가난한 어린이 설사로 죽는다


5살 미만 어린이 사망 원인 2위,
기후변화가 설사 발병을 부추겨

한겨레 등록 : 2013.04.11 15:45
http://www.hani.co.kr/arti/international/international_general/582365.html

Diarrhoeal disease

Key facts

• Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable.
  
• Each year diarrhoea kills around 700 000 children.
  
• A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and adequate sanitation and hygiene.
  
• Globally, there are nearly 1.7 billion cases of diarrhoeal disease every year.
  
• Diarrhoea is a leading cause of malnutrition in children under five years old.

Diarrhoeal disease is the second leading cause of death in children under five years old, and is responsible for killing around 700 000 children every year. Diarrhoea can last several days, and can leave the body without the water and salts that are necessary for survival. Most people who die from diarrhoea actually die from severe dehydration and fluid loss. Children who are malnourished or have impaired immunity as well as people living with HIV are most at risk of life-threatening diarrhoea.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not diarrhoea, nor is the passing of loose, “pasty” stools by breastfed babies.

Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking-water, or from person-to-person as a result of poor hygiene.

Interventions to prevent diarrhoea, including safe drinking-water, use of improved sanitation and hand washing with soap can reduce disease risk. Diarrhoea can be treated with a solution of clean water, sugar and salt, and with zinc tablets.

There are three clinical types of diarrhoea:

• acute watery diarrhoea – lasts several hours or days, and includes cholera;
  
• acute bloody diarrhoea – also called dysentery; and
  
• persistent diarrhoea – lasts 14 days or longer.

Scope of diarrhoeal disease

Diarrhoeal disease is a leading cause of child mortality and morbidity in the world, and mostly results from contaminated food and water sources. Worldwide, 780 million individuals lack access to improved drinking-water and 2.5 billion lack improved sanitation. Diarrhoea due to infection is widespread throughout developing countries.

In developing countries, children under three years old experience on average three episodes of diarrhoea every year. Each episode deprives the child of the nutrition necessary for growth. As a result, diarrhoea is a major cause of malnutrition, and malnourished children are more likely to fall ill from diarrhoea.

Dehydration

The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced.

The degree of dehydration is rated on a scale of three.

• Early dehydration – no signs or symptoms.
  
• Moderate dehydration:
  
  
  
  • thirst
    
  • restless or irritable behaviour
    
  • decreased skin elasticity
    
  • sunken eyes
  
  
• Severe dehydration:
  
  
  
  • symptoms become more severe
    
  • shock, with diminished consciousness, lack of urine output, cool, moist extremities, a rapid and feeble pulse, low or undetectable blood pressure, and pale skin.

Death can follow severe dehydration if body fluids and electrolytes are not replenished, either through the use of oral rehydration salts (ORS) solution, or through an intravenous drip.

Causes

Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms, most of which are spread by faeces-contaminated water. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning. Rotavirus and Escherichia coli are the two most common etiological agents of diarrhoea in developing countries.

Malnutrition: Children who die from diarrhoea often suffer from underlying malnutrition, which makes them more vulnerable to diarrhoea. Each diarrhoeal episode, in turn, makes their malnutrition even worse. Diarrhoea is a leading cause of malnutrition in children under five years old.

Source: Water contaminated with human faeces, for example, from sewage, septic tanks and latrines, is of particular concern. Animal faeces also contain microorganisms that can cause diarrhoea.

Other causes: Diarrhoeal disease can also spread from person-to-person, aggravated by poor personal hygiene. Food is another major cause of diarrhoea when it is prepared or stored in unhygienic conditions. Water can contaminate food during irrigation. Fish and seafood from polluted water may also contribute to the disease.

Prevention and treatment

Key measures to prevent diarrhoea include:

• access to safe drinking-water;
  
• use of improved sanitation;
  
• hand washing with soap;
  
• exclusive breastfeeding for the first six months of life;
  
• good personal and food hygiene;
  
• health education about how infections spread; and
  
• rotavirus vaccination.

Key measures to treat diarrhoea include the following:

• Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture of clean water, salt and sugar. It costs a few cents per treatment. ORS is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces.
  
• Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
  
• Rehydration: with intravenous fluids in case of severe dehydration or shock.
  
• Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods – including breast milk – during an episode, and by giving a nutritious diet – including exclusive breastfeeding for the first six months of life – to children when they are well.
  
• Consulting a health professional , in particular for management of persistent diarrhoea or when there is blood in stool or if there are signs of dehydration.

WHO response

WHO works with Member States and other partners to:

• promote national policies and investments that support case management of diarrhoea and its complications as well as increasing access to safe drinking-water and sanitation in developing countries;
  
• conduct research to develop and test new diarrhoea prevention and control strategies in this area;
  
• build capacity in implementing preventive interventions, including sanitation, source water improvements, and household water treatment and safe storage;
  
• develop new health interventions, such as the rotavirus immunization; and
  
• help to train health workers, especially at community level.

For more information contact:

WHO Media centre
Telephone: +41 22 791 2222
E-mail: mediainquiries@who.int

Ten Great Public Health Achievements — Worldwide, 2001–2010

Morbidity and Mortality Weekly Report (MMWR)

Worldwide, a child born in 1955 had an average life expectancy at birth of only 48 years (1). By 2000, the average life expectancy at birth had increased to 66 years and, if past trends continue, is projected to rise to 73 years by 2025 (1). These improvements in longevity have resulted from improved living conditions overall, advances in medical science, and a number of population-level interventions. However, major disparities persist. During the past decade, in low-income countries, average life expectancy at birth increased from 55 to 57 years (3.6%), while increasing from 78 to 80 years (2.6%) in high-income countries (2). Analogous to the recent MMWR report highlighting 10 public health achievements that occurred in the United States over the first 10 years of the new century, this report describes global public health achievements during the same period (3). Experts in global public health were asked to nominate noteworthy public health achievements that occurred outside of the United States during 2001–2010. From them, 10 have been summarized in this report. As with the previous report, the 10 global public health achievements are not ranked in any order. Additional information regarding these achievements is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5_addinfo.htm.

