Fish consumption and depression

CORRESPONDENCE

African traditional medicine—potential route for viral transmission?

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Sir—In Africa, heterosexual contact is the main route of transmission of HIV-1 and hepatitis B. We describe two potential non-sexual routes of viral transmission related to traditional medical practices in KwaZulu-Natal, South Africa. We also discuss how government antiwitchcraft legislation has altered traditional medical practice and increased the risk of transmission. The first and most common practice. Umgcabo is used as protection against malicious spells, harmful buried medicines, nightmares, headaches, epistaxis, lightning, and bullets (often sought by taxi drivers). The treatment may need to be repeated every 6 months and frequently involves whole families. In Zambia, entire village communities have been subjected to umgcabo by diviners.1 Umgcabo involves making multiple skin incisions with a razor blade, usually a new blade broken in half for each patient. The healer then takes the muthi (an oily suspension of up to 15 substances, usually of plant origin) and rubs this into the cuts, transferring blood from finger to muthi, thus to the next patient from this and any reused blades. The preparation may vary according to the disorder being treated, but in practice any one healer tends to use the same muthi for all conditions treated by umgcabo. The second practice ukutshobha, is a treatment for physical ailments such as fainting, lethargy, swollen legs, and lameness, rather than a preventative measure like umgcabo. This treatment involves injection with a porcupine quill or sharpened bicycle spoke. The skin is punctured every 5–10 cm down both sides of the body and at every fifth puncture, the quill is dipped into a bucks horn containing the muthi (figure). The preparation differs from umgcabo, and is used on individuals rather than groups, but throughout a day, many patients are treated with the same quill and muthi. The horns are frequently lent out to third parties to treat themselves and family members. For the treatment of AIDS, one healer claimed he used a combination of ukutshobha, umgcabo, and oral medicine. Zulu traditional medicine at the turn of the century was fundamentally different to the current practice described. The accounts of Bryant and Krige2,3 detail a medical system based on two distinct but interdependent branches, the diviner or diagnostician (isangoma) and the

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Bucks horn, porcupine quills and bicycle spoke used in ukutshobha. With kind permission, Enid Schildkraut, Natural History Museum, New York.

healer (inyanga) who selected and applied the remedies. The healers who had more obvious western counterparts (eg, herbalist, homoeopath) were recognised in colonial law in 1910 and granted licences to practice as herbalists “among their own people”. The diviners, part of their role being to “sniff out” witches, fell into the same category as witches under The Witchcraft Suppression Act of 1895, which remains in force today.4 The Act made divination, including medical diagnosis by divination, a criminal offence. To avoid the consequences of the law and to remain in practice, many diviners registered as herbalists, which gave rise to a new form of practitioner, the diviner/healer, who was untrained in the use of about 700 potential medicinal herbs.2,5 The result was a decrease in specific treatments for particular conditions and an increase in non-specific therapies and the indiscriminate use of umgcabo and ukutshobha. The potential risk of viral transmission is reinforced by the western equivalents of needle-sharing, non-sterile acupuncture, and haemotherapy. Interviews with current practitioners of traditional medicine suggest that they would welcome advice on aseptic technique and treatments of the muthi which might lower the risk of transmission of HIV-1 and hepatitis B. *Stephen Jolles, Frank Jolles *Department of Clinical Immunology, Royal Free Hospital, London NW3 2QG, UK, and University of Natal, Pietermaritzburg, Republic of South Africa

Auslander M. “Open the Wombs!” The symbolic politics of modern Ngoni witchfinding. In: Comaroff J, Comaroff, J, eds. Modernity and its malcontents: ritual and power in postcolonial Africa. Chicago: Chicago University Press, 1993. Bryant AT. Zulu medicine and medicinemen. Capetown, Struik, 1996. Krige EJ. the social system of the Zulus. Pietermaritzburg: Shuter and Shooter, 1988. South Africa Commission of Inquiry into Witchcraft Violence and Ritual Murder in the Northern Province of the Republic of South Africa. Report of the Commission of Inquiry into Witchcraft Violence and Ritual Murders in the Northern Province of the Republic of South Africa. Pietersburg, 1995. Hutchings A, Scott AH, Lewis G, Cunningham AB. Zulu medicinal plants: an inventory. Pietermaritzburg: University of Natal Press, 1996.

