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Aging E Book: Human Needs and

Nursing Response 9th Edition, (Ebook
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Ebersole and Hess' Toward
Healthy Aging

Human Needs and Nursing

Response

NINTH EDITION

Theris A. Touhy, DNP, CNS, DPNAP

Emeritus Professor, Christine E. Lynn College of Nursing, Florida Atlantic
University, Boca Raton, Florida

Kathleen Jett, PhD, GNP-BC

Gerontological Nurse Practitioner, Senior Care Clinic at Oak Hammock,
Department of Aging and Geriatric Research, University of Florida, College
of Medicine, Gainesville, Florida
To my three sons and daughters-in-law, thanks for surrounding me with love
and family. To my husband, just thanks for loving me for 47 years even
though it's not always easy!

To my beautiful grandchildren, Colin, Molly, and Auden Touhy. Being your

Grama TT makes growing older the best time of my life and I love you.
To all the students who read this book. I hope each of you will improve the
journey toward healthy aging through your competence and compassion.
To all of my students who have embraced gerontological nursing as their
specialty and are improving the lives of older people through their practice
and teaching.

To the wise and wonderful older people whom I have been privileged to
nurse, and to their caregivers. Thank you for making the words in this book
a reality for the elders for whom you care, and for teaching me how to be a
gerontological nurse.
Theris A. Touhy
To my patients and others who teach me every day about the highs and lows
of the furthest reaches of age and what really matters the most in life.
To my husband Steve, for his patience during the year I worked on this
edition, with little time for anything else.

To the staff at The Diner where I wrote and re-wrote for many hours in a
place with no distractions and a sunny window. They always kept my iced
tea glass full, knew what I wanted to eat, and how I liked it cooked!
I thank them.

And to Dr. Michael Johnson, who pushes me to grow and helps my soul
seek peace.

Kathleen Jett
ELSEVIER 325 I Riverport Lane
St. Louis, Missouri 63043

EBERSOLE & HESS' TOWARD HEALTHY AGING, NJ NTH EDITION ISBN: 978-0-323-32138-9

Copyright© 2016 by Elsevier, Inc. All rights reserved.

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2012, 2008, 2004, 1998, 1994, 1990, 1985, and 1981.

Library of Congress Cataloging-in-Publication Data

Touhy, Theris A., author.

Ebersole & Hess' toward healthy aging: human needs & nursing response/Theris A. Touhy, Kathleen F. Jett.­
Ninth edition.
p.;cm.
Ebersole and Hess' toward healthy aging
Toward healthy aging
Includes bibliographical references and index.
ISBN 978-0-323-32138-9 (pbk.: alk. paper)
I. Jett, Kathleen Freudenberger, author. 11. Title. Ill. Title: Ebersole and Hess' toward healthy aging. IV. Title:
Toward healthy aging.
[DNLM: 1. Geriatric Nursing. 2. Aged. 3. Aging. 4. Health Promotion. WY 152]
RC954
618.97'0231-dc23
2015004733

Conte,11 Strategist: Sandra Clark

Conte/11 Development Manager: Laurie Gower
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Theris A. Touhy, DNP, CNS, DPNAP, has been a clinical special-
ist in gerontological nursing and a nurse practitioner for over
35 years. Her expertise is in the care of older adults in nursing
homes and those with dementia. The majority of her practice as
a clinical nurse specialist and nurse practitioner has been in the
long-term care setting. She received her BSN degree from
St. Xavier University in Chicago, a master's degree in care of the
aged from Northern Illinois University, and a Doctor of Nursing
Practice from Case Western Reserve University. Dr. Touhy is an
emeritus professor in the Christine E. Lynn College of Nursing
at Florida Atlantic University, where she has served as Assistant
Dean of Undergraduate Programs and taught gerontological
nursing and long-term, rehabilitation, and palliative care nurs-
ing in the undergraduate, graduate, and doctoral programs. Her
research is focused on spirituality in aging and at the end of life,
caring for persons with dementia, caring in nursing homes, and
nursing leadership in long-term care. Dr. Touhy was the recipi-
ent of the Geriatric Faculty Member Award from the John A.
Hartford Foundation Institute for Geriatric Nursing in 2003, is
a two-time recipient of the Distinguished Teacher of the Year in
the Christine E. Lynn College of Nursing at Florida Atlantic
University, and was awarded the Marie Haug Award for Excel-
lence in Aging Research from Case Western Reserve University.
Dr. Touhy was inducted into the National Academies of Practice
in 2007. She is co-author with Dr. Kathleen Jett of Gerontological
Nursing and Healthy Aging and is co-author with Dr. Priscilla
Ebersole of Geriatric Nursing: Growth of a Specialty.
Kathleen Jett, PhD, GNP-BC, has been actively engaged in
gerontological nursing for over 30 years. Her clinical experience
is broad, from her roots in public health to clinical leadership in
long-term care, assisted living and hospice, researcher and
teacher, and advanced practice as both a clinical nurse specialist
and nurse practitioner. Dr. Jett received her bachelor's, master's,
and doctoral degrees from the University of Florida, where
she also holds a graduate certificate in gerontology. In 2000 she
was selected as a Summer Scholar by the John A. Hartford
Foundation-Institute for Geriatric Nursing. In 2004 she
completed a Fellowship in Ethno-Geriatrics through the Stan-
ford Geriatric Education Center. Dr. Jett has received several
awards, including recognition as an Inspirational Woman of
Pacific Lutheran University in 1998 and 2000 and for her excel-
lence in undergraduate teaching in 2005 and Distinguished
Teacher of the year within the Christine E. Lynn College of
Nursing at Florida Atlantic University. A board-certified geron-
tological nurse practitioner, Dr. Jett was inducted into the
National Academies of Practice in 2006. She has taught an array
of courses including public health nursing, women's studies,
advanced practice gerontological nursing, and undergraduate
courses in gerontology. She has coordinated two gerontological
nurse practitioner graduate programs and an undergraduate
interdisciplinary gerontology certificate program. The majority
of her research and practice funding has been in the area of re-
ducing health disparities experienced by older adults. The thread
that ties all of her work together has been a belief that nurses can
make a difference in the lives of older adults. She is currently
employed as a nurse practitioner at Oak Hammock, a life-care
community associated with the University of Florida, and pro-
vides research consultation for the College of Nursing. In addi-
tion to her professional activities, Dr. Jett is actively engaged in
the lives of her grandchildren in rural High Springs, Florida.
V
 , . ~-------- ................
CONTRIBUTORS REVIEWERS
Debra Hain, PhD, ARNP, ANP-BC, GNP-BC, FAANP Kathleen Koemig Blais, EdD, MSN, RN
Associate Professor/Lead Faculty AGNP Program Professor Emerita
Christine E. Lynn College of Nursing Florida International University
Florida Atlantic University College of Nursing and Health Sciences
Boca Raton, Florida
Miami, Florida
Nurse Practitioner
Department of Hypertension/Nephrology
Sherri Shinn Cozzens, MS, RN, GRN
Cleveland Clinic Florida
Weston, Florida
Nursing Faculty
De Anza College Nursing Program
Maria de los Angeles Ord6iiez, DNP, ARNP/GNP-BC Cupertino, California
Director, Louis and Anne Green Memory and Wellness Center
Memory Disorder Clinic Coordinator Gail Potter, RN, BScN, M. Div., MN, CGNC(C)
Assistant Professor Christine E. Lynn College of Nursing Nursing Faculty
Assistant Professor of Clinical Biomedical Science (Secondary) Department of Health and Human Services
Charles E. Schmidt College of Medicine Selkirk College
Florida Atlantic University Castlegar, British Columbia, Canada
Boca Raton, Florida
P. Janine Ray, RN, CR.RN, MSN, PhD(c)
Lisa Burroughs Phipps, PharmD, PhD Assistant Professor of Nursing
Assistant Professor
Department of Nursing
Virginia Commonwealth University
Academic Learning Transformation Lab
Angelo State University
Richmond, Virginia Member, Texas Tech University System
San Angelo, Texas
Jo Lynne Robins, PhD, RN, ANP-BC, AHN-C, FAANP
Assistant Professor Ann Christy Seckman, DNP, MSN-FNP, RN
Virginia Commonwealth University Associate Professor
School of Nursing Goldfarb School of Nursing
Department of Family and Community Health Barnes-Jewish College
Richmond, Virginia St. Louis, Missouri