Reductions in Child Mortality

Child mortality, a key measurement of United Nations Millennium Development Goal 4, is defined as deaths in children aged <5 years and serves as a major indicator of a nation's health and development, tracking health services and outcomes as well as important social and economic indicators. Currently, an estimated 8.1 million children die each year before reaching their fifth birthday, a decrease of approximately 2 million during the past decade. From 77 deaths per 1,000 live births in 2000, the child mortality rate declined to 62 per 1,000 in 2009. The annual rate of decline in the child mortality rate has increased substantially, from 1.3% per year in the 1990s to 2.2% since 2000. Approximately 99% of all childhood deaths occur in low-income and middle-income countries, with 49% occurring in sub-Saharan Africa and 33% in southern Asia.

Approximately 68% of deaths among children aged <5 years are attributable to infectious diseases, most notably diarrhea, pneumonia, malaria, and acquired immunodeficiency syndrome (AIDS). Undernutrition contributes to at least one third of all childhood deaths, usually in interaction with infectious causes. The vast majority of gains in child survival have been accomplished through scale-up of interventions such as immunization, micronutrient supplementation, access to safe water, insecticide-treated bednets, oral rehydration therapy, antibiotics, antimalarial therapy, and antiretroviral therapies. Increased financial resources, strong partnerships, intensified country support, and innovations in service delivery approaches have made these gains possible. Because of the success in reducing the number of deaths caused by infection, 41% of childhood deaths now occur among neonates; leading causes of neonatal death are preterm birth complications, birth asphyxia, and sepsis (4).

Vaccine-Preventable Diseases

Expanded vaccination coverage is one of the most cost-effective ways to advance global welfare (5). In the first decade of the 21st century, an estimated 2.5 million deaths were prevented each year among children aged <5 years through the use of measles, polio, and diphtheria-tetanus-pertussis vaccines. Expanded coverage with measles vaccine resulted in a 78% decline in measles mortality from 2000 to 2008, averting an estimated 12.7 million deaths. Polio eradication efforts decreased the number of countries with endemic disease from 20 to four, with fewer than 1,500 cases reported in 2010. Global coverage with the third dose of diphtheria-tetanus-pertussis vaccine (a performance measure for vaccination programs) increased from 74% to 82%. Newer vaccines, including hepatitis B vaccine and Haemophilus influenzae type B (Hib) vaccine also are now widely used in national immunization programs globally. The number of countries using hepatitis B vaccine increased from 107 in 2000, to 178 in 2009; with global vaccination coverage of 70% achieved by the end of the decade, at least 700,000 deaths from cirrhosis and liver cancer are expected to be averted in each annual birth cohort in these 178 countries. During 2000–2009, the number of countries using Hib vaccine worldwide increased from 62 to 161; the resulting global coverage of 38% prevented an estimated 130,000 pneumonia and meningitis deaths annually among children aged <5 years.

Studies of disease burden and vaccine efficacy and creation of innovative financing mechanisms accelerated development and use in developing countries of vaccines licensed during the decade. As a result, new and underutilized vaccines for global use (i.e., pneumococcal conjugate [PCV], rotavirus, and rubella vaccines), and vaccines recommended for introduction in certain regions or in countries where certain criteria are met (e.g., Japanese encephalitis, human papillomavirus, meningococcal group A conjugate, and typhoid vaccines) are expected to be available around the world much more quickly than they have been in the past. By the end of 2009, 44 countries had introduced PCV (11% of the global birth cohort), 23 had introduced rotavirus vaccine (11% of the global birth cohort), and 130 had introduced rubella vaccine (42% of the global birth cohort). Substantial work remains for these vaccines to be more widely introduced in developing countries.

Access to Safe Water and Sanitation

Water-related diseases, principally the 2.5 billion cases of diarrhea that occur annually, are the second leading cause of childhood mortality worldwide (6). Diarrhea, almost 90% of which is related to inadequate water, sanitation, and hygiene (WASH), kills 1.5 million children aged <5 years annually, more children than AIDS, malaria, and measles combined (6). From 2000 to 2008, the world’s population increased from 6.1 billion to 6.7 billion, while the proportion of the world’s population with access to improved drinking water sources increased from 83% to 87% (covering an additional 800 million persons), and the proportion with access to improved sanitation increased from 58% to 61% (covering an additional 570 million persons) (7). These gains were made through WASH initiatives to increase water and sanitation coverage and promote hygienic behaviors (e.g., handwashing), as well as through maintaining existing services.

During the previous century, in Europe, North America, and Japan, drinking water treatment virtually eliminated waterborne diseases such as cholera and typhoid (8,9). More recently, although improved WASH access has resulted in significant progress in controlling water-related disease in certain countries (e.g., Mexico and Chile), neglect of WASH infrastructure has contributed to large, deadly, waterborne outbreaks in others (e.g., cholera in Zimbabwe) (10). Continued improvements in global WASH coverage require intensifying current efforts, including long-term, multisectoral commitment to constructing and maintaining water and sanitation systems, behavior change promotion, and WASH-related disease surveillance.

