet, however recombinant camel rennet is incredibly efficient at coagulating cow milk and can also coagulate camel milk (there is a difference in the camel kappa-casein that makes it more resistant to cleavage) [1, 2].  With the right enzyme the job can be done, and there is at least one company that makes a camel cheese (nicknamed Camelbert!).

Camel milk isn’t much good for making yoghurt either, being much more resistant to lactic acid fermentation than cow milk. The result of camel milk lactic fermentation is very runny, with little microbial growth [3]. Gariss, a traditional Sudanese fermented camel’s milk product, is made with a mixed culture including Lactobacillus, Streptococcus, and yeast [4]. Here’s how it was traditionally made:

fermentation is carried out in two leather bags of tanned goat skin embedded in green or wet grass carried on the bag of camels and subjected to continuous shaking by the jerky walk inherent to camels. Whenever part of the product is withdrawn for consumption, a portion of fresh camel’s milk is added to make up volume and this continues for months [4].

According to one paper I spotted, food scientists can thicken fermented camel milk with gelatin or alginate (a thickener made from seaweed) in order to make a yoghurt-like product that consumers might find acceptable, but I didn’t spot any on the shelves in the stores of Dubai [5].

It seems to me that when it comes to camel milk it might be best to just keep it simple. Plain old milk.

CamelMilk

But camel milk may not be such simple stuff.  There is growing research that explores the use of camel milk for medicinal purposes.

I haven’t gone into the research in depth, but there are a number of small studies looking at the benefits of camel milk for people with diabetes (type 1 and type 2), with rather remarkable results. The addition of 500mL of camel milk on top of usual care for patients with type 1 diabetes resulted in significant improvements in a number of parameters in comparison to people who just received standard care. The camel milk group had a decrease in mean blood glucose levels and hemoglobin A1c.  The study was small, but 3 of the 12 participants in the camel milk group were able to completely stop using insulin (an almost unheard of occurrence for those with type 1 DM).  While the mean amount of insulin used in the control group remained constant, the amount used in the camel milk group dropped rapidly [4].

Abdelgadir et al [4]

Abdelgadir et al [4]

It hasn’t been determined how camel milk affects those with diabetes, but there are a number of hypotheses. Some sources think that insulin from camel milk is uniquely able to escape digestion when ingested or that camel milk contains a unique insulin-like small peptide that is bioavailable when consumed [6]. This is unlikely to be the whole story, however, as camel milk is able to increase endogenous insulin secretion in type 1 diabetics (individuals in standard of care + camel milk groups have higher levels of C-peptide, showing an increase in insulin production) [7].

Some readers may know that I have a fondness for fatty liver disease, so I was particularly interested to learn that, in a rat study, camel milk reversed alcohol-induced liver injury. This was seen histologically, where there was minimal fatty accumulation in the livers of alcohol-treated animals supplemented with camel milk in comparison to those just treated with alcohol alone, and serologically, where animals that were treated with ethanol alone had significantly increased liver enzymes in comparison to controls and those fed alcohol and camels milk [8]. I would postulate that it might have something to do with the high levels of carnitine found in camel milk [9], but that’s a story for another day.

Nutritionally, camel milk is unique. As I just mentioned, it has a more free carnitine as a percentage of total carnitine than other species and higher total carnitine than cow or human milk (though lower than sheep and goat milk) [9]. Camel milk has three-times the vitamin C of cow milk, but a similar amount of vitamin E and considerably less vitamin A and riboflavin [10]. Camel milk is low in short chain fatty acids in comparison to other milks and it has primarily long chain fatty acids, a significant portion of which is linoleic acid [11].  I tend to avoid this omega-6 FA, but I suspect that as part of a traditional diet the amount found in camel milk does not cause a problem.
Camels can carry a number of zoonotic organisms, including Coxiella burnetii (which causes Q fever) and Brucella sp. (which causes brucellosis), which can be transmitted through the milk. In fact, there was a recent brucellosis outbreak in Israel caused by raw camel milk [12].  If you’re drinking milk from an untested camel, it’s probably best to have it pasteurized. All the milk that’s available in Dubai supermarkets is pasteurized and homogenized. There are a variety of brands, and you can get milk in an array of flavors!

I spied plain, chocolate, strawberry, saffron, rose, cardamom, and date flavor! In this pic there's saffron, chocolate, strawberry, date, and plain.

I spied plain, chocolate, strawberry, saffron, rose, cardamom, and date flavor! In this pic there’s saffron, chocolate, strawberry, date, and plain.

Of course I had to try some… I opted for plain milk, and found it slightly sour in comparison to cow’s milk, with a watery mouthfeel. It’s been at least a decade since I drank skim milk, but as I remember the mouthfeel is similar.

Sculptors of human evolution

Camels have played central roles in the lives of desert dwelling people for millennia. They are the “ship of the desert” and their milk has nourished and sustained generations.  Their milk has also shaped the human genome…

The predominance of lactase persistence in populations is a well-known and well-studied example of human evolution. In populations that had access to animal milk, a mutation that allowed for the production of lactase past the age of weaning gave humans access to a rich food source. This was a huge advantage to those that had such a mutation.  Those that could easily consume milk were able to have more children, and the mutation spread throughout the population.  The advantage of having persistent lactase expression is so advantageous it has occurred independently in multiple populations over time.  While some mutations are linked back to the domestication of the cow, there are novel mutations found in Middle Eastern populations that are linked to the domestication of, and subsequent milk consumption from, Arabian camels [13].