JoAnn Swanson, MSN, RN-BC, ONC

Assistant Professor
BSN Program Director
Bellin College School of Nursing
Green Bay, Wisconsin

vi

In 1981, Dr. Priscilla Ebersole and Dr. Patricia Hess published
the first edition of Toward Healthy Aging: Human Needs and
Nursing Response, which has been used in nursing schools
around the globe. Their foresight in developing a textbook that
focuses on health, wholeness, beauty, and potential in aging has
made this book an enduring classic and the model for geronto-
logical nursing textbooks. In 1981, few nurses chose this spe-
cialty, few schools of nursing included content related to the
care of elders, and the focus of care was on illness and problems.
Today, gerontological nursing is a strong and evolving specialty
with a solid theoretical base and practice grounded in evidence-
based research. Dr. Ebersole and Dr. Hess set the standards for
the competencies required for gerontological nursing education
and the promotion of healthy aging. Many nurses, including us,
have been shaped by their words, their wisdom, and their pas-
sion for care of elders. We thank these two wonderful pioneers
and mentors for the opportunity to build on such a solid foun-
dation in the three editions of this book we have co-authored.
We hope that we have kept the heart and spirit of their work, for
that is truly what has inspired us, and so many others, to care
with competence and compassion.
We believe that Toward Healthy Aging is the most compre-
hensive gerontological nursing text available. Within the covers,
the reader will find the latest evidence-based gerontological
nursing protocols to be used in providing the highest level of
care to adults in settings across the continuum. The content is
consistent with the Recommended Baccalaureate Competencies
and Curricular Guidelines for the Nursing Care of Older Adults
and the Hartford Institute for Geriatric Nursing Best Practices
in Nursing Care to Older Adults. The text has been on the list of
recommended reading for the ANCC Advanced Practice Exam
for many years and is recommended as a core text by geronto-
logical nursing experts. Toward Healthy Aging is an appropriate
text for both undergraduate and graduate students and is an
excellent reference for nurses' libraries. This edition makes an
ideal supplement to health assessment, medical-surgical, com-
munity, and psychiatric and mental health textbooks in pro-
grams that do not have a freestanding gerontological nursing
course.
Information about evidence-based practice is presented
where available. A holistic approach, addressing body, mind,
and spirit, along a continuum of wellness, and grounded in car-
ing and respect for person, provides the framework for the text.
The ninth edition has been totally revised to facilitate student
learning. Several new chapters have been added to expand and
update content areas from previous editions. We present aging
within a cultural and global context in recognition of diversity
of all kinds and health inequities which persist. We hope to
encourage readers to develop a world view of aging challenges
and possibilities and the significant role of nursing in promot-
ing healthy aging.
__ _______
.., ,..
ORGANIZATION OF THE TEXT
Toward Healthy Aging has 36 chapters, organized into 5 sections.
Section 1 introduces the theoretical model on which the text
is based and discusses the concepts of health and wellness in
aging and the roles and responsibilities of gerontological nurses
to provide optimal and informed caring. It includes a discus-
sion of the changing population dynamics around the globe as
more and more persons live longer and longer.
Section 2 provides the reader with the basic information
needed to perform the day-to-day activities of gerontological
nursing such as assessment, communication, and interpretation
of laboratory tests.
Section 3 explores concerns that may affect functional abilities
in aging such as vision, hearing, elimination, sleep, physical activ-
ity, and safety and security. Nursing interventions to enhance
wellness, maintain optimal function, and prevent unnecessary
disability are presented.
Section 4 goes into more depth regarding the chronic disor-
ders covered in just one chapter in previous editions. Among
these are chapters on mental health and neurodegenerative
disorders such as Alzheimer's and Parkinson's diseases.
Section 5 moves beyond illness and functional limitations that
may occur in aging and focuses on psychosocial, legal, and ethical
issues that affect elders and their families/significant others. Content
ranges from the economics of health care to sexuality and palliative
care. Aging is presented as a time of accomplishing life's tasks,
developing and sharing unique gifts, and reflecting on the meaning
of life. Wisdom, self-actualization, creativity, spirituality, transcen-
dence, and legacies are discussed. The unique and important
contributions of elders to society, and to each of us, calls for nurses
to foster appreciation of each older person, no matter how frail.
KEY COMPONENTS OF THE TEXT
A Student Speaks/An Elder Speaks: Introduces every chapter
to provide perspectives of older people and nursing students on
chapter content
Learning Objectives: Presents important chapter content and
student outcomes
Promoting Healthy Aging: Implications for Gerontological
Nursing: Special headings detailing pertinent assessment and
interventions for practice applications of chapter content
Key Concepts: Concise review of important chapter points
Nursing Studies: Practice examples designed to assist students
in assessment, planning, interventions, and outcomes to pro-
mote healthy aging
Critical Thinking Questions and Activities: Assist students in
developing critical thinking skills related to chapter and nursing
study content and include suggestions for in-classroom activi-
ties to enhance learning
vii
 Preface

Research Highlights Box

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lips for Best Practice Box

l

Research Questions: Suggestions to stimulate thinking about
ideas for nursing research related to chapter topics
Boxes
Safety Alerts: QSEN competencies and safety issues related to
care of older adults
Research Highlights: Summary of pertinent current research
related to chapter topics
Resources for Best Practice (New to the ninth edition): Sugges-
tions for further information for chapter topics and tools for
practice
Tips for Best Practice (New to the ninth edition): Summary of
evidence-based nursing interventions for practice
Healthy People: Reference to the goals cited in Healthy
People 2020
EVOLVE ANCILLARIES
Instructors
Test Bank: Hundreds of questions with rationales to use in
creating exams
PowerPoint: Lecture slides for each chapter, including
integrated audience response questions
Teach for Nurses Lesson Plans: Detailed listing of resources
available to instructors for their lesson planning, and including
Preface
unique case studies and class activities that can be shared with
students
Students
Student Review Questions: Open-ended study questions cov-
ering nearly every element of each chapter
Case Studies: Accompanying select chapters, these provide
short case studies with questions to help students see content
put into practical use
ACKNOWLEDGEMENTS
This book would not have been possible without the support
and guidance of the staff at Elsevier. Especially Karen C. Turner,
who listened to all of our suggestions and concerns and under-
stood how important this work was to us and to nursing stu-
dents. Special thanks also to Sandra Clark, Content Strategist
and Tracey Schriefer, Project Manager. We also acknowledge
our reviewers and contributors, because without their efforts
this edition would not have been possible. Finally, we acknowl-
edge the past and future readers who, we hope, will provide us
with enough feedback to keep us honest in any future writing.
Theris A. Touhy
Kathleen Jett
PART 1 Foundations of Healthy Aging 7 Health Assessment. 74
Kathleen Jett
1 Health and Wellness in an Aging Society, 1 The Health History, 75
Kathleen Jett and Theris A. Touhy Physical Assessment, 75
The Years Ahead, 2 Functional Assessment, 79
Aging, 3 Function and Cognition, 81
A Wellness-Based Model, 6 Assessment of Mood, 82
Disease Prevention and Health Promotion Comprehensive Geriatric Assessment, 84
for Older Adults, 8
8 Laboratory Values and Diagnostics, 88
2 Gerontological Nursing: Past. Present, and Future, 13 Kathleen Jett
Theris A. Touhy Hematological Testing, 88
Care of Older Adults: A Nursing Imperative, 13 Measures of Inflammation, 91
Development of Gerontological Nursing, 14 Vitamins, 91
Gerontological Nursing Education, 18 Blood Chemistry Studies, 92
Organizations Devoted to Gerontology Uric Acid, 94
Research and Practice, 18 Prostate-Specific Antigen, 94
Research on Aging, 19 Laboratory Testing for Cardiac Health, 94
Gerontological Nursing Roles, 20 Testing for Body Proteins, 95
Transitions Across the Continuum: Laboratory Tests of Renal Health, 96
Role of Nursing, 23 Monitoring for Therapeutic Blood Levels, 96
Appendix 2-A Recommended Baccalaureate Competencies Urine Studies, 97
and Curricular Guidelines 9 Geropharmacology, 101
for the Nursing Care of Older Adults, 29 Kathleen Jett
3 Theories of Aging, 31 Pharmacokinetics, 101
Kathleen Jett Pharmacodynarnics, 104
Biological Theories of Aging, 31 Issues in Medication Use, 104
Psychosocial Theories of Aging, 35 Safe Medication Use, 111

4 Cross-Cultural Caring and Aging, 40 10 The Use of Herbs and Supplements, 115
Kathleen Jett Jo Lynne Robins and Lisa Burroughs Phipps
Culture and Health Care, 40 Standards in Manufacturing, 116
Diversity, 41 Herb Forms, 116
Health Inequities and Disparities, 41 Select Commonly Used Teas, Herbs, and
Obstacles to Cross-Cultural Caring, 42 Supplements, 117
Providing Cross-Cultural Health Care, 43 Use of Herbs and Supplements for Select
Integrating Concepts, 50 Conditions, 121
Herb and Supplement Interactions with
5 Cognition and Learning, 54 Standardized Drugs, 122
Theris A. Touhy
Adult Cognition, 54
Learning in Later Life, 57 PART 3 Wellness and Function
Health Literacy, 60
11 Vision, 130
Theris A. Touhy

----~~.....;=---------
PART 2 Foundations of Caring
6 Communicating with Older Adults, 65
Changes in Vision with Age, 130
Visual Impairment, 132
Diseases and Disorders of the Eye, 133
Theris A. Touhy
Ageism and Communication, 66 12 Hearing, 142
Therapeutic Communication with Older Adults, 67 Theris A. Touhy
The Life Story, 67 Hearing Impairment, 142
Communicating with Groups of Older Adults, 70 Interventions to Enhance Hearing, 144
Tinnitus, 149
 Contents ···:f;