Malaria Prevention and Control

Malaria is the fifth leading cause of death from infectious disease worldwide and the second leading cause in Africa, after human immunodeficiency virus/(HIV)/AIDS (11). The Roll Back Malaria partnership launched in 1998 is a coordinated response to malaria (additional information available at http://www.rollbackmalaria.org). During 2003–2010, financial assistance to malaria-endemic countries increased from approximately $100 million annually to nearly $1.8 billion annually, enabling increased coverage with insecticide-treated bednets, indoor residual spraying, rapid diagnosis and prompt treatment with artemisinin combination therapy, and intermittent preventive treatment during pregnancy (12). As a result, in sub-Saharan Africa, household ownership of insecticide-treated bednets increased from 3% in 2000 to 42% in 2009, protecting approximately 75% of the at-risk population. Protection with indoor residual spraying increased from 13 million households in 2005 to 75 million in 2009. Over the course of the past decade, the estimated number of malaria cases worldwide peaked at 244 million in 2005 but declined to 225 million in 2009. This decline was associated with a 21% decrease in estimated global malaria deaths, from approximately 985,000 in 2000 to 781,000 in 2009.

Prevention and Control of HIV/AIDS

The HIV epidemic continues to be a major global health challenge, with an estimated 33.3 million persons living with HIV at the end of 2009, compared with 28.6 million in 2001 (13). In 2009, 68% of persons living with HIV (22.5 million) were in sub-Saharan Africa (13). Despite this increase, the number of new infections annually has declined from an estimated 3.1 million in 2001 to 2.6 million in 2009. A decline also has been observed in the estimated number of AIDS-related deaths worldwide, from a peak of 2.1 million in 2004 to an estimated 1.8 million deaths in 2009 (13). Public health interventions possibly contributing to decreasing global HIV incidence have included the expansion of programs for provider-initiated HIV testing and counseling, prevention of mother-to-child HIV transmission, which covered an estimated 53% of pregnancies in HIV-positive mothers in 2009 (14), expanded availability and use of condoms and sterile injection equipment, improved blood safety, and antiretroviral therapy (ART). The scale-up of these interventions, including the provision of ART to 5.25 million persons in low-income and middle-income countries in 2009, has been concurrent with the decline in mortality (15). By averting new infections and offering improved health and longer lives to those already infected, these programs have enabled millions to contribute productively to families, communities, and economies.

Tuberculosis Control

During the past decade, 81 million new tuberculosis (TB) cases and 10 million deaths from TB occurred, largely in sub-Saharan Africa and Asia (16). In 1995, the World Health Organization (WHO) published its directly observed therapy, short-course (DOTS) strategy for TB control, focusing on finding and successfully treating TB cases with standardized regimens and rigorous treatment and program monitoring (16,17). Since 1995, DOTS has resulted in 41 million cases cured and 6 million deaths prevented (16). Since 2000, case detection and treatment success rates each have risen nearly 20%, with incidence and prevalence declining in every region. The world is on track to reduce TB mortality to 50% of 1990 levels by 2015 (16). DOTS also is cost effective: in sub-Saharan Africa, implementation of DOTS at a cost of $12 billion (U.S.) would produce $129 billion in economic benefits to the region in 10 years (18).

Despite these successes, HIV-related and multidrug-resistant TB threaten to undermine progress, and TB incidence is declining, but slowly. HIV infection is the primary reason for failure to meet TB control targets in settings with high HIV prevalence, and TB is a major cause of death among persons living with HIV/AIDS. Interventions such as initiation of antiretroviral therapy in TB patients coinfected with HIV can decrease mortality. To address the threat of multidrug-resistant TB, DOTS-Plus strategies, which incorporate practical steps to improve infection control and special guidance on use and quality control of second-line drugs, have been implemented in countries with a high prevalence of this disease (18).

Control of Neglected Tropical Diseases

Neglected tropical diseases affect approximately 1 billion persons worldwide. Three of these diseases have been targeted for elimination or eradication: dracunculiasis (Guinea worm disease), onchocerciasis (river blindness) in the Americas, and lymphatic filariasis. Of these programs, those targeting dracunculiasis and onchocerciasis in the Americas are on the verge of success. In 1986, an estimated 3.5 million cases of dracunculiasis occurred in 20 countries. Using filters, safe water sources, larvicide, and most importantly, health education to encourage water filtration and prevention of water contamination, dracunculiasis transmission has been interrupted in all but four countries (Southern Sudan, Mali, Ethiopia, and Ghana), with most remaining cases in Southern Sudan. With only 1,797 cases reported in 2010, including 10 cases from an outbreak in Chad, the goal of eradication in 2012 is within reach.

The Onchocerciasis Elimination Program in the Americas began in 1992 to use mass drug administration to reduce blindness from onchocerciasis among the 500,000 persons at risk in six countries. By 2010, new cases of onchocercal blindness were eliminated in all 13 regional foci, and Onchocerca volvulus transmission was interrupted completely in eight of these. The goal is to eliminate transmission in all foci in the Americas by 2012.

In 2000, 1.34 billion persons in 72 countries were at risk for lymphatic filariasis and required mass drug administration, and 120 million were infected. With elimination targeted for 2020, the Global Programme to Eliminate Lymphatic Filariasis, begun in 2000, has delivered approximately 3 billion courses of antifilarial treatment at a cost of $0.05–$0.50 per person. Nine of the 72 countries have reached the WHO target for stopping mass drug administration. During 2000–2007, the program prevented infection in an estimated 6.6 million newborns, prevented disease in 9.5 million persons, and averted 32 million disability-adjusted life years.

Tobacco Control

In 2000, 4.8 million premature deaths were attributable to tobacco use (19). By the end of the decade, that number had risen to 5.4 million (20). In 2003, commitments were made through the WHO Framework Convention on Tobacco Control (WHO FCTC), WHO’s first global health treaty, which was adopted by 168 countries by 2010 (21) and four more by June 2011. In addition, WHO developed a package of strategies called MPOWER (monitor tobacco use, protect from tobacco smoke, offer help to quit, warn about the dangers, enforce marketing bans, and raise taxes on tobacco) to support WHO FCTC (20). By 2010, 163 countries had completed youth surveys, and 14 had completed adult surveys as part of the Global Tobacco Surveillance System (22). Survey findings enable countries to track tobacco use and respond with interventions such as price increases; smoke-free policies; bans on tobacco advertising, promotion, and sponsorship; and tobacco-related health information provided via mass media campaigns and graphic health warnings (20).