The advantage of camel domestication is still present today.  A paper from 1996 looked at child health in three populations of Rendille pastoralists in Northern Kenya. Two of the groups had abandoned their nomadic roots to become settled, while one group remained nomadic.  In wet years (good years) there was a similar number of malnourished children in the three groups; however in a drought year, the children of the nomadic group faired significantly better.  The differences in malnutrition were attributed to food- specifically camels milk.  In drought years, the children in the nomadic group consumed three times as much milk as those from the sedentary group, where the children got more starches and sugar.  Other studies have found that nomadic groups generally do poorly during drought years (because of decreased production of milk from their herd), but because the Rendille maintain a large number of camels, they faired better during hard times [14].

So there you have it… I went diving into pubmed looking for a few fun facts to incorporate into a blog post on my trip to Dubai and found myself swept up in a mess of Dromedary data… I hope you found it as interesting as I did!

Camel

1.            Kappeler, S.R., H.J. van den Brink, H. Rahbek-Nielsen, Z. Farah, Z. Puhan, E.B. Hansen, and E. Johansen, Characterization of recombinant camel chymosin reveals superior properties for the coagulation of bovine and camel milk. Biochem Biophys Res Commun, 2006. 342(2): p. 647-54.

2.            Sorensen, J., D.S. Palmer, K.B. Qvist, and B. Schiott, Initial stage of cheese production: a molecular modeling study of bovine and camel chymosin complexed with peptides from the chymosin-sensitive region of kappa-casein. J Agric Food Chem, 2011. 59(10): p. 5636-47.

3.            Attia, H., N. Kherouatou, and A. Dhouib, Dromedary milk lactic acid fermentation: microbiological and rheological characteristics. J Ind Microbiol Biotechnol, 2001. 26(5): p. 263-70.

4.            Abdelgadir, W., D.S. Nielsen, S. Hamad, and M. Jakobsen, A traditional Sudanese fermented camel’s milk product, Gariss, as a habitat of Streptococcus infantarius subsp. infantarius. Int J Food Microbiol, 2008. 127(3): p. 215-9.

5.            Hashim, I.B., A.H. Khalil, and H. Habib, Quality and acceptability of a set-type yogurt made from camel milk. J Dairy Sci, 2009. 92(3): p. 857-62.

6.            Malik, A., A. Al-Senaidy, E. Skrzypczak-Jankun, and J. Jankun, A study of the anti-diabetic agents of camel milk. Int J Mol Med, 2012. 30(3): p. 585-92.

7.            Mohamad, R.H., Z.K. Zekry, H.A. Al-Mehdar, O. Salama, S.E. El-Shaieb, A.A. El-Basmy, M.G. Al-said, and S.M. Sharawy, Camel milk as an adjuvant therapy for the treatment of type 1 diabetes: verification of a traditional ethnomedical practice. J Med Food, 2009. 12(2): p. 461-5.

8.            Darwish, H.A., N.R. Abd Raboh, and A. Mahdy, Camel’s milk alleviates alcohol-induced liver injury in rats. Food Chem Toxicol, 2012. 50(5): p. 1377-83.

9.            Alhomida, A.S., Total, free, short-chain and long-chain acyl carnitine levels in Arabian camel milk (Camelus dromedarius). Ann Nutr Metab, 1996. 40(4): p. 221-6.

10.            Farah, Z., R. Rettenmaier, and D. Atkins, Vitamin content of camel milk. Int J Vitam Nutr Res, 1992. 62(1): p. 30-3.

11.            Gorban, A.M. and O.M. Izzeldin, Fatty acids and lipids of camel milk and colostrum. Int J Food Sci Nutr, 2001. 52(3): p. 283-7.

12.            Shimol, S.B., L. Dukhan, I. Belmaker, S. Bardenstein, D. Sibirsky, C. Barrett, and D. Greenberg, Human brucellosis outbreak acquired through camel milk ingestion in southern Israel. Isr Med Assoc J, 2012. 14(8): p. 475-8.

13.            Enattah, N.S., T.G. Jensen, M. Nielsen, R. Lewinski, M. Kuokkanen, H. Rasinpera, H. El-Shanti, J.K. Seo, M. Alifrangis, I.F. Khalil, A. Natah, A. Ali, S. Natah, D. Comas, S.Q. Mehdi, L. Groop, E.M. Vestergaard, F. Imtiaz, M.S. Rashed, B. Meyer, J. Troelsen, and L. Peltonen, Independent introduction of two lactase-persistence alleles into human populations reflects different history of adaptation to milk culture. Am J Hum Genet, 2008. 82(1): p. 57-72.

14.            Nathan, M.A., E.M. Fratkin, and E.A. Roth, Sedentism and child health among Rendille pastoralists of northern Kenya. Soc Sci Med, 1996. 43(4): p. 503-15.

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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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