13 Skin Care, 152 PART 4 Wellness and Chronic Illness

Theris A. Touhy
.. -~ - _ _ . _
Skin,153 21 Living Well with Chronic Illness, 278
Common Skin Problems, 154 Kathleen Jett
Skin Cancers, 158 A Model for Chronic Illness, 280
Pressure Ulcers, 160 Frailty, 281
14 Nutrition, 170 22 Cardiovascular and Cerebrovascular Health and
Theris A. Touhy Wellness, 283
Global Nutrition Concerns, 171 Kathleen Jett
Age-Related Requirements, 171 The Aging Heart, 283
Obesity (Overnutrition), 173 Cardiovascular Disease (CVD), 284
Malnutrition (Undernutrition), 174 The Aging Peripheral Vascular System, 291
Factors Affecting Fulfillment of Nutritional Peripheral Vascular Disease, 291
Needs, 175 Cerebrovascular Disorders, 292

15 Hydration and Oral Care, 191 23 Neurodegenerative Disorders, 299

Theris A. Touhy Kathleen Jett
Hydration Management, 191 Diagnosis, 300
Dehydration, 192 Parkinson's Disease, 301
Oral Health, 194 Alzheimer's Disease, 302
Neurocognitive Dementia with Lewy Bodies, 304
16 Elimination, 200 Complications, 305
Theris A. Touhy
Age-Related Changes in the Renal and Urological 24 Endocrine and Immune Disorders, 308
Systems, 201 Kathleen Jett
Urinary Incontinence, 201 The Immune System, 308
Urinary Tract Infections, 210 The Endocrine System, 309
Bowel Elimination, 212 25 Respiratory Health and Illness, 319
Accidental Bowel Leakage/Fecal Incontinence, 216 Kathleen Jett
17 Sleep, 221 Normal Age-Related Changes, 319
Theris A. Touhy Respiratory Disorders, 320
Biorhythm and Sleep, 222
26 Common Musculoskeletal Concerns, 327
Sleep and Aging, 222
Kathleen Jett
Sleep Disorders, 223
The Aging Musculoskeletal System, 327
18 Physical Activity and Exercise, 233 Musculoskeletal Disorders, 328
Theris A. Touhy
27 Pain and Comfort, 339
Physical Activity and Aging, 234 Kathleen Jett
19 Falls and Fall Risk Reduction, 244 Pain in the Older Adult, 340
Theris A. Touhy
28 Mental Health, 352
Mobility and Aging, 244
Theris A. Touhy
Falls, 245
Stress and Coping in Late Life, 353
Restraints and Side Rails, 257
Factors Influencing Mental Health Care, 356
20 Safety and Security , 263 Mental Health Disorders, 359
Theris A. Touhy Schizophrenia, 363
Environmental Safety, 263 Psychotic Symptoms in Older Adults, 364
Home Safety, 263 Bipolar Disorder (BD), 366
Crimes Against Older Adults, 265 Depression, 366
Fire Safety for Elders, 266 Suicide, 371
Vulnerability to Environmental Temperatures, 266 Substance Use Disorders, 373
Vulnerability to Natural Disasters, 269
29 Care of Individuals with Neurocognitive
Transportation Safety, 269
Disorders. 381
Emerging Technologies to Enhance Safety of
Debra Hain. Marfa Ord6iiez, and Theris A. Touhy
Older Adults, 273
Caring for Individuals with Neurocognitive
Elder-Friendly Communities, 274 Disorders, 381
 ,l Contents

Neurocognitive Disorder: Delirium, 382 Sexuality, 448

Care of Individuals with Mild and Major Sexual Health, 449
Neurocognitive Disorder, 389 Sexual Dysfunction, 450
Communication, 391 Alternative Sexual Lifestyles: Lesbian, Gay, Bisexual,
Behavior Concerns and Nursing Models of and Transgender, 452
Care,393 Intimacy and Chronic Illness, 453
Providing Care for Activities of Daily Living, 398 Intimacy and Sexuality in Long-Term Care
Wandering, 399 Facilities, 455
Nutrition, 400 Intimacy, Sexuality, and Dementia, 456
Nursing Roles in the Care of Persons HIV/AIDS and Older Adults, 456
with Dementia, 401
34 Relationships, Roles, and Transitions, 463
Theris A. Touhy
Later Life Transitions, 463
PART 5 Healthy Aging for Elders and Their Relationships in Later Life, 466
Families Families, 467
Caregiving, 472
30 Economics and Health Care in Later Life, 407
Kathleen Jett 35 Loss, Death, and Palliative Care, 482
Economics in Late Life, 407 Kathleen Jett
Economics and Health Care, 409 Loss, Grief, and Bereavement, 482
Grief Work, 483
31 Common Legal and Ethical Issues, 417
Dying and Death, 489
Kathleen Jett
Palliative Care, 493
Decision-Making, 417
Decision-Making at the End of Life, 494
Elder Mistreatment, 419
36 Self-Actualization, Spirituality, and Transcendence, 502
32 Long-Term Care, 427
Priscilla Ebersole and Theris A. Touhy
Theris A. Touhy
Self-Actualization, 503
Future Projections, 427
Wisdom,504
Costs of Long-Term Care, 428
Creativity, 506
LTC and the U.S. Health Care System, 429
Recreation, 507
Global Approaches to LTC, 430
Bringing Young and Old Together, 507
Formal Long-Term Care Service Providers, 431
Spirituality, 508
Quality of Care in Skilled Nursing Facilities, 437
Transcendence,512
33 Intimacy and Sexuality, 445 Legacies, 515
Theris A. Touhy
Touch,445
Intimacy, 447

A STUDENT SPEAKS
I was so surprised when I went to the senior center and saw all those old folks doing tai chi! I feel a bit
ashamed that I don't take better care of my own body.
AN ELDER SPEAKS
Just a change in perspective! I can choose to be well or ill under all conditions. I think, too often we feel
like victims of circumstance. I refuse to be a victim. It is my choice and I have control.
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Compare and contrast the historical events influencing the
health and wellness of those 60 and older.
2. Discuss the implications of the wide range of life expectan-
cies of older adults in different parts of the world.
3. Describe a wellness-based model that can be used to pro-
mote the health of an aging, global community.
4. Describe the priorities of the National Prevention Council
and suggest how these apply to the aging adult.
Herb is an 85-year-old man who considers himself"American."
His great grandfather was born just after the American Civil
War. Earlier in Herb's life he was a business executive but his
passion was car racing. Today he works out in the gym and
walks 8 miles a day. He no longer races but is active in teaching
others to do so. He is talkative and enjoys interacting with those
around him. He has mild hypertension and atrial fibrillation.
For these conditions he takes a low dose of an antihypertensive
and a blood thinner (warfarin), respectively. When asked why
he is so healthy and active "at his age;' he replies, "I never
thought I would live to be this age, but I have lived life to the
fullest. Mostly I think it is having the right genes, staying as
active as possible and having a positive attitude."
From a perspective of Western medicine, health was long con-
sidered the absence of physical or psychiatric illness. It was
measured in terms of the presence of accepted "norms," such
as a specific range of blood pressure readings and results of
laboratory testing, and the absence of established signs and
symptoms of illness. When any of the parameters negatively
Health and Wellness
in an Aging Society
Kathleen Jett and Theris A. Touhy
@http://evolve.elsevier.com/Touhy/TwdHlthAging
Maggie, age 24
Maria, age 86
5. Discuss the multidimensional nature of wellness and its
implications for healthy aging.
6. Define and describe the three levels of prevention.
7. Develop health-promoting strategies at each level of
prevention that are consistent with the wellness-based
model.
8. Describe the role of the nurse in promoting health in
later life.
affected the ability of the individual to function independently,
debility was assumed. The measurement of a population's health
status was usually infer~ed almost entirely from life expectancy,
morbidity, and mortality statistics. The numbers provided infor-
mation about illness but the health-related quality of life and
wellness of the population could not be inferred. Measuring
health in terms of illness does not reflect the life of persons with
functional limitations, their ability to contribute to the commu-
nity, or their movement toward self-actualization.
Although there had been efforts for many years to recognize
that health meant more than the absence of disease, a national
effort was not organized in the United States until 1979. At that
time initial national goals were set and described in the docu-
ment The Surgeon General's Report on Health and Disease
Prevention (HealthyPeople, 2009). This has been updated every
10 years with the most current document Healthy People 2020.
Many new topical foci have been added to the newest version,
which are especially important to aging (HealthyPeople, 2013b ).
Among these are the dementias and a general area related to
1
.. a J PART 1 Foundations of Healthy Aging