Smoke-free environments, a component of WHO FCTC and MPOWER, protect persons from tobacco smoke. The U.S. Surgeon General’s report conclusion that no safe level of exposure to tobacco smoke exists (23) and studies showing that smoke-free laws do not harm businesses have heightened worldwide interest in smoke-free policies. By the end of the decade, about half of the world’s population was protected in health-care and educational facilities, although only about 5% of persons were protected by laws encompassing all public places (24). The total global population covered by comprehensive smoke-free laws increased from 3.1% in 2007 to 5.4% in 2008, providing protection for an additional 154 million persons (24).

Increased Awareness and Response for Improving Global Road Safety

Since 2000, when the International Federation of the Red Cross International Disasters Report raised an alarm regarding the worldwide impact of road traffic injuries, significant progress has been made in establishing a global response strategy (25,26). In 2001, WHO launched a 5-year plan to improve global road safety; in 2004, along with the World Bank, WHO issued the World Report on Road Traffic Injury Prevention (26). From 2001 to 2009, the number of annual traffic-related fatalities in the European Union declined 36%, from 55,700 to 34,900 (27). The largest declines in the traffic-related mortality rates from 2000 to 2009 were observed in Spain and Portugal; rates decreased 59.2% in Spain, from 14.5 deaths per 100,000 population to 5.9, and 47% in Portugal, from 12.9 to 6.8 (28).

Despite such advances in road safety in developed countries, approximately 1.3 million persons die on the world’s roads each year (3,000 every day), and this number is projected to double by 2030. Much of the projected worldwide increase is expected to come from low-income and middle income countries, which already account for 90% of global road deaths despite having less than half of the world’s vehicles, and where the number of autos in use in rapidly emerging economies is expected to expand sixfold by 2018, potentially without corresponding improvements in road infrastructure or traffic safety. The Commission for Global Road Safety issued recommendations in 2006 and 2010, further raising the profile of global road traffic injuries and culminating in 2009 with adoption of a United Nations General Assembly resolution proclaiming the period 2011–2020 as the Decade of Action for Road Safety (29,30). The resolution established a 2020 goal of stabilizing and then reducing the forecasted growth of road traffic fatalities around the world by increasing road safety activities, including improved road and vehicle design, speed control, seat belt and helmet use, improved public transport, reduced alcohol-impaired driving, and more effective care of the injured at the national, regional, and global levels. If this goal is achieved, over the decade it could save 5 million lives and $3 trillion and prevent 50 million serious injuries.

Improved Preparedness and Response to Global Health Threats

Pandemic diseases and emerging diseases such as AIDS, severe acute respiratory syndrome, and influenza continue to cause fear, economic instability, severe illness, and premature death. In the past decade, the public health community has improved preparedness for and detection of pandemic threats and is now responding more effectively than before. The 2005 International Health Regulations, which entered into force in 2007, have modernized the international legal framework to improve systematic preparedness and response to pandemic and other emerging public health threats. Use of the Internet and other media for public health surveillance has expanded, and the Global Public Health Information Network, CDC’s Global Disease Detection Operations Center (GDDOC), additional international influenza response networks, and other systems routinely detect and respond to clusters of unusual disease earlier than traditional surveillance. Laboratory and epidemiologic capacity also has improved. For example, since 2006, GDDOC worked with ministries of health to add availability of 185 new diagnostic tests in 59 countries, enabling these countries to conduct tests for pathogens they could not previously perform. Since 2000, a total of 21 new Field Epidemiology Training Programs have been established, three of which are now self-sustained. From 2000 to 2010, these new programs graduated approximately 500 epidemiologists. Cooperative agreements with ministries of health, regional training conducted in collaboration with WHO and other international organizations, and vital public health work to reduce transmission at the animal-human interface also have contributed to reducing the risk of influenza pandemics.

As a result of these and other efforts, the global response to the 2009 influenza A (H1N1) pandemic, which affected more than 214 countries and territories, was the most rapid and effective response to an influenza pandemic in history. The pandemic virus was rapidly identified and characterized. Epidemiologic investigations were conducted to characterize the severity and risk groups, and surveillance data were used to estimate the burden of disease and guide the response in real time. Within weeks of detecting the pandemic virus, diagnostic reagents were provided to laboratories in 146 countries, and laboratory and clinical training was provided, in collaboration with partners, to more than 6,100 health professionals in 34 countries. A vaccine was developed within 20 weeks of virus detection, and through an international donation program, made available to 86 countries. The lessons and experiences of the 2009 H1N1 response continue to inform preparedness efforts for future influenza pandemics as well as future public health emergencies.

Conclusion

During the previous century, great progress was made in raising life expectancy and reducing mortality among infants and young children through improvements in living conditions and activities to combat major infectious causes of death. Collectively, interventions such as those described in this report have contributed to the shifts in major causes of death observed in the new century, with chronic, noninfectious causes increasingly prevalent not only in affluent countries, but also in lower-income and middle-income countries. Noncommunicable diseases and health conditions are expected to account for an estimated 75% of all deaths worldwide by the year 2030 (31). The achievements described in this report demonstrate the capacity of public health agencies to harness and adapt the scientific, technical, legal, and political resources necessary to respond effectively to the problems at hand. This capacity will be tested in the years ahead as public health agencies continue to address communicable diseases while responding to the increasing prevalence of cardiovascular disease, diabetes, cancer, and other noncommunicable conditions and injuries that will require innovative responses to ensure significant public health achievements in the future.