Fish consumption and depression Sir—Joseph R Hibbeln (April 18, p 1213)1 suggests that dietary factor could account for the variation of the annual prevalence of major depression across countries. With a simple correlational model, he found a strong correlation between apparently high fish consumption and lower annual prevalence of major depression, in a multinational comparison. As Hibbeln rightly states, low plasma concentrations of docosahexaenoic acid (DHA), an essential fatty acid found in fish, predict low concentrations of cerebrospinal fluid (CSF) 5-hydroxyindolacetic acid (5-HIAA) (the major metabolite of serotonin) and, in turn, low concentrations of CSF 5-HIAA are strongly associated with depression and suicide. As mentioned in the closing remark, also, he quotes a paper that shows that higher levels of DHA in redblood-cell membranes predict less severe symptoms of depression. However, various cultural, economic, social, and other factors can confound this simple correlational relation, so the conclusion that fish consumption can cause differences in the prevalence of major depression or that eating fish or oils are useful in treatment should not be drawn. Evidence argues against the results from Hibbeln’s study. Since the most common cause of suicide is major depression, it is noteworthy that there have been several reports of reduced concentrations of CSF 5-HIAA in individuals with major depression and in those with a history of serious suicide Moreover, if lower attempts.2 serotonergic activity contributes to suicide risk, there are also several factors associated not only with increased risk of suicide but also with

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lower serotonergic activity. Low serum concentrations of cholesterol or cholesterol-lowering treatments is one of these factors.2,3 Low cholesterol increases the likelihood of suicidal behaviour and, at least in non-human primates, it decreases serotonergic function selectively. Given the effects of fish consumption on serum lipids, people who live in the countries cited by Hibbeln with a high annual fish consumption would be expected to have lower cholesterol serum concentrations. Accordingly, they would also be expected to have lower CSF 5-HIAA concentrations, increased suicide risk, and higher rates of major depression, thus contravening the correlational relation found by Hibbeln. Xavier Bosch Internal Medicine Unit, Hospital Casa Maternitat, Corporació Sanitària Clínic, 08028-Barcelona, Spain 1 2 3

Hibbeln JR. Fish consumption and major depression. Lancet 1998; 351: 1213. Mann JJ. The neurobiology of suicide. Nat Med 1998; 4: 25–30. Golomb BA. Cholesterol and violence: is there a connection? Ann Intern Med 1998; 128: 478–87.

approach to the informed-consent process, but leads him also to support the involved-participant approach, as advocated so eloquently by Lisa Power.4 This approach supports my own belief5 that “we all have a responsibility to contribute to research”, not necessarily by being passive patients or participants but by being full partners in the whole research process—formulation of hypothesis; choice of relevant outcome; design of protocol and information for patients; running of trial; and dissemination and interpretation of results. Tobias’s identification of the potential of the Consumers’ Advisory Group for Clinical Trials might provide a more democratic proposal for the way forward, one which counters today’s clamour for autonomy with provision of opportunities for exercising responsibility? Hazel Thornton Consumers’ Advisory Group for Clinical Trials, “Saionara”, 31 Regent Street, Rowhedge, Colchester, Essex CO5 7EA, UK 1 2