older adults. There is now a new area specific to health-related

quality of life and wellness (HealthyPeople, 2013a). The impor-
tance of social well-being as a part of physical and mental
health was recognized by the World Health Organization
(WHO) in 1949, and the WHO recognized the importance of
measuring social well-being in 2005 (WHO, 2005).
A wellness-based model, derived from a holistic paradigm,
has reshaped how health is viewed and revolutionized the
way health care and health are perceived. Instead of snapshots
in time during a person's illness, a state of wellness can be
uniquely defined anywhere along the continuum of health.
Age and illness influence the ease at which one moves along the
continuum but do not define the individual.
Aging is part of the life course. Caring for persons who are aging
is a practice that touches nurses in all settings: from pediatrics in-
volving grandparents and great-grandparents, to the residents of
skilled nursing facilities and their spouses, partners, and children,
Many grandparents in Africa must care for their young grand-
to nurses providing relief support in countries outside of their
children. (©iStock.com/Peeter Viisimaa.)
own. Holroyd et al. (2009) have estimated that"by 2020, up to 75%
of nurses' time will be spent with older adults" (p. 374). The core
knowledge associated with gerontological nursing affects all of the Population growth will change the face of aging as we
profession and is not limited to any one subgroup of nurses know it and present many challenges today and in our future.
(Young, 2003). Although healthy aging is now an achievable goal for many in
Gerontological nurses can help shape a world in which developed and developing regions, it is still only a distant vision
persons can thrive and grow old, not merely survive. They
have unique opportunities to facilitate wellness in those who
are recipients of care. As we move forward in the twenty-first 2,500
century, the manner in which nurses respond to our aging
society will determine our character because we are no 2,000
greater than the health of the country and the world in which
we Jive. This text is written using a wellness-based model to Ill 1,500
C
guide the reader in maximizing strengths, minimizing limita- ~
tions, facilitating adaptation, and encouraging growth even ~ 1,000
in the presence of chronic illness or an acute health event.
It is about helping persons move Toward Healtlzy Aging. 500
In this ninth edition we appreciate your willingness to join us
in this adventure.
0
1980 2010 2050
Year
THE YEARS AHEAD
AGURE 1-1 Growth in the Number of Persons at Least 60
As we look to the future, the world's population will soon include Across the Globe. (Data from United Nations, Department of Eco-
more persons older than 60 years than ever before. Although nomic and Social Affairs, Population Division: World population
highly variable by country, in 2050 the number of persons older prospects: the 2008 revision, New York, 2009, United Nations.)
than 60 worldwide is expected to more than double from 2010-
that is, the number will increase from 10% to 22%, the majority
100%
of whom are women (Figure 1-1). (United Nations, Department Less developed regions
80%
of Economic and Social Affairs, Population Division [UNDE-
SAPD ], 2005). Most of those older than 60 live in what is referred
..
CII
Cl
,a
C
CII
60%
to as "less developed regions" and the percentage is expected to !:! 40%
Cl
increase from 66% to 79% in this same time period (Figure 1-2) 11. 20%
Developed regions
.....,
(United Nations [UN], 2012a). These elders are the most likely to 0%
1950 1970 1990 2010 2030 2050
be very poor and in need of support to an extent that is not seen Year
in other parts of the world. For example, many grandparents are
FIGURE 1-2 Distribution of World Population Aged 60 and
caring for the estimated 1.3 million Zimbabwean children or- Older by Development Region: 1950-2050. (From United
phaned by acquired immunodeficiency syndrome (AIDS). They Nations, Department of Economic and Social Affairs, Population
have few, if any, organizations in place to help them (UNICEF, Division: World population ageing 2009, New York, 2009, United
2010). Nations.)
 CHAPTER 1
for any of those living in less developed areas of the world,
where lives are shortened by persistent communicable diseases,
inadequate sanitation, and lack of both nutritious food and
health care. It is essential that nurses across the globe have the
knowledge and skills to help people of all ages achieve the high-
est level of wellness possible. Some of the questions that must
be asked include the following: How can global conditions
change for those who are struggling? How can the years of
elderhood be maximized and enriched to the extent possible,
regardless of the conditions in which one lives?
AGING
The term geriatrics was coined by American physician, Ig-
natz Nascher, around 1900 in recognition that the medical
care of persons in later life differed from that of other popu-
lation groups, such as pregnant women or children. Nascher
authored the first medical textbook on treatment of the
"old" in the United States (Nascher, 1914). Aging was re-
flected in his eyes as it was in society-a problem that must
be reversed, eradicated, or held at bay as long as possible.
From the early 1900s, the measurement of the incidence and
prevalence of disease and associated morbidity or death was
the focus . Although monitoring statistics is still important,
the study of later life has been expanded to consideration of
the nexus of time and human development, referred to as
gerontology.
How Old Is Old?
Each culture has its own definition of when one is recognized
as "old." A range of terms is used including elderly, senior citi-
zens, elders, granny, older adult, or tribal elder. In some cultures
elderhood is defined in functional terms-when one is no lon-
ger able to perform one's usual activities (Jett, 2003). Social
aging is often determined by changes in roles, such as retire-
ment from one's usual occupation, appointment as a wise
woman/man of the community, or at the birth of a grandchild.
Transitions may be marked by special rituals, such as birthday
and retirement parties, invitations to join groups such as the
American Association of Retired Persons (AARP, 2014), the
qualification for "senior discounts" (Box 1-1 ), eligibility for age-
related pensions, or recognition of special honor.
Biological aging is a complex and continuous process involv-
ing every cell in the body from birth to death (Chapter 3). The
physical traits by which we identify one as "older" (e.g., gray
hair, wrinkled skin) are referred to as the aging phenotype, that
is, an outward expression of one's individual genetic makeup.
sox...1-1- The Aging Phenotype
A few years ago I stopped coloring my hair. which is almost completely silver
now. It was quite a surprise to me the first time the very young clerk in the
booth at the movie theater assumed I was 65 and automatically gave me the
"senior discount." My husband's hair is only fading to a dull brown. When he
goes alone they tentatively ask. "Do you have any discounts?"
Kathleen, at age 60
Health and Wellness in an Aging Society
The aging phenotype. (©iStock.com/LPETTET; Mlenny.)
Chronological aging may be combined with any of the
previously mentioned biological aging traits or used alone to
define aging. In most developed and developing areas of the
world, chronological late life is recognized as beginning some-
time between the ages 50 and 65, with the World Health Or-
ganization using the age of 60 in their discussions (World
Health Organization (WHO), 2013a). These arbitrary num-
bers have been defined with the expectation that persons
are in the last decade or two of their lives. This is no longer
applicable to men and women in some developed countries
where life expectancies are rising. Japan is most notable.
There, women have the longest potential life expectancy in the
world-29 additional years at the age of 60 (UN, 2012b). In
striking contrast are those living in many West African coun-
tries such as Mali, where both men and women can expect to
live only 13 more years after 60 (Sanderson and Scherbov,
2008). Women at the age of 60 in the United States can expect
to live another 25 years and men another 22 years (UN,
2012b). However, because the population in the United States
is quite diverse, so is life expectancy. Although there has been
a steady increase overall, this has been slower for those consid-
ered non-white when compared with those considered white
(racial classification). For example, in 2010 the life expectancy
at birth for black American men was 4.7 years less than that
for white American men and 3.3 years less than that for black
women (Kochanek et al, 2013) (Figure 1-3).
There is an ongoing controversy among demographers and
gerontologists regarding the use and accuracy of chronological
aging. In 1800 only 25% of men in Western Europe lived to the
age of 60, yet today 90% of this same demographic live to the
age of90 (Sanderson and Scherbov, 2008, p. 3). So in 1800, was
one "old" at 40? Is "old age" delayed until 70 today? How old is
old and can there ever be a universal number?
As life expectancy increases how will we define aging? How
will these definitions, as well as the meaning and the percep-
tion of aging, change as the health and wellness of individuals,
communities, and nations improve? How will nursing roles
and responsibilities change? How can we promote wellness
in those who have a much greater chance of living into their
l00s?
In the countries where the average life expectancies have
expanded most rapidly, the following four generational sub-
groups have emerged: the super-centenarians, the centenarians,
5 rs I PART 1 Foundations of Healthy Aging
90 - All races ~ White
85
I!! 81.0 81.3
g: 80 78.7 78.9
>, r- 15_1 76.2 76.5
.!: 75
QI
:f
"
70
'. j'ln•
~ -=-
0 '--....;,,____:i_---'----'- ~j _ """--=-
___:.I.....__
. ] _
Both sexes Male Female
FIGUF:E 1-3 Life Expectancy at Birth, by Race and Sex: United
States, 201 O. (From Kochanek KD, Arias E, Anderson RN: How did
cause of death contribute to racial differences in life expectancy
in the United States in 2010? INCHS data brief no. 1251. Hyatts-
ville, MD, 2013, National Center for Health Statistics. http://www.
cdc.gov/nchs/data/databriefs/db 125.htm. Accessed September
11, 2014.)
the baby boomers, and those in-between. Elderhood has the
potential to span 40 years or more, attributable in a large part
to increased access to quality health services and emphasis on
improving the health of the public.
The Super-Centenarians
The super-centenarians are those who live until at least
110 years of age. As of 2015 they were born in 1905 or earlier
(Box 1-2). This elite group emerged in the 1960s as those first
documented to have lived so long. According to the New Eng-
land Super-Centenarian Study at Boston University, there are
about 200 to 300 of these exceptionally long-lived persons
worldwide and about 60 in the United States (Schoenhofen
et al, 2006).
Many of the fathers and older siblings of the oldest of this
cohort fought and died in World War I (WWI) (1914 to 1918).
Too old to fight in WWII, they saw their younger siblings repeat
this service to their countries. There are no WWI veterans alive
today. American Frank Buckles died at the age of 110 (1901 to
On August 4. 1997, Mme Calment of Aries, France. died a rich woman at report-
edly the age of 122 years and 4½ months, a super-centenarian. In 1965. when
she was 90 years old, her lawyer recognized the value of the apartment in which
she lived and owned and made her, what turned out to be, the deal of a lifetime.
In eKchange for the deed to the apartment, he would pay her a monthly "pen-
sion" for life and she could live in the apartment the rest of her life. Over the next
32 years she was paid three times the apartment's value. She also outlived the
lawyer. his son, her husband of 50 years. her daughter, and her only grandson.
An active woman. she took up fencing at 85 an9 was still riding a bike at 100.
She smoked until she was 117 and preferred a diet rich in olive oil.
Data from National Institute of Aging (NIA): Aging under the micro-
scope: a biological quest, NIH Pub No. 02-2756. Bethesda, MD, 2003,
U.S. Government Printing Office; Nemoto S, Finkel T: Aging and the
mystery of Aries, Science 429: 149, 2004.
Black 2011) (Duggan, 201 I) and British veteran Florence Green died
at the age of 111 (1901 to 2012) (Fox, 2012).
As teens or young adults the super-centenarians of today
78.0 survived the influenza pandemic of 1918 to 1919, which killed
an estimated 50 million people or one fifth of the world's popu-
II
lation (National Archives, n.d.; U.S. Department of Health and