Reported by

Global Public Health Achievements Team, CDC. Corresponding contributor: Ram Koppaka, MD, PhD, Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology, and Laboratory Svcs, CDC; rkoppaka@cdc.gov, 347-396-2847.

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31. World Health Organization. World health statistics 2008. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf . Accessed June 17, 2011.

메이지 시기 서양으로 파견된 이와쿠라 사절단(岩倉使節団)을 통해서 서양의 ‘위생’ 개념이 동아시아에 수입되었다. 

이와쿠라 도모미(岩倉 具視)를 단장으로 한 48명의 사절단은 1871년 12월 23일 요코하마에서 미국 샌프란시스코로 출발하였다.  이들은 워싱턴 DC, 영국, 프랑스, 벨기에, 네덜란드, 러시아, 프로이센, 덴마크, 스웨덴, 오스트리아, 이탈리아, 스위스를 여행하였다. 그리고  돌아오는 길에 이집트, 아덴, 실론, 싱가포르, 사이공, 홍콩, 상하이를 방문하고, 1873년 10월 13일 귀국하였다.

이와쿠라 사절단의 일원이었던 의학자 나가요 센사이(長與專齋, 1838~1902)는 생명이나 생활을 지키는 개념으로서 독일어의 ‘Hygiene’이 사회기반의 정비를 포함하고, 국가와 도시를 포함하고 있는 것에 주목하였다. 그는 서양에서 사용되고 있는 sanitation, health, Hygiene 같은 용어가 단순히 건강보호의 측면에만 사용되지 않는다는 사실을 깨달았으며, 건강과 위생을 담당하는 행정기구의 사무범위가 인간 생활의 거의 모든 분야를 포괄하고 있다는 사실을 알게 되었다.

나가요 센사이는 이 행정기구가  “세상의 危害를 제거하고 국가의 복지를 완전히 하는 기구로서 유행병, 전염병예방은 물론, 빈민구제, 토지청결, 상하수도 설치․배수, 시가 가옥 건축방식부터, 약품․염료․음식물의 단속에 이르기까지, 대체로 인간 생활에 관계된 것은 모두 망라”하고 있다고 전했다.

그는 이 행정기구를 번역함에 있어서 양생(養生), 의무(醫務), 건강(健康), 보건(保健) 같은 직설적인 단어들이 적합하지 않다고 판단하고, 새로운 번역어를 만들어냈다. 그가 독일어 ‘Hygiene’의 번역어로 찾아낸 단어는 장자(莊子) ｢경상초편(庚桑楚篇)｣에 있는 ‘위생(衛生)’이었다. 이 단어는 그 자체로 고아( 高雅)하고 발음도 나쁘지 않기 때문에 ‘Hygiene’의 번역어로 채택하였다.
(松本順自傳․長與專齋自傳, 東京 : 平凡社, 1980, 133-134쪽, 139쪽)

나가요 센사이가 ‘Hygiene’의 번역어로 수용한 ‘위생’이라는 개념에는 서양에서 근대국가가 성립되면서 형성된 국민의 건강을 보호하기 위해서는 국가가 적극적으로 개입해야 한다는 의미가 내포되어 있었다. 다시 말해 국가가 국민의 건강을 보호하기 위해 국민의 생활 전반에 걸쳐서 적극적인 개입을 시행한다는 의미가 들어 있었다.(笠原英彦, 日本の醫療行政, 慶應義塾大學出版會, 1999, 32-33쪽)

나가요 센사이는 1874년(메이지(明治)7년) 일본 문교부 의무국장에 취임했으며, 도쿄의학교(현재의 도쿄대(東京大) 의학부)의 교장을 겸했다. 같은 해 도쿄사약장(東京司薬場, 국립의약품 식품위생연구소의 전신)을 창설했다. 1875년에 의무국이 내무성으로 이관되면서 위생국으로 개칭되었는데, 그 초대국장으로 나가요 센사이가 취임하였다. 그는 콜레라 등 전염병의 유행에 대비하여 위생공사를 추진하고, 위생사상의 보급에 진력하였다. (http://ja.wikipedia.org/wiki/%E9%95%B7%E8%88%87%E5%B0%88%E9%BD%8B)

일본의 메이지 시기 나가요 센사이에 의해  ‘Hygiene’의 번역어로 도입된 ‘위생’ 개념은 조선 말 우리나라로 수입되었다. 강화도조약으로 개항을 한 조선은 1877년 1차 수신사를 일본으로 파견하였다. 김기수의 ‘일동기유’에는 일본으로 출발하기 직전 동래에 머물러 있을 때 일본측으로부터 전해 받은‘성내(城內)’에서 금지조항 28조가 수록되어 있다. 그 내용은 성내’에서는 오물투기, 가옥 앞의 청소, 오수의 준설, 분뇨처리, 방뇨장소 등에 규칙을 마련하고 이를 어길 경우 엄벌에 처한다는 내용이었으며, 김기수 일행은 얼마 후 실제 일본에 도착하여 도로, 하수도, 변소 등 위생관련 시설들의 상황과 관리실태를 주의 깊게 관찰하고 돌아왔다.

고종은 1881년의 총 64명의 조사시찰단(朝士視察團)을 일본으로 파견하여 메이지 일본의 문물과 제도를 시찰하고 보고서를 작성하라고 지시하였다. 이 보고서에는 일본의 정치, 경제, 사법, 교육, 군사 등의 제도가 상세히 기술되어 있다. 일본 내무성 산하에 위생국이 설치되어 있다는 내용도 들어 있다.

1882년 임오군란 이후 박영효는 수신사로 일본에 다견되었는데, 당시 일본에 체류중이던 김옥균과 치도(治道)의 시행에 대해 토론하였다. 이후 김옥균은 “치도략론(治道略論)”과 “치도략칙(治道略則)”을 작성했다. 그 내용에는 분뇨수거, 도로정비, 방화대책 등의 위생에 관한 내용이 많이 포함되어 있다.