Patients’ understanding of clinical trials Sir—I welcome J R Farndon’s concern (May 30, p 1663)1 for making progress in medical understanding and treatments through clinical trials. There are, however, serious drawbacks to the recommendations he proposes to remedy the question of timing for the provision of information and consent through the UK’s NHS Breast Screening Programme (BSP), in which as he states, an ideal opportunity for public education continues to be missed! There, I fully agree. He is correct in identifying that the honest and informative approach of telling women about the uncertainties surrounding in-situ disease might affect their decision to be screened. Herein lies the rub! To do so would prejudice the NHS BSP’s target of 70% uptake required to make the programme work. Farndon’s solution pre-supposes that we are pursuing a sensible and acceptable policy in offering population mammographic screening for women aged 50–64 years, and that the UK trial on ductal carcinoma insitu of the breast is an acceptable study to both the profession and patient, whereas this is far from the truth.2 Jeffrey Tobias’s preference for a “traditional pastoral approach”3 not only leads him to recommend a flexible

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Farndon JR. Patient’s understanding of clinical trials. Lancet 1998; 351: 1663. Thornton H. Randomised clinical trials: the patient’s point of view. In: Silverstein MJ, ed. Ductal carcinoma in situ of the breast. Baltimore USA: Williams and Wilkins, 1997. Tobias JS. Changing the BMJ’s position on informed consent would be counterproductive. BMJ 1998; 316: 1001–02. Power L. Trial subjects must be fully involved in design and approval of trials. BMJ 1998; 316: 1003–04. Thornton H. We all have a responsibility to contribute to research. BMJ 1997; 314: 1479.

Down on the farm Sir—Picture this. It is a warm day in early May, around lunch time. The sun is high in the clear blue sky and a gentle breeze moves the early growth on the vines. A large white goose struts across the farmyard, honking loudly at unfamiliar faces. The hens cluck in protest, fearful that their eggs might be disturbed. The policeman lights a cigarette and flicks the match on to the ground. In the barn, a bitch sits in the shade with her half dozen puppies. Some men are erecting a makeshift bench with a broad piece of wood found in the yard, possibly part of an old door. They place it on two trestles under a lean-to at the side of the farmhouse. The family, all dressed in black, look on; some of the women and young girls are crying. They are unhappy with the proceedings and would like to intervene, but the policeman is here. They are wary of

him, perhaps they still remember the old days. The body of a man in his early fifties, still fully clothed, is carried out of the house. He is placed on the bench and undressed. One of the men unpacks a box of sharp knives and makes two long cuts, one across the top of the head; the other from neck to pubis. From the side of the shed a large black pig sniffs the air nervously, he can smell the blood. The skull is sawn open and the dead man’s brain is placed on the bench beside him, then the internal organs are removed. The family are aware of what is happening, but are kept at the front of the house. They are unable to see, but they can hear. Some friends and neighbours have gathered and they talk. Perhaps for distraction, some of the women prepare lunch. The same flies that were attracted to the body now show an interest in the food. One of the men starts to examine the organs. He has done this many times before and it’s so much easier in the warm weather, when his fingers don’t freeze and the flesh is soft. The examination finishes and the men call for water from the well to wash the body. They remove their gloves; now it is time for the paperwork. A scene from a war zone? Some state atrocity against the people? Perhaps a passage from a horror novel? No, this is a routine necropsy in Romania. An unexpected death at home, what we would call a coroner’s case. The doctor, a good man, does this perhaps two or three times a week. He always insists on the police being present since this prevents any serious protests from the family. He knows it’s not ideal, but even if the body could be taken to the hospital mortuary, there would be no system to return it to the family for the funeral; the distances involved are too great and they are far too poor to pay for transport. For the moment it has to be done this way. Two people are present as observers. They look different to the others, slightly foreign. The family can see from the way the police and the doctor speak with them that they have some status. They offer them plum brandy, which they politely decline. The dead man’s son gives three bottles to the technician in return for his help in dressing the body. We are there with Medical Support in Romania (a registered charity based in Cambridge, UK). Perhaps between us we can find an alternative. M D Harris Hinchingbrooke Hospital, Hinchingbrooke Park, Huntingdon, Cambridgeshire PE18 8NT, UK

THE LANCET • Vol 352 • July 4, 1998