Human Services [USDHHS], n.d.b ). Referred to as the "Spanish
Flu" or "Le Grippe;' this outbreak began in the United States,
Europe, and a small part of Asia. It spread worldwide almost
overnight. The virulence was such that the period between
exposure and death could be a matter of hours. In 1 year the
life expectancy in the United States dropped by 10 to 12 years
(National Archives, n.d.). Those alive today have also survived
the three subsequent pandemics and three pandemic flu threats
(Table 1-1).
In most developed countries, especially in nontropical
areas, there were no new cases of yellow fever after 1905; how-
ever, cholera, typhoid, and polio still occurred. During the
1916 polio epidemic in New York City, many of the super-
centenarians were toddlers. The sheer numbers affected by the
communicable diseases of the 1800s and 1900s changed the
view of science and the acceptance of governments' role in
protecting the public's health.
A study of 32 super-centenarians in the United States
found that "A surprisingly substantial portion of these
individuals were still functionally independent or required
minimal assistance (Schoenhofen et al, 2006, p. 1237)." Most
functioned independently until after age 100, with no signs
of frailty until about the age of 105. They were found to be
remarkably homogeneous. None had Parkinson's disease,
only 25% had ever had cancer, and stroke and cardiovascular
disease were rare if they occurred at all. Few had been diag-
nosed with dementia. A study of super-centenarians in Japan
corroborated these findings. It is theorized that these unusual
persons have survived this long for "rare and unpredictable"
reasons (Willcox et al, 2008). The unique phenotype is con-
sistent, both biologically and socially. Scientists report that
contributing factors include improvements in socio-political
TABL:E "'t~.,_Pandemic·Flu ·History·Sincea.1 918
YEAR(S) HISTORICAL NAME
Pandemics
1918 The Spanish flu; le Grippe (Hl N1)
1957-1960 Asian flu (H2N2I
1968-1969 Hong Kong flu (H3N2)
2009-2010 H1N1 (Swine flul
Pandemic Flu Threats•
1946-1947 Pseudopandemic
1976 Swine flu
1977 !Northern China) affecting mostly children
1997 and 1999 H5N1 (avian flul
1997 Russian flu (Red flu). affecting only those < 25 years old
*Those influenza outbreaks which were anticipated to spread world-
wide but were controlled before this happened.
Data from the Centers for Disease Control and Prevention.
 CHAPTER 1
conditions, medical care, and quality of life (Vacante et al,
2012). While the number alive today is small, it is predicted
to grow as the centenarians behind them live longer and
healthier (Robine and Vaupel, 2001).
The Centenarians
Centenarians today are between 100 and 109 years of age, the
majority of whom are between 100 and 104 years old (Meyer,
2012). Born between 1905 and 1914, they are primarily the
younger siblings of the super-centenarians. Only the very young-
est of these fought in WWII (1939 to 1946), when approximately
55 million people died, some of whom would have been cente-
narians today.
The Great Depression (approximately 1929 to 1940) was a
global event with disastrous consequences for many. Jobs were
scarce and poverty and malnutrition were rampant. Millions
were unemployed. Young parents struggled to provide their
children with even the barest necessities. American President
Roosevelt implemented "New Deal" programs to provide some
relief through the form of work programs. This included the
Civilian Conservation Corp., which served as a source of a mini-
mal amount of income for 3 million men but put great distances
between family members. Nonetheless, entire families often had
to work, and the skin color of the workforce shifted. African
Americans lost the majority of jobs, with only 50% working in
1930 (Public Broadcasting Service [PBS], 1996-2013).
Smallpox has been a threat to centenarians until about
35 years ago when it was essentially eradicated globally (College
of Philadelphia Physicians [CPP), 201 3). Many centenarians
had all or most of the "childhood" diseases, such as measles,
mumps, chickenpox, and whooping cough; some survivors of
today also had polio as children.
The percentage of those older than 100 years of age is rising
more rapidly than the total population: an estimated increase of
93% between 1980 and 2012 or approximately 61,985 persons in
the United States alone (Administration on Aging [AOA], 2013).
However, several countries have a higher percentage of centenar-
ians per 10,000 persons in their population (Figure 1-4). Based
on the U.S. Census report of 2010, centenarians were over-
whelmingly white (82.5%) , women (82.8%), and living in urban
areas of the Southern states (AOA, 2012). For the first time in
history, parents and their children and grandchildren m ay all
belong to this same "generation."
Along with the rapidly expanding numbers in this cohort,
there is an exponential increase in genetics research to better
understand exceptional longevity in humans and the underpin-
nings of morbidity that is compressed toward the end of their
lives (Sebastiani et al, 2013). Although centenarians still carry
genetic markers within their chromosomes for any number of
health problems, for as yet unknown reasons, these are not
"activated" until much later, if at all, when compared with other
persons (Sebastiani and Perls, 2012).
Those In-Between
There is also a unique cohort born in the 30 years between
1915 and 1945, that is, between those referred to as the baby
boomers and the centenarians; they are the 69- to 99-year-olds
Health and Wellness in an Aging Society
4
3
2.70
0
0
0
0 1.95 1.92
... 2
1.73
g_
-
Japan France United Sweden United
Kingdom States
FIGURE 1-4 Number of Persons Older than 100 per
10,000 Persons in the Population (Select Countries). (Data
from Meyer J: Centenarians: 2010, 2012. 2010 Census special
reports, C201 0SR-03. https://www.census.gov/prod/cen 2010/
reports/c2010sr-03 .pdf. Accessed October 1, 2014.)
of 2015. The oldest were born in the last year or two of WWI
and the youngest at the very end of WWII. This age group in-
cludes some of the last survivors of the Holocaust. Many
fought in WWII. It includes those considered "War Babies"
conceived as a result of relationships between men in the mili-
tary and local women and "left behind" in the countries of
their births (Trucco, 1987).
This cohort in particular came of age during tumultuous
times. Some witnessed or had personal experience with the
American Civil Rights Movement (1955 to 1968) or the assas-
sination of President John F. Kennedy (1963) . Most were old
enough to have been drafted or volunteered to serve in Vietnam
(1959 to 1975).,The"Cold War" was felt by many as the tensions
between the United States and the former Soviet Union reached
fever pitch. Others lost friends and family to the global AIDS
epidemic before the human immunodeficiency virus (HIV) was
isolated in France and the United States in 1983. If born be-
tween about 1929 and 1939, they were children during the
Great Depression. Food was scarce, and for many, medical
and dental care was not possible unless the care could be
"bartered" (for example, a basket of eggs in exchange for a tooth
extraction). In areas where the water lacked natural fluoride,
children's teeth were soft and cavity prone. " Pigeon chest," a
malformation of the developing rib cage caused by lack of vita-
min D, was common. Goiter and myxedema were less common
but were present regionally because of unrecognized iodine
deficiencies. Those who were infants at this time have survived
any number of childhood illnesses. Depending on the year they
were born, they have also survived a number of communicable
disease outbreaks and influenza pandemics (see Table 1-1 ).
Polio infection was a major fear for this cohort and for
some, either they or their friends were affected. A vaccine was
not available to children in the United States until 1955, pro-
viding the most benefits to the youngest of the "in-betweeners"
(CPP, 2013). Penicillin, first discovered in 1928 by Alexander
we w:r:Gb n J PART 1 Foundations of Healthy Aging
Fleming, became usable in humans in 1936 and likely pre-
vented many infection-related mortalities from then to the
present time (Markel, 2013).
The number of persons between the ages of 70 and 99 is
growing at an exponential rate as the boomers begin to join
their ranks. At this time the population in the United States of
those 85 + years of age is expected to triple between 2011 and
2040-from 5.7 million to 14. l million. There is slowly growing
racial and ethnic heterogeneity-88.5% of persons in their 90s
self-identified as white alone, 87.6% in their 80s, and 84% in
their 70s. The group growing older at an increased rate is those
who self-identify as Hispanic (AOA, 2012) (Figure 1-5).
The "Baby Boomers"
The youngest of the "older generation" are referred to as "baby
boomers" or "boomers." They were born somewhere between
approximately 1946 and 1964 depending on how they have
been defined by any one country. In the United States the first
to become baby boomers turned 64 in 2010; the last will do so
20
17.5
u,
15 13.2
C
~ 10
:i
5
0.7
1980 1990 2000 2010 2020 2030 2040 2050
FIGURE 1-5 Projected Increase in Number of Persons Con-
sidered Hispanic in the United States. (From U.S. Administra-
tion on Aging , U.S. Department of Health and Human Services:
A statistical profile of Hispanic older Americans aged 65+ . http://
www.aoa .gov/Agi ng_Statistics/minority _ag ing/Facts-
on-Hispanic-Elderly.aspx. Accessed September 11, 2014.)
21 years later in 2031. More babies were born in the United
States in 1946, the year after the end of WWII, than any other
year-3.4 million or 20% more than in 1945. These numbers
increased every year until they tapered off in 1964. In just
18 years, 76.4 million babies had been born ( History, 1996-
2013 ). Each day another 11,000 "boomers" turn 50 years old
(American Hospital Association [AHA), 2007).
The differences in the life experiences between those born
in the late 1940s and early l 960s are quite significant. For ex-
ample, the eldest had mothers and fathers who had served in
WWII and as young adults they may have been drafted into
the Vietnam War, obtained a "college deferment," or volun-
teered to serve in the military. The youngest in this cohort
may have had only a childhood recollection, if any, of that
period of time.
The baby boomers of today have better access to medication
and other treatment regimens than previous cohorts but will
nevertheless live longer with chronic disease than any of their
predecessors (see Chapter 21). Of particular concern are obe-
sity, diabetes, arthritis, congestive heart failure, and dementia,
all of which we discuss in this text. Some of this increased rate
is related to a lack of importance placed on what we now con-
sider healthful living as they were growing up. For example, in
the 1950s and 1960s smoking was not only condoned, but also
considered a sign of status. Candy in the shape and appearance
of cigarettes was popular with children. Work and public places
and homes were filled with smoke, affecting both the smokers
themselves and those who were exposed to second-hand smoke.
In the 1950s, 50% of the men and 33% of the women in the
United States smoked cigarettes. By 2005 this had decreased to
23% and 19%, respectively (AHA, 2007). Although there has
been improvement in some areas and some parts of the world,
the damage done to the cardiovascular system has already oc-
curred. Cardiovascular disease is the overall number one cause
of noncommunicable death worldwide, killing almost
17 million in 2011 (Figure 1-6) (WHO, 2014b).
The "boomers" in developed countries have had the ben-
efit of the ongoing development of immunizations against
communicable diseases. Although the super-centenarians and
centenarians may not have received these immunizations,
they became a standard of care from 1960 on, when the eldest
boomer was 13 years of age. The ability to produce the potent
antibiotic penicillin and those to follow has been significantly
influential in the survival of this cohort into 2015. The social
emphasis today on healthier lifestyles will go far to help per-
sons reach higher levels of wellness, but for this group, the
challenges are many.
A WELLNESS-BASED MODEL
The burgeoning population of persons entering the last 20 to
40 years of life presents the nurse with opportunities to make a
difference in promoting wellness and stemming the tide of pro-
longed life accompanied by chronic disease and disability, espe-
cially for the baby boomers. While we provide the implications
for nursing practice for the most common health challenges in
aging, we do this from the perspective that a state of relative
 CHAPTER 1 Health and Wellness in an Aging Society