1883년 1월 한성판윤에 임명된 박영효는 치도국(治道局)을 설치하고, 순경부(巡警部)를 창설하였다.

1884년 한성순보에는  ｢만국위생회(萬國衛生會)｣라는 기사가 실렸는데, 위생을  “이미 발생한 병을 치료”하는 醫療와 대비되는 개념으로, “모든 병이 발생하기 전에 예방”한다는 개념으로 이해되었다. 또한 위생사업은 “백성을 오래 살게 하는 훌륭한 방법이며 국가를 튼튼하게 하는 참된 법”으로 칭송받았다.( ｢萬國衛生會｣, 漢城旬報, 1884. 5. 5.)

1894년 갑오개혁으로 내무아문 아래 위생국이 설치되었고 ‘경무청관제’가 새행되어 위생관련 업무를 경무청에서 담당하게 되었다.

메이지 일본을 거쳐 조선에 들어온 서양의 위생개념은 국가 공권력의 개입을 통해 일제 식민지 시기를 거쳐 우리나라에 뿌리내리게 된 것이다.

[참고]

‘위생(hygiene)’의 어원은 그리스어 휘게이아(Hygeia)이다. 히게이아는  태양의 신 아폴로(Apollo)의아들인 의학의 신 아스클레피오스(Aesculapius)의 딸이다. 아스클레피오스는 에피오네와 결혼하여 두 명의 아들과 5명의 딸을 두었다. 두 명의 아들은 마카온(Machaon, 외과의사)과 포달레이리오스(Podalirius, 내과의사)이고, 5명의 딸은 휘게이아(Hygieia, 위생), 이아소(Iaso, 의학), 아케소(Aceso, 치유), 아글레이아(Aglæa, 건강한 혈색), 파나케이아(Panacea, 만병통치약)이다.

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PREVENTING PATHOGENIC FOOD POISONING: SANITATION NOT IRRADIATION

Samuel S. Epstein and Wenonah Hauter

Bacterial food poisoning can be readily prevented by long overdue basic sanitary measures rather than by ultrahazardous irradiation technologies.

The food and nuclear industries, with strong government support, have capitalized on recent outbreaks of pathogenic E.coli 0157 meat poisoning to mobilize public acceptance of large scale food irradiation.  Already, the Food and Drug Administration (FDA) is allowing the use of high-level radiation to “treat” beef, pork, poultry, eggs, vegetables, fruit, flour and spices, while the United States Department of Agriculture (USDA) proposes the imminent irradiation of imported fruit and vegetables.

Caving in to powerful corporate industry interests, both House and Senate Appropriations Committees have recently proposed to sanitize the FDA’s already weakened labeling requirements for irradiated food by eliminating the word “irradiated” in favor of “electronic pasteurization” (1); this term was proposed by the San Diego based Titan corporation, an erstwhile major defense contractor using highly costly linear accelerator “E-beam” technology, originally designed for President Reagan’s “Star Wars” program, which shoots food with a stream of electrons travelling at the speed of light.  However, the proposed electronic pasteurization label is a euphemistic absurdity, especially since the FDA’s approved meat radiation dosage of 450,000 rads  is approximately 150 million times greater than that of a chest X-ray, besides circumventing consumers’ fundamental right to know.

             Furthermore, the new labeling initiative is reckless.  Irradiated meat is a very different product from cooked meat.  Whether irradiated by linear accelerators or pelletized radioactive isotopes, the resulting ionizing radiation produces highly reactive free radicals and peroxides from unsaturated fats.  U.S. Army analyses in 1977 revealed major differences between volatile chemicals formed during irradiation or cooking meat (2).  Levels of the carcinogen benzene in irradiated beef were found to be some tenfold higher than cooked beef.  Additionally, high concentrations of six poorly characterized “unique radiolytic chemical products”  admittedly “implicated as carcinogens or carcinogenic under certain conditions,”  were also identified (2).

Based on these striking changes in the chemistry of irradiated meat, FDA’s 1980 Irradiated Food Committee explicitly warned that safety testing should be based on concentrated extracts of irradiated foods, rather than on whole foods, to maximize the concentration of radiolytic products (3).  This would enable development of sufficient sensitivity essential for routine safety testing.  In 1984, Epstein and Gofman more specifically urged that “stable radiolytic products could be extracted from irradiated foods by various solvents which could then be concentrated and subsequently tested.  Until such fundamental studies are undertaken, there is little scientific basis for accepting industry’s assurances of safety” (4).  In an accompanying editorial comment, FDA was quoted as admitting that “it is nearly impossible to detect (and test radiolytic products) with current techniques” on the basis of which the agency’s claims of safety and regulatory abdication still persist (5).

While refusing to require standard toxicological and carcinogenicity testing of concentrated extracts of radiolytic products from irradiated meat and other foods, FDA instead has relied on some five studies selected from 441 published prior to the early 1980’s, on which its claims of safety still remain based.  However, the chair of FDA’s Irradiated Food Task Committee which reviewed these studies insisted that none were adequate by 1982 standards (6), and even less so by the 1990’s (7).  Furthermore, detailed analysis of these studies revealed that all were grossly flawed and non-exculpatory (8).

             These results are hardly surprising since a wide range of independent studies prior to 1986 clearly identified mutagenic and carcinogenic radiolytic products in irradiated food, and confirmed evidence of genetic toxicity in tests on irradiated food (9).  Studies in the 1970’s, by India’s National Institute of Nutrition, reported that feeding freshly radiated wheat to monkeys, rats, mice and to a small

group of malnourished children induced gross chromosomal abnormalities in blood or bone marrow cells, and mutational damage in the rodents (10).

             Food irradiation results in major micronutrient losses, particularly vitamins A, C, E, and the B complex (11).  As admitted by the U.S. Department of Agriculture’s (USDA) Agriculture Research Service, these losses are synergistically increased by cooking, resulting in “empty calorie” food (12); this is a concern of major importance for malnourished populations.  Radiation has also been used to clean up food unfit for human consumption, such as spoiled fish, by killing odorous contaminating bacteria.

            While the USDA is strongly promoting meat and poultry irradiation, it has been moving to deregulate and privatize the industry by promoting a self-policing Hazard Analysis and Critical Control Point (HACCP) control program (13); in late 2000, the agency will start a rulemaking process to privatize meat inspection. Moreover, the Department of Energy (DOE) continues its decades long aggressive promotion of food irradiation as a way of reducing disposal costs of spent military and civilian nuclear fuel by providing a commercial market for cesium nuclear wastes.

Irradiation facilities using pelletized isotopes pose risks of nuclear accidents to communities nationwide from the hundreds of facilities envisaged for the potentially enormous radiation market; in contrast to nuclear power stations, these facilities are small, minimally regulated, unlikely to be secure, and require regular replenishment of cobalt (Co-60) or cesium (Cs-137) isotopes, entailing nationwide transportation hazards.  Furthermore, linear accelerators, besides plants using radioactive isotopes, pose grave hazards to workers and are subject to virtually no regulation (9, 14).

The track record of the irradiation industry is, at best, unimpressive.  Robert Alvarez, former DOE Senior Policy Advisor, recently warned that the Nuclear Regulatory Commission files are bulging with unreported documents on radioactive spills, worker over-exposure, and off-site radiation leakage (15).  Strangely, the Environmental Protection Agency has still failed to require an Environmental Impact Statement prior to the siting of food irradiation facilities.

The focus of the radiation and agribusiness industries is directed to the highly lucrative cleanup of contaminated food rather than to preventing contamination at its source (16).  However, E. coli 0157 food poisoning can be largely prevented by long overdue improved sanitation.  Feedlot pen sanitation, including reducing overcrowding, drinking water disinfection and fly control, would drastically reduce cattle infection rates.  Moreover, E. coli 0157 infection rates could be virtually eliminated by feeding hay, rather than the standard unhealthy starchy grain diet, for seven days prior to slaughter (17).  Sanitation would also prevent water contamination from feed lot run off, incriminated in the recent outbreak of E. coli 0157 poisoning in Walkerton, Ontario (18); run off will remain a continuing threat even if all meat was irradiated.

Pre-slaughter, post-knocking and post-evisceration sanitation at meat packing plants is highly effective for reducing carcass contamination rates (16).  Testing pooled carcasses for E. coli 0157 and Salmonella contamination is economical, practical, and rapid.  The expense of producing sanitary meat would be trivial compared to the high costs of irradiation, including possible nuclear accidents, which would be passed on to consumers.  Additional high costs are likely to result from an anticipated international ban on the imports of irradiated U.S. food, and also from losses of tourist revenues.

             We charge that support of the “electronically pasteurized” label by the food and radiation industries, governmental agencies, and Congress, is a camouflaged denial of citizen’s fundamental right to know.  Rather than sanitizing the label in response to special interests, Congress should focus on sanitation and not irradiation of the nation’s food supply.

Note – This article is largely based on a June 6, 2000 P.R. Newswire press release by the Cancer Prevention Coalition and Public Citizen.

REFERENCES

1.        Congress Pressures FDA For Softer Labeling Of Irradiated Foods.  FDA Week, p. 9-10, May 12, 2000.

2.        Federation of American Societies for Experimental Biology, Evaluation of The Health Aspects of Certain Compounds Found in Irradiated Beef.  Report to the U.S. Army Medical Research and Development Command, Bethesda, MD, August 1977.

3.        U.S. Food and Drug Administration.  Recommendations for Evaluating the Safety of Irradiated Food.  Final Report of FDA’s Irradiated Food Committee.  Washington, D.C.,  July 1980.

4.        Epstein, S. S., and Gofman, J. W.  Irradiation of food.  Science 223:1354, 1984.

5.        Sun, M.  Science 223:1354, 1984.

6.        van Gemert, M.   Memorandum Re: Final Report of the Task Group for the Review of Toxicology Data on Irradiated Food. April 9, 1982.

7.        van Gemert, M.  Letter to New Jersey Assemblyman John Keller, October 19, 1993.

8.        Public Citizen’s Critical Mass Energy and Environment Program and the Cancer Prevention Coalition.  A Broken Record:  How the FDA Legalized and Continues to Legalize Food Irradiation Without Testing it for Safety.  Special Report, October 2000.

9.        Piccioni, R.  Food irradiation: contaminating our food.  Ecologist 18(2):48-55, 1988.

10.     Vijayalaxmi, and Srikantia, S. G.  A review of the studies on the wholesomeness of irradiated wheat conducted at the National Institute of Nutrition, India.  Radiat. Phys. Chem. 34(6):941-952, 1989.

11.     Murray, D. R.  Biology of Food Irradiation.  RSP Research Studies Press Ltd., Taunton, Somerset, England, 1990.

12.     Food Chemical News, Irradiation compounds vitamin loss from cooking, ARS Reports.  November 10, 1986, p. 42.

13.     USDA Food Safety Inspection Service, Irradiation of Red Meat: A Complication of Technical Data for its Authorization and Control.  International Consultative Group on Food Irradiation, August, 1996.

14.     Trager, E. A.  Review of events at large pool-type irradiators.  Office of Analysis and Evaluation of Operational Data, U.S. Nuclear Regulatory Commission, Washington, D.C., March, 1989.

15.     Alvarez, R.  Food irradiation: 50 years of hollow promises.  Bull. Atom. Sci. 2000, in press.

16.     Elder, R. O. et al.  Correlation of enterohemorrhagic E.coli 0157 prevalence in feces, hides and carcasses of beef cattle during processing.  Proc. Nat. Acad. Sci. 97(7):2999-3003, 2000.

17.     Diaz-Gonzalez, F. et al.  Science 281:1666-1668, 1998.

18.     Analysis of Ontario E.coli Walkerton pollution disaster.  The Gallon Environmental Letter, Montreal, Quebec, May 2000.

ENDORSEMENTS

Robert Alvarez, Former Senior Policy Advisor to the Secretary of Energy and Executive

                  Director the STAR Foundation

Kenny Ausubel, Collective Heritage Institute/Bioneers, Santa Fe, NM

Dr. Neal Barnard, President Physicians Committee for Responsible Medicine, Washington, DC

Tewolde Berhan and Sue Edwards, Institute for Sustainable Development, Addis Ababa, Ethiopia

Dr. Rosalie Bertell, International Institute of Concern for Public Health, Toronto, Canada

Barbara Brenner, J.D. Executive Director Breast Cancer Action, San Francisco, CA

Dr. Barry Castleman, Environmental Consultant, Baltimore, MD

Vera Chaney, Green Network, Leyden, Colchester, Essex, U.K.

Citizens Concerns, USA

Ronnie Cummins, National Director Organic Consumers Association, Little Marais, MN

Dr. Donald Dahlsten, Professor and Associate Dean, University of California, Berkeley, CA

Dr. Robert Elder, Senior Microbiologist Neogen Co., Lansing, MI, formerly Senior Scientist

                  Agricultural Research Service, USDA

Margarita Florez, Instituto Latinoamericano de Servicios Legales (ILSA), Columbia

Dr. John Gofman, Emeritus Professor Molecular and Radiation Biology, University of

                  California, Berkeley, CA

Edward Goldsmith, M.A., Publisher and Editor The Ecologist, London, U.K.

Dr. Jay M. Gould, Director Radiation and Public Health Project, USA

Randall Hayes, President Rainforest Action Network, USA

Luc Hens, M.D., Professor Department of Human Ecology, Brussels Free University, Belgium

Dr. Mae-Wan Ho, Director Institute of Science in Society, The Open University, Milton

                  Keynes, U.K.

Jeffrey A. Hollender, President Seventh Generation, Burlington, VT

Dr. Vyvyan Howard, Professor Pathology, University of Liverpool, U.K.

S. M. Mohamed Idris, President, Consumers’ Association of Penang, Sahabat Alam Malaysia (Friends of the Earth Malaysia) and Institute Masyarakat Berhad, Penang, Malaysia

Martin Khor, Director Third World Network, Penang, Malaysia

Dr. David Kriebel, Professor Epidemiology, University of Massachusetts, Lowell, MA

Lynn Landes, Founder and Director Zero Waste America, Yardley, PA

Dr. Marvin Legator, Professor Preventive Medicine, University of Texas, Galveston, TX

Rabbi Michael Lerner, Ph.D., Editor TIKKUN Magazine, San Francisco, CA

Dr. William Lijinsky, former Director Chemical Carcinogenesis, Frederick Cancer Research

                  Center, MD

Dr. E. Lichter, Professor Community Medicine, University of Illinois Medical School, Chicago

                  IL

Dr. Donald Louria, Chairman Department Preventive Medicine, New Jersey Medical School,

                  Newark, NJ

Dr. Sheldon Margen, Emeritus Professor Public Health Nutrition, University of California,

                  Berkeley, CA and Chairman of the Berkeley Wellness Letter

George Monbiot, Health and Science Columnist, The Guardian, London, U.K.

Raymond Monbiot, Fellow of the Marketing Society, London, U.K.

Dr.  Vicente Navarro, Professor Health and Public Policy, The Johns Hopkins University,

                  Baltimore, MD, and Professor Political and Social Sciences, University Pompeu Fabra,

                  Spain

Dr. Herbert L. Needleman, Professor Pediatrics and Psychiatry, University of Pittsburgh,

                  Pittsburgh, PA

Debbie Ortman, National Field Organizer, Organic Consumers Association, Duluth, MN

Dr. Peter Phillips, Professor Sociology, Sonoma State University, Rohnert Park, CA

Dr. Robert Rinehart, Emeritus Professor Biology, San Diego State University, CA

Dr. Janette Sherman, Research Associate Radiation and Public Health Project, and Adjunct

                  Professor Department of Sociology, Western Michigan University, MI

Dr. Vandana Shiva, Director Research Foundation for Science, Technology and Natural

                  Resource Policy, Dehradun, India

Dr. George Tritsch, Cancer Research Scientist, Roswell Park Memorial Institute, New York

                  State Department of Health, NY

Stephen L. Tvedten, CEO Get Set, Inc., President of the Institute of Pest Management, Marne, MI

Dr. Vijayalaxmi, Associate Professor Department Radiation Oncology, University of Texas

                  Health Science Center, San Antonio, TX

Frank D. Wiewel, President People Against Cancer, Otho, IA

Dr. Gesa Staats de Yanes, Professor Fetal and Infant Pathology, University of Liverpool, U.K.

Dr. Quentin Young, past President American Public Health Association, Chicago, IL

NOTE:  Additional endorsements by activist groups and scientists, nationally and internationally, would be welcome. 

Direct reprint requests and further endorsements to:

Dr. Samuel S. Epstein

Emeritus Professor Environmental Medicine,

and Chairman the Cancer Prevention Coalition

University of Illinois School of Public Health

2121 W. Taylor St., Chicago, IL 60612

Wenonah Hauter

Public Citizen

Critical Mass, Energy and Environment Program

215 Pennsylvania Avenue, S.E., Washington, D.C., 20003