lschemic opportumt1es, and access to health care. The challenge to

heart disease both living and dying in wellness is to balance each of these
Stroke dimensions to the extent possible. The dimensions are like
overlapping petals on a flower, anchored together at the center.
COPD Wellness involves each of these singularly and in interaction
making a fully, richer whole.
A wellness-based model is one in which health is viewed on
a continuum. At one end there is either an absence of disease as
we know it or the presence of chronic diseases that are con-
HIV/AIDS
trolled to the point where their damaging effects are minimized
Diarrheal
diseases
(e.g., a person's blood pressure reading or blood glucose level is
Diabetes within normal limits). At the other end of the continuum is the
mellitus point when an acute episode or multiple concurrent conditions
Road injury result in approaching death but one in which suffering of all
Hypertensive
kind is minimized to the extent possible. The gerontological
heart disease nurse has the opportunity and the responsibility when working
0 2 4 6 8 10 with persons all along the continuum, including at the time of
Millions death, to promote wholeness and wellness as defined by the
FIGURE 1-6 Ten Leading Causes of Noncommunicable individual at any point in time.
Causes of Death Worldwide, 2012. (From World Health Organi-
zation: The top 10 causes of death [Fact sheet no. 310]. http:// The Wellness-Based Model for Healthy Aging
www.who.int/mediacentre/f actsheets/f s310/en/index.html. Healthy aging can no longer be viewed by looking only at later
Accessed September 11, 2014.) life. Reaching for wellness begins in the prenatal period and
continues to death. "To a substantial degree, the health of the
emergent adult is in the hands of the pediatrician" (Barondess,
wellness can be an ongoing goal for both nursing practice and 2008, p. 147). Exciting research in the field of epigenetics is
individuals themselves. This includes how we approach those to leading to new understanding of the effect of environmental
whom we provide care and how we foster health-promoting factors and lifestyle habits such as diet, stress, smoking, and
behaviors. prenatal nutrition on life expectancy and healthy aging.
In this text we use a broad view of wellness to provide nurses The concept of healthy aging from a wellness perspective is
with a framework for addressing the needs of our aging popula- uniquely defined by each individual and likely to change over
tion on a global scale. A wellness-based model encompasses the time. The subcomponents within the wellness model particu-
idea that health is composed of multiple dimensions. Wellness larly applicable to healthy aging are functional independence,
is expressed in functional, environmental, intellectual, psycho- self-care management of chronic illness and disability, positive
logical, spiritual, social, and biological dimensions of the hu- outlook, personal growth, social contribution, and activities
man experience within the context of culture (Figure 1-7). that promote one's health.
These dimensions are juxtaposed on a myriad of other factors, The exponential increase in the number of persons older
including normal changes of aging, income, education, gender, than the age 65 across the globe is a driving force behind the
race, ethnicity and country of origin, place of residence, life social and political pressure to develop, test, and implement
strategies to promote wellness and healthful living across the
continuum of life and country (WHO, 2013b). Some of these
strategies have been found to be effective based on empirical
evidence, others are no longer supported, and many others are
believed to be helpful but we do not yet have the evidence. Be-
cause of the inherent increased health vulnerability as we age,
the efficacy of health-promoting strategies is especially impor-
tant in helping us achieve and maintain the highest level of
wellness possible along the continuum. There are still consider-
able challenges to implement evidence-based practices as a re-
sult of the paucity of research specific to health promotion and
aging, especially when applied to those from historically under-
represented groups. Although this may change as the "baby
boomers" enter the stage of elderhood, the numbers of those
who participate in preventive services at this time are low-
only 25% of those between 40 and 64 years of age and less than
40% of those 65 years and older utilize the preventive services
FIGURE 1-7 Flower model. available to them (Centers for Disease Control [CDC], 2014).
' t efb ,I PART 1 Foundations of Healthy Aging
DISEASE PREVENTION AND HEALTH
PROMOTION FOR OLDER ADULTS
In an effort to move forward, a provision of the Affordable Care
Act in the United States called for creation of the National Preven-
tion Council. Chaired by Surgeon General Dr. Regina Benjamin,
the charges were to partner community and governmental
agencies and establish an action plan for the specific purpose of
accelerating prevention in six priority areas (USDHHS, n.d.a)
(Box l-3). The overarching goals are to implement evidence-
based prevention strategies at the community level (Box 1-4).
These strategies are consistent with both our wellness-based
model and the goals and objectives established by Healthy People
2020 (see www.healthypeople.gov) with a new emphasis on the
needs of d1e older adult (Box 1-5) (USDHHS, 2012) (http://www.
healthypeople.gov/2020/topics-objectives/topic/older-adults).
Primary Prevention
Primary prevention refers to strategies that can and are used to
prevent an illness before it occurs. For example, through a col-
laboration of the Centers for Disease Control and Prevention in
Tobacco-free living
Preventing drug abuse and excessive alcohol use
Healthy eating
Injury and violence free living
Reproductive and sexual health
Mental and emotional well-being
Empowered people
Healthy and safe community environments
Clinical and community preventive services
Elimination of health disparities
~ BOX 1-5 . HEALTHY PEOPLE 2020
Regarding the Health of Older Adults
Goal
Improve the health, function, and quality of life of older persons.
Emerging Issues
Coordination of care
Helping older adults manage their own care
Establishing quality of care measures
Identifying the minimum levels of training for people who care for older
adults
Promoting research and analysis of appropriate training to equip providers
with the tools they need to meet the needs of older adults
Data from U.S. Department of Health and Human Services, Office of
Disease Prevention and Health Promotion: Healthy People 2020, 2012.
http://www.healthypeople.gov/2020
the United States and many worldwide partners, wellness is pro-
moted at the primary level by reducing the incidence and preva-
lence of annual influenza infections (CDC, 2013; WHO, 2013c).
An annual vaccination has been found to be the most safe and
effective way to prevent influenza and related illness globally;
complications are reduced by up to 60% in the elderly and deaths
reduced by 80% among those who become infected (WHO,
2014a). Worldwide there are 3 to 5 million cases a year and
250,000 to 500,000 deaths, the majority of these among persons
more than 65 years of age (WHO, 2014a). In the United States
90% of flu-related death and 60% of flu-related hospitalization
occur in persons 65+ years of age (CDC, 2013). Yet the rates for
influenza vaccinations for persons 65 years and older vary by age,
economic status, place of residence, and race/ethnicity (Box 1-6).
Moving toward and maintaining wellness along the contin-
uum in the context of primary prevention includes many choices
that are under the control of the person. These may include never
starting or stopping smoking, maintaining an ideal body weight,
exercising regularly, eating a well-balanced diet, and using select
age-appropriate dietary supplements such as vitamin D and cal-
cium (see Chapters 14, 18, & 19). Among other strategies at the
primary level are stress management, social engagement, intel-
lectual stimulation, and restful sleep, all of which are essential but
too often not emphasized in gerontological nursing practice.
Non-Hispanic Black People
• In 2009 non-Hispanic blacks at least 65 years old were 30% less likely
(50.8%1 to have received the influenza vaccination than their non-Hispanic
white counterparts (68.6%1.
• In 2010 non-Hispanic blacks were 30% less likely (46.2%1 to have ever re-
ceived a pneumonia vaccination than their non-Hispanic white counterparts
(63.5%1.
American Indian/Native Alaskan People
• Between 2010 and 2011 American Indians/Native Alaskans at least
65 years of age were slightly more likely (68.7%1 to have received an influ-
enza vaccination than their non-Hispanic white counterparts (67.7%1.'
Asian People
• In 2011 Asians at least 65 years of age were only 20% less likely (48%1to
have received the pneumococcal vaccination than their white counterparts
(63.5%1.
• In 2011 Asians were only 20% less likely (48%1 to have received the pneu-
mococcal vaccination than their white counterpans (63.5%1.
Hispanic People
• In 2010 Hispanics at least 65 years of age were only 40% less likely (39%1
to have received the pneumococcal vaccination than their white counter-
parts (63.5%1.
• In 2010 Hispanics were only 30% less likely (50.6%1 to have received the
influenza vaccination than their white counterparts (68.6%1.
*Only U.S. statistics are available. Data from the U.S. Department of
Health and Human Services, Office of Minority Health. http://
minorityhealth.hhs.gov.
'Data for the specific age group not available.
 CHAPTER 1
Secondary Prevention
Secondary prevention is the early detection of a disease or
health problem that has already developed. The goal of early
detection is to increase the likelihood that the problem can be
adequately and effectively addressed and therefore the person
may return to the prior level of wellness or as close to it as pos-
sible (CDC, 2014). The majority of the strategies considered
secondary prevention are in the form of health screenings of
some type and are particularly important in promoting healthy
aging in those whose life expectancy increases with each year
and are active and engaged. Secondary prevention occurs in
comm,mity and senior centers, health fairs, and in health care
providers' offices. Nurses and nurse practitioners are usually
advocates and organizers of these strategies. While one cannot
entirely compensate for a lifetime of lifestyle choices that were
detrimental to one's health, many small health-promoting
changes can ameliorate their impact in later life.
Although primary prevention is extremely important and has
demonstrated efficacy, secondary and tertiary prevention (see
following section) take on new meaning for older adults. For
example, determining who should undergo health screening de-
pends on several key factors, especially relevant as we age or
develop comorbid conditions: if knowing one has a disease or
condition will change the course along the continuum and pro-
jected timing of death or if aggressive treatment such as radiation
or surgery is a reasonable option for any one person (Box 1-7).
Tertiary Prevention
A wellness-based model is most salient in facilitating tertiary
prevention for persons living with chronic diseases or subse-
quent to an acute health event. Tertiary prevention addresses
the needs of persons who have their day-to-day wellness chal-
lenged, either by slowing a disease process (e.g., chemotherapy)
or by limiting complications from a previous event (e.g., reha-
bilitation following a stroke) (Box 1-8). The goals of tertiary
prevention are to promote wellness to the extent possible in
the presence of an active health challenge. Tertiary prevention
may be as "simple" as diabetic meal planning or as complex as
combining speech, swallowing, and occupational and physical
therapy for the person who has had a stroke. With aggressive
A breast mass was noted in a patient in a skilled nursing facility. The nurse
was adamant that the patient should have a mammogram. Although the
85-year-old woman was still quite mobile and cheerful, she also had very ad-
vanced dementia. My inclination was to not pursue this screening. In conversa-
tion with her only living child, we decided that a screening !the mammogram)
would be a hardship for her mother because she would not understand what
was being done to her and the screening itself was not innocuous. If cancer
was found (which was very likely), questions about radiation, chemotherapy,
and so on would need to be addressed. It was agreed that the patient could
neither understand her screening procedure nor withstand any treatment. both
of which would negatively affect her current quality of life. The woman did
not receive the mammogram and died of an acute myocardial event about
3 months later.
Health and Wellness in an Aging Society
B0.~...1-s- Tertiary Prevention in Action
About 9 months ago Helen suffered a stroke that left her partially paralyzed on
the right side. With extensive rehabilitation she was able to regain independent
ambulation with the help of a cane (declining a walker) and functional use of her
affected hand with a brace. The left shoulder had become quite tender because
of a combination of chronic arthritis and overuse. the laner occurring because
she relied on it to a great extent to remain mobile. She came to the wellness
clinic requesting a referral for physical therapy for stretching, heat therapy, and
massage therapy, all of which she was readily given. She has now returned to
her usual activities, until she needs another "dose" of tertiary prevention.
tertiary prevention the person may reach a new level of wellness
in the face of health challenges.
+ Promoting Healthy Aging: Implications
for Gerontological Nursing
The gerontological nurse can use the wellness-based model to
promote healthy aging across the continuum of wellness and
care settings. The model builds on the goals described in the
strategies of the National Prevention Council (Box 1-9) and
Healthy People 2020, expanded now to recognize emerging issues
relevant to healthy aging (see Box 1-4). Gerontological nurses
are active in promoting wellness at the primary level through
participating in and facilitating even the simplest of activities,
such as when the bedside nurse ensures that the patient is served
a meal that is nutritious but also culturally appropriate. Nurses
in the community promote wellness as health educators, advo-
cates, and case managers, making sure people know the services
to which they are entitled and recommended. Advanced practice
nurses are becoming champions of the Annual Health Promo-
tion visit for Medicare recipients (see Chapter 30).
Yet both the goals and the objectives and interventions for
healthy older adults will differ from those for very frail older
adults or those with limited life expectancies. When select pre-
ventive approaches are questionable, the nurse can inform
those involved in health care conversations, leading to the best
decision for any one person. Secondary prevention such as
health screening for the most impaired or those with very short
life expectancies is generally not recommended, but primary
and tertiary prevention is always appropriate. It is the responsi-
bility of the skilled gerontological nurse to design interventions
all along the continuum-from the very active person, like
Active Living
Encourage community design and development that support physical
activity.
Healthy Eating
Improve nutritional quality of food supply (e.g., that provided to residents in
nursing facilities).
Mental and Emotional Well-Being
Promote the early identification of mental health needs and access to quality
services.
•• PART 1 Foundations of Healthy Aging
Herb in the opening paragraph, to those with advanced cogni-
tive impairments, to those who are nearing death.
The nurse promotes biological wellness by promoting regular
physical activity such as playing tennis, participating in wheel-
chair bowling, or sitting upright for intervals throughout the
day. Healthy lifestyles can also be encouraged by promoting
healthy eating and adequate and restful sleep, taking control of
acquired health problems such as hypertension or diabetes, and
avoiding tobacco or tobacco products. Fostering maximal bio-
logical wellness also means advocating for the person to secure
the highest quality of medical care when it is needed. Theim-
plementation of evidence-based care and cutting-edge research
is no longer an option (Box 1-10). At all times the wellness-
based model requires that the lifestyle recommendations be
balanced between burden and benefit.
Tht: nurse promotes social wellness by facilitating activities in
which interactions with others, pets, or both are possible, as
desired. Ongoing social interactions have been found to have a
significant effect on cognition, memory, and mood (Chapters 28
and 29). Through social interaction, persons can be recognized
with inherent value not only in the neutral "person" but also as
sexual beings, as men and women, regardless of sexual orienta-
tion, age, or functional ability (Box 1-11 ).
Nurses promote functional wellness across the continuum of
care and roles. The bedside nurse ensures that the physical en-
vironment is one that promotes healing and encourages the
person to remain active and engaged at the highest level possi-
ble. For example, it is not appropriate to help someone out of a
chair who is able to do so, albeit slower. This type of "help"
negatively affects both muscle tone and self-esteem.
Promoting Health
r- ~OIW~~i~n ;~sear~hers re~i:t~~ 30 persons at least-75 years old to participate
I in a study to test the effectiveness of a series of telephone support calls on a
1 rituals are taken into account when scheduling medical ap-
' number of factors, including mental health. sense of coherence, self-care, and
a sense of ability to perform self-care activities. A significant difference was
found between those who received the calls and those who did not. Those who
1
received the calls improved especially in the indicators of mental health,
' thought to be precursors of the use of health-promoting activities.
L---··· ---- --··. -· --- --·· - --------------
·--.. ·---- -···--·- ·--------
Data from Sudsli K, Soderhamn U, Espner GA, et al: Self-care telephone
talks as a health promotion intervention in urban home-living 75+ years
of age: a randomized controlled study, Clin lnteN Aging 9:95-103, 2014.
sox-.1--1-1- The Social Dimension
There was a long-term care facility in which the staff was consistently friendly
to the residents, regardless of their functional or cognitive status. For many of
the residents the staff was all of the family they had left. One of the residents
had been there a long time and would likely spend the rest of his life there
because of brain damage from uncontrollable seizures. Although communica-
tion was difficult, he got much pleasure in "flirting" with the staff. One day a
nurse was observed stopping by his chair and commenting on a new baseball
cap he had been given. She said "you're smokin' in that cap there! " His smile
could not be broader and they each went about their different directions.
Addressing the environmental dimension of the wellness
model is individual to the person but often includes political
activism. Those living in the inner city may be facing increased
crime and victimization, exposure to pollution, reduced access
to fresh fruits and vegetables, and greater dependence on dwin-
dling public transportation. It may be necessary for the nurse to
become involved in creating healthy living spaces by advocating
for adequate funding for a wide range of resources from street
lighting to funding of local agencies that provide aging-related
services, such as the American Aging Association (http://
www.americanagingassociation.org), the National Society for
American Indian Elderly (http://nsaie.org), or EUROFAMCARE
(Family Care of Older Adults in Europe). The gerontological
nurse helps to create living spaces and practices that respect and
support an environment that supports healthy aging.
Addressing the psychological dimension of the wellness model
most often calls for identifying potential threats to this aspect of
the person. Psychological health includes being aware of and
accepting one's feelings. The nurse is often the one to observe
and assess this dimension and challenge the view held by both
persons themselves and health care providers-that declines in
mental and cognitive health are "normal changes with aging:' In
many cases the signs and symptoms of dementia may actually
be the misdiagnosis of depression (Chapter 28). The nurse can
take the lead in addressing these misconceptions and helping
persons who are wrestling with new or life-long psychological
challenges as they age.
The spiritual dimension of the wellness-based model may be
described as that which gives one's life meaning, be this a rela-
tionship with a greater source (e.g., God, Allah, The Great
Spirit, Wakan Tanka, Gitche Manitou) or a relationship with
others or the sense of the community or world. The nurse fos-
ters the spiritual dimension of the person through awareness or
at least openness to how others view and express their own
spirituality. This may be ensuring that the person's spiritual
pointments or procedures or even when taking vital signs in the
hospital setting. It also means that the nurse and the rest of the
health care team respect and account for dying and death ritu-
j
als as appropriate (Chapter 35).
I
j When nurses address the person's needs along the contin-
uum within his or her personal perspective, they are respecting
the patient's culture regardless of what it is and the form it
takes. It may be ensuring the appropriate food is provided, such
as a serving of pasta or rice with each meal, or facilitating the
inclusion of an indigenous healer in the care team.
The nurse promotes wellness in all dimensions within the
context of the person's culture. By listening closely, nurses can
hear what is most important to persons and what can be done
to promote their wellness. The nurse's role across the globe is
to facilitate the creation of economic, social, and physical envi-
ronments that enhance the opportunity for persons to move
toward wellness through the promotion of healthy lifestyles,
timely health screening, and the ability to participate in
tertiary prevention at every stage of life. The wellness-based
approach is perhaps the most equitable in supporting the
individual's potential for maximal health and functioning at
all ages.
 CHAPTER 1 Health and Wellness in an Aging Society

I KEX__CONCEPTS
Wellness is a multidimensional concept, not a condition. It is
human adaptation at the most individually satisfying level in
response to existing internal and external conditions.
• With increasing life expectancy and numbers of persons
alive, the positive outcomes of health promotion and disease
prevention interventions are more important now than in
any previous time in history.
• The numbers of aging persons in undeveloped areas of the
world will shortly far exceed those living in the more devel-
oped parts of the world.
• For the first time in history an individual and his or her
parent and grandparent may all be of the same socially
described "generation" of older adults.
• The definition of who is "old" and "elder" or a "senior citi-
zen" is changing rapidly; this is expected to change even
further as more and more of the "baby boomers" live longer.
• The promotion of the health of older adults is now recog-
nized in unique and specific ways as noted in the U.S. docu-
ment Healthy People 2020.
• By using a wellness perspective as a basis of practice, the
gerontological nurse can promote health regardless of where
a person is on the health continuum.
A nurse with a wellness focus designs interventions to pro-
mote optimal living, enhance healthy aging, and maximize
quality of life.

Rhonda recently celebrated her 90th birthday with a large number of family
and friends attending from far and near. She said, "That was the best day of my
life! I was married three times but none of the weddings were as exciting as this.
I have attained what I would never have thought possible when I was 50. Yes,
life has been a struggle. One husband died in the Second World War, one was
abusive and we were divorced, and the last husband, a wonderful man, devel-
oped Alzheimer's and I cared for him for six years. My children sometimes
wonder how I have managed to keep such a positive outlook. I believe my pur-
pose in living so long is to be an example of aging well."
Rhonda is frail and thin, and she has advanced osteoarthritis for which she
routinely takes ibuprofen and calcium tablets. She does not tolerate dairy prod-
ucts, so she uses lactose-free products. She eats sparingly but likes almost all
foods and is concerned about good nutrition. Until last year she walked a brisk
mile each day until she broke her hip after slipping on an acorn. Since her fall
she has not regained her full strength and is frustrated that she now has to use
a cane to help steady herself. She is hoping that with enough exercise in the gym
she wi 11 make it to her next birthday.
• Which of the dimensions of wellness as discussed in this chapter are re-
flected in the narrative provided?
• Where would you place Rhonda in the continuum of wellness? Explain your
reasons for doing so.
• Identify three health promotion or disease prevention strategies to talk with Rhoda
about. In doing so you will either listen as she tells you how she has addressed
these over time or suggest to her how they may be incorporated into her life.

I CR ITI _CA L____T _H_I N Kl N G_-·a U_E S TI_O N_S __A_N D ACTI V _I_TI_E S_
-_ - ...
1. Construct a personal definition of health that incorporates promoting health and in preventing illness and which are
the dimensions of the wellness-based model. not. Think of a strategy you use or have heard of and be-
2. Looking into the future, consider which decade you expect lieve to be effective based on evidence. Then look in scien-
wilJ be your last. In what state of health do you expect to be? tific literature (not the newspaper or Wikipedia) to see
3. There are three levels of prevention. As science advances, so what the evidence is at this time.
does our knowledge of which strategies are effective in

I RES E A_R_C H _ au EST ION s _ _ _ _ _ _ _ _ _ _ _ __

-----···-------
1. What factors are the most significant influences of health in 4. How can nurses enhance wellness for older adults in various
aging? stages across the continuum?
2. What are the factors that indicate one is in a state of"wellness"?
3. What are the perceptions of younger people about the pos-
sibility of healthy aging?

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socind/. Accessed December I, 2013.
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topicid=31. Accessed December 1, 2013.
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 Gerontological Nursing:
Past, Present, and Future
Theris A. Touhy

@ http://evolve.elsevier.com//Touhy/TwdHlthAging

A YOUTH SPEAKS
Until my grandmother became ill and needed our help, I really didn't know her well. Now I can look at
her in an entirely different light. She is frail and tough, fearful and courageous, demanding and delight-
ful, bitter and humorous, needy and needed. I'm beginning to think that old age is the culmination of
all the aspects of living a long life.
Jenine, 28 years old

A PERSON AT MID-LIFE SPEAKS

Gerontological nursing brings one in touch with the most basic and profound questions of human exis-
tence: the meanings of life and death; sources of strength and survival skills; beginnings, endings, and
reasons for being. It is a commitment to discovery of the self-and of the self I am becoming as I age.
Stephanie, 46 years old

AN ELDER SPEAKS
I'm 95 years old and have no family or friends that still survive. I wonder if anyone will be there for me
when I leave the planet, which will be very soon I am sure. Mothers deliver, but who will deliver me
into the hand of God?
Helen, 87 years old

LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Discuss strategies to prepare an adequate and competent
eldercare workforce to meet the needs of the growing
numbers of older people across the globe.
2. Identify several factors that have influenced the development
of gerontological nursing as a specialty practice.
3. Discuss several formal geriatric organizations and describe
their significance to nurses.
4. Discuss the role of gerontological nurses in research related
to aging
5. Compare various gerontological nursing roles and require-
ments across the health-wellness continuum.
6. Discuss interventions to improve outcomes for older adults
during transitions between health care settings.

CARE OF OLDER ADULTS: A NURSING
IMPERATIVE
Healthy aging is now an achievable goal for many. It is essential
that nurses have the knowledge and skills to help people of all
ages, races, and cultures to achieve this goal. The developmental
period of elderhood is an essential part of a healthy society and
as important as childhood or adulthood (Thomas, 2004). We
can expect to spend 40 or more years as older adults. Enhancing
health in aging requires attention to health throughout life, as
well as expert care from nurses.
How do nurses maximize the experience of aging and enrich
the years of elderhood for all individuals regardless of the physi-
cal and psychological changes that commonly occur? Nurses have
a great responsibility to help shape a world in which older people
can thrive and grow, not merely survive. Most nurses care for
older people during the course of their careers. Estimates are
"that by 2020, up to 75% of nurses' time will be spent with older
adults" (Holroyd et al, 2009, p. 374). In addition, the public will
look to nurses to have the knowledge and skills to assist people to
age in health. Every older person should expect care provided by
nurses with competence in gerontological nursing.

13
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN