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THE IMPORTANCE OF PRENATAL CARE
Regular Checkups 198
Blood Tests 198
Prenatal Nutrition 198
Avoiding Drugs and Other Environmental Hazards
Prenatal Activity and Exercise 202
Preparing for Birth 202
COMPLICATIONS OF PREGNANCY AND PREGNANCY
LOSS 202
Ectopic Pregnancy 203
Spontaneous Abortion 203
Stillbirth 203
Preeclampsia 203
Placenta Previa 204
Placental Abruption 204
Gestational Diabetes 204
Preterm Labor and Birth 204
Labor Induction 204
Low Birth Weight and Premature Birth
Infant Mortality 205
Coping with Loss 205
CHILDBIRTH 205
Choices in Childbirth 205
Labor and Delivery 206
The Postpartum Period 208
Tips for Today and the Future 210
Summary 210
For More Information 210
Selected Bibliography 211
© Wavebreakmedia Ltd/Getty Images
PA R T T H R E E
SUBSTANCE USE DISORDERS: MAKING
RESPONSIBLE DECISIONS
9 DRUG USE AND ADDICTION
ADDICTION 214
What Is Addiction? 215
Diagnosing Substance Misuse and Addiction
198 The Development of Addiction 217
Examples of Addictive Behaviors 217
WHY PEOPLE USE AND MISUSE DRUGS 220
The Allure of Drugs 220
199
Risk Factors for Drug Misuse and Addiction 221
RISKS ASSOCIATED WITH DRUG MISUSE 222
HOW DRUGS AFFECT THE BODY 223
Changes in Brain Chemistry 224
Drug-Related Factors 224
Physical Factors 225
Psychological Factors 225
Social Factors 225
GROUPS OF PSYCHOACTIVE DRUGS 225
Opioids 225
Central Nervous System Depressants 228
Central Nervous System Stimulants 229
Marijuana and Other Cannabis Products 232
204
Hallucinogens 233
Inhalants 234
Prescription Drug Misuse 234
Synthetic Recreational Drugs 234
PREVENTING DRUG-RELATED PROBLEMS 235
Drugs, Society, and Families 235
Legalizing Drugs 236
Drug Testing 236
Treating Drug Addiction 237
Preventing Drug Misuse 240
Tips for Today and the Future 241
Summary 241
For More Information 241
Selected Bibliography 242
10 ALCOHOL: THE MOST POPULAR DRUG 244
ALCOHOLIC BEVERAGES AND THEIR EFFECTS ON
THE BODY 245
Common Alcoholic Beverages 245
Absorption 247
Metabolism and Excretion 247
Alcohol Intake and Blood Alcohol Concentration 248
ALCOHOL’S IMMEDIATE AND LONG-TERM EFFECTS 249
Immediate Effects 249
Drinking and Driving 251
Long-Term Effects of Chronic Abuse 253
Alcohol Use during Pregnancy 255
Possible Health Benefits of Alcohol? 256
EXCESSIVE USE OF ALCOHOL 256
Statistics on Alcohol Use 257
Alcohol Use Disorder: From Mild to Severe 257
213
Binge Drinking 257
Alcoholism 257
Gender and Ethnic Differences 261
216 Helping Someone with an Alcohol Problem 262
CONTENTS vii
DRINKING BEHAVIOR AND RESPONSIBILITY 262
Examine Your Drinking Behavior 263
Drink Moderately and Responsibly 263
Promote Responsible Drinking 264
Tips for Today and the Future 266
Summary 266
For More Information 266
Selected Bibliography 267

11 TOBACCO USE 269

WHO USES TOBACCO? 270
Young People and Tobacco 271
Gender and Smoking 271
Tobacco and Other Drugs 271

WHY PEOPLE USE TOBACCO 271

Nicotine Addiction 273
Social and Psychological Factors 273
Genetic Factors 274
Why Start in the First Place? 274

HEALTH HAZARDS 276

Tobacco Smoke: A Toxic Mix 276
The Immediate Effects of Smoking 278
The Long-Term Effects of Smoking 279
Additional Health, Cosmetic, and Economic Concerns 282 © Maica/Getty Images RF
Risks Associated with Other Forms of Tobacco Use 283

THE EFFECTS OF SMOKING ON THE NONSMOKER 286

Environmental Tobacco Smoke 286
Smoking and Pregnancy 287
The Cost of Tobacco Use to Society 288
WHAT CAN BE DONE TO COMBAT SMOKING?
Action at the Local Level 288
Action at the State and Federal Levels
FDA Regulation of Tobacco 288
International Action 289
Action in the Private Sector 289
Individual Action 289
HOW A TOBACCO USER CAN QUIT
Benefits of Quitting 290
Options for Quitting 290
Tips for Today and the Future 292
Summary 293
For More Information 293
Selected Bibliography 293
PA R T F O U R
GETTING FIT
12 NUTRITION BASICS
296
COMPONENTS OF A HEALTHY DIET
Energy 298
Proteins—The Basis of Body Structure
Fats—Essential in Small Amounts 300
Carbohydrates—An Ideal Source of Energy 303
Fiber—A Closer Look 305
Vitamins—Organic Micronutrients 306
288
Minerals—Inorganic Micronutrients 308
Water—Vital but Often Ignored 308
288
Other Substances in Food 310
NUTRITIONAL GUIDELINES: PLANNING YOUR
DIET 311
Dietary Reference Intakes (DRIs) 311
Dietary Guidelines for Americans 312
290
USDA’s MyPlate 317
DASH Eating Plan 322
The Vegetarian Alternative 322
Dietary Challenges for Various Population Groups 323
Global Nutrition Transitions 324
A PERSONAL PLAN: MAKING INFORMED CHOICES
ABOUT FOOD 325
Reading Food Labels 325
Calorie Labeling: Restaurants and Vending Machines 327
Dietary Supplements 327
Protecting Yourself against Foodborne Illness 329
Environmental Contaminants 330
Organic Foods 331
298 Guidelines for Fish Consumption 331
Additives in Food 331
299 Functional Foods 331

viii CONTENTS
Food Biotechnology 332 Body Fat Distribution 378
Food Allergies and Food Intolerances 332 What Is the Right Weight for You? 379
Tips for Today and the Future 333 BODY FAT AND WELLNESS 380
Summary 333 Diabetes 380
For More Information 334 Heart Disease and Other Chronic Conditions 382
Selected Bibliography 335 Problems Associated with Very Low Levels of Body Fat 382
FACTORS CONTRIBUTING TO EXCESS BODY FAT 382
13 EXERCISE FOR HEALTH AND FITNESS 342 Energy Balance 382
Genetic Factors 383
THE BENEFITS OF EXERCISE 343
Physiological Factors 383
Reduced Risk of Premature Death 343
Lifestyle Factors 385
Improved Cardiorespiratory Functioning 344
Psychosocial Factors 386
More Efficient Metabolism and Improved Cell Health 344
Environmental Factors 387
Improved Body Composition 345
Disease Prevention and Management 345 ADOPTING A HEALTHY LIFESTYLE FOR SUCCESSFUL
Improved Psychological and Emotional Wellness 346 WEIGHT MANAGEMENT 388
Improved Immune Function 347 Dietary Patterns and Eating Habits 389
Prevention of Injuries and Low-Back Pain 347 Physical Activity and Exercise 392
Improved Wellness for Life 347 Thinking and Emotions 392
Coping Strategies 392
WHAT IS PHYSICAL FITNESS? 347
Cardiorespiratory Endurance 348 APPROACHES TO OVERCOMING A WEIGHT
Muscular Strength 348 PROBLEM 392
Muscular Endurance 349 Doing It Yourself 392
Flexibility 349 Diet Books 394
Body Composition 349 Dietary Supplements and Diet Aids 395
Skill-Related Components of Fitness 349 Weight Loss Programs 396
Prescription Drugs 398
COMPONENTS OF AN ACTIVE LIFESTYLE 349
Surgery 398
Levels of Physical Activity 350
Increasing Physical Activity 350 BODY IMAGE AND EATING DISORDERS 399
Reducing Sedentary Time 351 Severe Body Image Problems 399
Eating Disorders 400
DESIGNING YOUR EXERCISE PROGRAM 353
Positive Body Image: Finding Balance 403
First Steps 353
Cardiorespiratory Endurance Exercise 357 Tips for Today and the Future 403
Exercises for Muscular Strength and Endurance 360 Summary 404
Flexibility Exercises 362 For More Information 404
Training in Specific Skills 363 Selected Bibliography 404
Putting It All Together 363
GETTING STARTED AND STAYING ON TRACK 364 PA R T F I V E
Selecting Instructors, Equipment, and Facilities 364 PROTECTING YOURSELF FROM DISEASE
Eating and Drinking for Exercise 364
Managing Your Fitness Program 366 15 CARDIOVASCULAR HEALTH 408
Tips for Today and the Future 369 THE CARDIOVASCULAR SYSTEM 409
Summary 369 The Heart 410
For More Information 370 The Blood Vessels 411
Selected Bibliography 370
RISK FACTORS FOR CARDIOVASCULAR
DISEASE 412
14 WEIGHT MANAGEMENT 374 Major Risk Factors That Can Be Changed 412
Contributing Risk Factors That Can Be Changed 418
EVALUATING BODY WEIGHT AND BODY
Major Risk Factors That Can’t Be Changed 422
COMPOSITION 375
Possible Risk Factors Currently Being Studied 423
Body Composition 376
Defining Healthy Weight, Overweight, and Obesity 376 MAJOR FORMS OF CARDIOVASCULAR DISEASE 425
Estimating Body Composition 377 Atherosclerosis 426
Body Mass Index 377 Coronary Artery Disease and Heart Attack 427

CONTENTS ix

© Leonardo Patrizi/Getty Images RF
Stroke 431
Peripheral Arterial Disease 433
Congestive Heart Failure 433
Other Forms of Heart Disease 434
PROTECTING YOURSELF AGAINST CARDIOVASCULAR
DISEASE 434
Eat Heart-Healthy 435
Exercise Regularly 437
Avoid Tobacco Products 437
Manage Your Blood Pressure, Cholesterol Levels, and
Stress/Anger 437
Tips for Today and the Future 437
Summary 438
For More Information 438
Selected Bibliography 438
16 CANCER 441
BASIC FACTS ABOUT CANCER
Tumors 442
Metastasis 443
The Stages of Cancer 444
Remission 444
The Incidence of Cancer 444
THE CAUSES OF CANCER
The Role of DNA 445
Cancer Promoters 448
Tobacco Use 448
Dietary Factors 449
Inactivity and Obesity 450
Carcinogens in the Environment
DETECTING, DIAGNOSING, AND TREATING
CANCER 452
Detecting Cancer 452
x CONTENTS
Diagnosing Cancer 452
Treating Cancer 454
COMMON TYPES OF CANCER 454
Lung Cancer 456
Colon and Rectal Cancer 456
Breast Cancer 457
Prostate Cancer 459
Cancers of the Female Reproductive Tract 460
Skin Cancer 461
Testicular Cancer 463
Other Cancers 463
NEW AND EMERGING CANCER TREATMENTS 465
Beyond Traditional Treatments 465
Experimental Techniques 466
Support During Cancer Therapy 467
Living with Cancer 467
Tips for Today and the Future 467
Summary 468
For More Information 468
Selected Bibliography 468
17 IMMUNITY AND INFECTION 471
THE BODY’S DEFENSE SYSTEM 472
Physical and Chemical Barriers 472
The Immune System: Cells, Tissues, and Organs 473
Immunization 476
Allergy: A Case of Mistaken Identity 477
THE SPREAD OF DISEASE 480
Symptoms and Contagion 480
The Chain of Infection 480
Epidemics and Pandemics 481
PATHOGENS, DISEASES, AND TREATMENTS 482
Bacteria 482
Viruses 488
Fungi 493
Protozoa 493
442 Parasitic Worms 494
Emerging Infectious Diseases 494
Immune Disorders 495
SUPPORTING YOUR IMMUNE SYSTEM 496
Tips for Today and the Future 497
Summary 497
445 For More Information 497
Selected Bibliography 498
18 SEXUALLY TRANSMITTED INFECTIONS 499
THE MAJOR SEXUALLY TRANSMITTED
451
INFECTIONS 500
HIV Infection and AIDS 501
Chlamydia 511
Gonorrhea 513
Pelvic Inflammatory Disease 514
Human Papillomavirus 514
Genital Herpes 516
Hepatitis B 517
Syphilis 518
Other Sexually Transmitted Infections
AIR QUALITY AND POLLUTION 534
Air Quality and Smog 534
The Greenhouse Effect and Global Warming 535
Thinning of the Ozone Layer 538
Indoor Air Quality (IAQ) 538
519 Preventing Air Pollution 539

WHAT YOU CAN DO ABOUT SEXUALLY TRANSMITTED WATER QUALITY AND POLLUTION 539
INFECTIONS 520 Water Contamination and Treatment 539
Education 520 Water Shortages 541
Diagnosis and Treatment 520 Sewage 541
Prevention 520 Protecting the Water Supply 541
Tips for Today and the Future 521 SOLID WASTE POLLUTION 542
Summary 522 What’s in Our Garbage? 542
For More Information 523 Disposing of Solid Waste 542
Selected Bibliography 523 Biodegradability 543
Reducing Solid Waste 544

CHEMICAL POLLUTION AND HAZARDOUS WASTE 544

Asbestos 544
Lead 545
Pesticides 546
Mercury 546
Other Chemical Pollutants 546
Preventing Chemical Pollution 546

RADIATION POLLUTION 548

Nuclear Weapons and Nuclear Energy 548
Medical Uses of Radiation 549
Radiation in the Home and Workplace 549
Avoiding Radiation 549

NOISE POLLUTION 550

Tips for Today and the Future 551
Summary 551
For More Information 551
Selected Bibliography 552

20 CONVENTIONAL AND COMPLEMENTARY

MEDICINE 554
© visdia/123RF
SELF-CARE 555
PA R T S I X Self-Assessment 555
Knowing When to See a Physician 556
LIVING WELL IN THE WORLD
Self-Treatment 556
19 ENVIRONMENTAL HEALTH 526
PROFESSIONAL CARE 558
ENVIRONMENTAL HEALTH DEFINED 527
CONVENTIONAL MEDICINE 560
POPULATION GROWTH AND CONTROL 529 Premises and Assumptions of Conventional Medicine 560
How Many People Can the World Hold? 530 Pharmaceuticals and the Placebo Effect 561
Factors That Contribute to Population Growth 530 The Providers of Conventional Medicine 563
Choosing a Primary Care Physician 564
ENVIRONMENTAL IMPACTS OF ENERGY USE AND
Choosing a Specialist 565
PRODUCTION 531
Getting the Most Out of Your Medical Care 565
Environmental Threats of Extreme Energy Sources 531
Renewable Energy 532 INTEGRATIVE HEALTH 569
Alternative Fuels 533 Alternative Medical Systems 569
Hybrid and Electric Vehicles 534 Mind–Body Medicine 572

CONTENTS xi
Natural Products 573
Manipulative and Body-Based Practices 575
Other CAM Practices 575
When Does CAM Become Conventional Medicine? 576
Evaluating Complementary and Alternative Therapies 577

PAYING FOR HEALTH CARE 579

The Current System 580
Health Insurance 580
Tips for Today and the Future 583
Summary 583
For More Information 583
Selected Bibliography 584

21 PERSONAL SAFETY 586

UNINTENTIONAL INJURIES 588
What Causes an Injury? 588
Home Injuries 588
Motor Vehicle Injuries 591
Leisure Injuries 596
Work Injuries 598

VIOLENCE AND INTENTIONAL INJURIES 600

Factors Contributing to Violence 600
Assault 602
Homicide 602
Gang-Related Violence 602
Hate Crimes 603
School Violence 603
Workplace Violence 604 © R Chiang/Splash News/Newscom

Terrorism 604
Family and Intimate-Partner Violence 604
Sexual Violence 607
What You Can Do about Violence 611
PROVIDING EMERGENCY CARE
Tips for Today and the Future 613
Summary 613
For More Information 614
Selected Bibliography 615
LIFE IN AN AGING AMERICA 628
America’s Aging Minority 628
Family and Community Resources for Older Adults 629
Government Aid and Policies 630
611 Changing the Public’s Idea of Aging 632
Tips for Today and the Future 633
Summary 633
For More Information 633
Selected Bibliography 634

PA R T S E V E N 23 DYING AND DEATH 635

ACCEPTING PHYSICAL LIMITS UNDERSTANDING AND ACCEPTING DEATH

AND DYING 636
22 AGING: A VITAL PROCESS 617 Defining Death 637
GENERATING VITALITY AS YOU AGE 618 Learning about Death 638
What Happens as You Age? 619 Denying versus Acknowledging Death 639
Life-Enhancing Measures: Age-Proofing 619 PLANNING FOR DEATH 639
Making a Will 639
DEALING WITH THE CHANGES OF AGING 622
Considering Options for End-of-Life Care 640
Planning for Social Changes 622
Difficult Decisions at the End of Life 641
Adapting to Physical Changes 623
Completing an Advance Directive 643
Handling Psychological and Mental Changes 625
Giving the Gift of Life 645
AGING AND LIFE EXPECTANCY 627 Planning a Funeral or Memorial Service 646

xii CONTENTS
COPING WITH IMMINENT DEATH 648
Awareness of Dying 648
The Tasks of Coping 648
Supporting a Person in the Last Phase of Life 649
The Trajectory of Dying 649
COPING WITH LOSS 650
Experiencing Grief 650
Supporting a Grieving Person 652
When a Young Adult Loses a Friend 652
Helping Children Cope with Loss 652
COMING TO TERMS WITH DEATH 653
Tips for Today and the Future 654
Summary 654
For More Information 655
Selected Bibliography 655
APPENDIXES
A NUTRITION RESOURCES 657
b A SELF-CARE GUIDE FOR COMMON MEDICAL
PROBLEMS 658
Index 665
BOXES
ASSESS YOURSELF
Wellness: Evaluate Your Lifestyle 16
The Perceived Stress Scale 30
Are You Suffering from a Mood Disorder? 73
Are You Emotionally Intelligent? 93
Which Contraceptive Method Is Right for You and Your
Partner? 166
Creating a Family Health Tree 189
Is Internet Use a Problem for You? 219
Do You Have a Problem with Alcohol? 264
Tobacco Use Disorder: Are You Hooked? 274
Your Diet versus MyPlate Recommendations 321
The 1.5-Mile Run–Walk Test 367
What Triggers Your Eating? 386
Anger, Hostility, and Heart Disease 421
Are You at Risk for CVD? 436
What’s Your UV Risk? 461
Do Your Attitudes and Behaviors Put You at Risk for
STIs? 522
Environmental Health Checklist 529
Exploring What You Know about CAM 578
Are You an Aggressive Driver? 594
BEHAVIOR CHANGE STRATEGY
Behavior Change Contract 27
Taking Control of Your Sleep 56
Dealing with Social Anxiety 86
Changing Your Drug Habits 243
Kicking the Tobacco Habit 295
Improving Your Diet by Choosing Healthy Beverages 337
Planning a Personal Exercise Program 372
Creating a Personal Weight Management Plan 407
Reducing the Saturated and Trans Fats in Your Diet 440
Incorporating More Fruits and Vegetables into
Your Diet 470
Talking about Condoms and Safer Sex 525
Adhering to Your Physician’s Instructions 585
Adopting Safer Habits 616
CRITICAL CONSUMER
Evaluating Sources of Health Information 18
Choosing and Evaluating Mental Health Professionals 82
Sex Enhancement Products 127
Obtaining a Contraceptive from a Health Clinic or
Physician 150
Home Pregnancy Tests 192
Choosing a Drug Treatment Program 239
Alcohol Advertising 265
Tobacco Advertising 277
Using Food Labels 326
Using Dietary Supplement Labels 328
What to Wear 365
Evaluating Fat and Sugar Substitutes 391
Are All Calories and Dietary Patterns Equal for
Weight Loss? 394
Avoiding Cancer Quackery 455
Sunscreens and Sun-Protective Clothing 463
Preventing and Treating the Common Cold 489
Tattoos and Body Piercing 492
Getting an HIV Test 508
Endocrine Disruption: A “New” Toxic Threat 547
Avoiding Health Fraud and Quackery 570
Choosing a Health Insurance Plan 581
Choosing a Place to Live 631
A Consumer Guide to Funerals 647
DIVERSITY MATTERS
Moving toward Health Equity 12
Diverse Populations, Discrimination, and Stress 40
Ethnicity, Culture, and Psychological Health 70
Marriage Equality 103
Genital Alteration 116
Barriers to Contraceptive Use 164
The Adoption Option 175
Abortion around the World 179
Ethnicity and Genetic Disease 187
Drug Use and Race/Ethnicity 237
Metabolizing Alcohol: Our Bodies Work Differently 247
Ethnic Foods 316
Overweight and Obesity among U.S. Ethnic Populations 385
Gender, Race/Ethnicity, and Cardiovascular Disease 424
Race/Ethnicity, Poverty, and Cancer 446
CONTENTS xiii
Poverty, Ethnicity, and Asthma 479
HIV/AIDS around the World 504
Poverty, Gender, and Environmental Health 545
Health Care Visits and Gender 565
Injuries among Young Men 589
Why Do Women Live Longer? 627
TAKE CHARGE
Financial Wellness 5
Life Expectancy and the Obesity Epidemic 8
Mindfulness Meditation 45
Digital Devices: Help or Harm for a Good Night’s
Sleep? 50
Overcoming Insomnia 52
Realistic Self-Talk 65
Does Exercise Improve Mental Health 79
Guidelines for Effective Communication 97
Strategies of Strong Families 108
Communicating about Sexuality 137
Talking with a Partner about Contraception 165
Physical Activity during Pregnancy 202
If Someone You Know Has a Drug Problem . . . 240
Dealing with an Alcohol Emergency 250
Avoiding ETS 287
Strategies to Quit Smoking 292
Fats and Health 302
Choosing More Whole-Grain Foods 305
Eating for Healthy Bones 310
Positive Changes to Meet the Dietary Guidelines 315
Judging Portion Sizes 319
Safe Food Handling 330
Making Time for Physical Activity 352
Move More, Sit Less 353
Interval Training: Pros and Cons 355
Determine Your Target Heart Rate 357
Lifestyle Strategies for Successful Weight Management 393
If Someone You Know Has an Eating Disorder . . . 402
xiv CONTENTS
Warning Signs and Symptoms of Heart Attack, Stroke, or
Cardiac Arrest 428
Testicle Self-Examination 464
Preventing STIs 512
Don’t Wait—Early Treatment of STIs Really Matters 521
High-Efficiency Lighting 540
Evaluating Health News 562
Head Injuries in Contact Sports 597
Repetitive Strain Injury 600
Recognizing the Potential for Abusiveness in a Partner 605
Preventing Date Rape 609
Can Exercise Delay the Effects of Aging? 621
Coping with Grief 651
Surviving the Violent Death of a Loved One 653
WELLNESS ON CAMPUS
Wellness Matters for College Students 14
Coping with News of Traumatic Events 41
Deliberate Self-Harm 77
Hooking Up 100
Questions to Ask Before Engaging in a Sexual
Relationship 133
Contraception Use and Pregnancy among College
Students 144
Drug Use among College Students 222
Alcoholic Energy Drinks: The Dangers of Being “Drunk and
Wide Awake” 252
Peer Pressure and College Binge Drinking 258
Eating Strategies for College Students 324
The Freshman 15: Fact or Myth? 389
Meningococcal Meningitis and College Students 485
The Riskiest Sexual Behavior Is Becoming More
Common 506
College Students and STIs 515
Creating Your Own Health Record 566
Cell Phones and Distracted Driving 593
Staying Safe on Campus 612
 LEARN WITHOUT LIMITS

CONNECT IS PROVEN EFFECTIVE

McGraw-Hill ConnectⓇ is a digital teaching and

learning environment that improves performance over a
­variety of critical outcomes; it is easy to use; and it is proven
effective. Connect empowers students by continually adapt-
ing to deliver precisely what they need, when they need it,
and how they need it, so your class time is more engaging
and effective. Connect for Connect Core Concepts in Health
offers a wealth of interactive online content, including Well-
ness Worksheets and other self-assessments, video activities
on timely health topics, and practice quizzes with immediate
feedback.

ADDITIONAL ADVANCED CAPABILITIES OF CONNECT

®
Available within Connect, SmartBook makes study time as productive and efficient as possible by identifying and closing
knowledge gaps. SmartBook is powered by the proven LearnSmart® engine, which identifies what an individual student knows
and doesn’t know based on the student’s confidence level, responses to questions, and other factors. LearnSmart builds an optimal,
personalized learning path for each student, so students spend less time on concepts they already understand and more time on
those they don’t. As a student engages with SmartBook, the reading experience continuously adapts by highlighting the most
impactful content a student needs to learn at that moment in time. This ensures that every minute spent with SmartBook is returned
to the student as the most value-added minute possible. The result? More confidence, better grades, and greater success.

P R E FAC E xv
Connect Insight® is Connect’s new one-of-a-kind visual
analytics dashboard—now available for both instructors and
students—that provides at-a-glance information regarding
student performance, which is immediately actionable. By
presenting assignment, assessment, and topical performance
results together with a time metric that is easily visible for
aggregate or individual results, Connect Insight gives the
user the capability to take a just-in-time approach to teaching
and learning, which was never before available. Connect
­Insight presents data that empowers students and helps
­instructors improve class performance in a way that is effi-
cient and effective.

xvi    P R E F A C E
PROVEN, SCIENCE-BASED CONTENT

McGraw-Hill’s digital teaching and learning tools are built on the solid foundation of
Connect Core Concepts in Health’s authoritative, science-based content. Connect
Core Concepts in Health is written by experts who work and teach in the fields of
exercise science, medicine, physical education, and health education. Connect Core
Concepts in Health provides accurate, reliable, current information on key health and
wellness topics, while also addressing issues related to mind–body health, research,
diversity, and consumer health. The pedagogical program for the 15th edition main-
tains important features on behavior change, personal reflection, critical thinking, and
other key content and skills.

Assess Yourself features provide assessments Ask Yourself: Questions for Critical
for students to use in analyzing their own health Thinking and Reflection encourage critical
and health-related behaviors. reflection on students’ own health-related
behaviors.

Take Charge boxes challenge students to take

meaningful action toward personal improvement. Quick Stats sections, updated for the 15th
edition, focus attention on particularly striking
statistics related to the chapter content.
Critical Consumer sections help students to
navigate the numerous and diverse set of health-
related products currently available. Tips for Today and the Future end each
chapter with a quick, bulleted list of concrete
actions readers can take now and in the near future.
Diversity Matters features discuss the ways
that our personal backgrounds influence our
health strengths, risks, and behaviors.

Wellness on Campus sections focus on

health issues, challenges, and opportunities that
students are likely to encounter on a regular
basis.

Behavior Change Strategy sections offer

specific behavior management/modification
plans related to the chapter topic. © Jakub Zak/Shutterstock

P R E F A C E     xvii
 WHAT’S NEW IN CONNECT CORE
CONCEPTS IN HEALTH, 15TH EDITION?

UPDATES INFORMED BY STUDENT DATA

Changes to the 15th edition reflect new research findings, updated statistics, and current hot topics that impact students’ well-
ness behaviors. Revisions were also guided by student performance data collected anonymously from the tens of thousands of
students who have used LearnSmart with Connect Core Concepts in Health. Because virtually every text paragraph is tied to
several questions that students answer while using LearnSmart, the specific concepts that students are having the most difficulty
with can be pinpointed through empirical data.

Aggregated student performance

data collected anonymously from
LearnSmart helps pinpoint concepts
students find most challenging,
guiding revisions to the text and
Connect program.

CHAPTER-BY-CHAPTER LIST OF CHANGES

Chapter 1: Taking Charge of Your Health
∙ New Take Charge feature: Life Expectancy and the
Obesity Epidemic
∙ New section on the Affordable Care Act
∙ New information on qualities and behaviors associated
with each dimension of wellness
∙ Updated information on making life changes, on ­financial
wellness, on key wellness issues for college ­students, and
on health disparities, including an ­updated Diversity
­Matters feature: Moving toward Health Equality
∙ Updated statistics on leading causes of death in the
United States; key contributors to death among Americans;
progress toward Healthy People 2020 targets; and
deaths attributed to low educational attainment,
­poverty, and income inequality
Chapter 2: Stress: The Constant Challenge
∙ New major section on sleep and its role in stress,
­including a new Behavior Change Strategy: Taking Con-
trol of Your Sleep and a new Take Charge ­feature: Digi-
tal Devices: Help or Harm for a Good Night’s Sleep?
∙ New information on the influence of motivation on
health, on connectedness and health, and on gender and
stress; updated information on steps for managing stress

xviii P R E FAC E
 ∙ Updated Diversity Matters feature: Diverse Populations,
Discrimination, and Stress; updated Wellness on
­Campus feature: Coping with News of Traumatic
Events; updated Take Charge feature: Mindfulness
Meditation
Chapter 3: Psychological Health
∙ Updated information on psychological defense mech­
anisms; mood disorders; professional help; and warning
signs, risk factors, and preventive factors related to
­suicide
∙ Updated Diversity Matters feature: Ethnicity, Culture,
and Psychological Health and updated Wellness on
Campus feature: Deliberate Self-Harm
∙ New and updated statistics on the prevalence of selected
psychological disorders among Americans, on suicide
methods, and on the prevalence of suicidal thoughts
Chapter 4: Intimate Relationships and Communication
∙ Updated information on gender roles, sexual orienta-
tion, and gender identity in relationships
∙ New and updated statistics on marital status; median
age of marriage; married women in the labor force; and
Americans’ attitudes toward gay relationships, online
dating, cohabitation, and single-parent families
∙ Updated information on digital communication and
­social networks and on strategies of strong families
∙ Updated Wellness On Campus feature: Hooking Up and
updated Diversity Matters feature: Marriage ­Equality
Chapter 5: Sex and Your Body
∙ Updated Diversity Matters feature: Genital Alteration
∙ Updated information on differentiation of an embryo,
intersex, gender roles, sexual orientation, gender
­identity, commercial sex, and treatments for female
­hypoactive sexual desire disorder
Chapter 6: Contraception
∙ Updated information on modern versus traditional
­contraception
∙ New figure on women’s use of contraception and its
­effectiveness
∙ Updated statistics on the rate of unintended
­pregnancies and contraceptive use worldwide
∙ Updated Critical Consumer feature: Obtaining a
­Contraceptive from a Health Clinic or Physician
and Diversity Matters feature: Barriers to
­Contraceptive Use
Chapter 7: Abortion
∙ Updated statistics on pregnancy, birth, and abortion rates
∙ New information about the history of abortion, safety
of abortions, and medical versus aspiration abortion
∙ Updated information on personal considerations for
men about abortion, legal restrictions and state-specific
requirements for abortion, and the public debate about
abortion
Chapter 8: Pregnancy and Childbirth
∙ New coverage related to the Zika virus
∙ Updated statistics on the average age of first-time
mothers in the United States; costs of raising a child;
infertility; fetal alcohol syndrome; depression during
pregnancy; hospital versus at-home births in the United
States; breastfeeding; and premature births, low birth
weight, and infant mortality
∙ Updated information on the second trimester of preg-
nancy and on avoiding drugs and other environmental
hazards
∙ Updated Critical Consumer feature: Home Pregnancy
Tests and Take Charge feature: Physical Activity
­during Pregnancy
Chapter 9: Drug Use and Addiction
∙ New information on Internet gaming disorder
∙ Updated statistics on drug overdose deaths, nonmedical
drug use among Americans, heroin use and deaths, use
of opioid painkillers and correlation with heroin use,
psychoactive drugs and their potential for substance
­disorder and addiction, sex and drug use, drug use among
college students, workplace drug testing, and state and
federal prison inmates serving time for drug offenses
∙ Updated information on diagnosing drug use and
­addiction; risk factors for drug use and addiction;
­commonly misused drugs and their effects; and
­marijuana legalization, medical uses for marijuana, and
long-term effects of using marijuana
∙ Updated Diversity Matters feature: Drug Use and
Race/ Ethnicity
Chapter 10: Alcohol: The Most Popular Drug
∙ New information about alcohol absorption
∙ Updated information on the possible health benefits of
alcohol
∙ Updated Wellness on Campus features: Alcoholic
­Energy Drinks: The Dangers of Being “Drunk and Wide
Awake”; and Peer Pressure and College Binge Drinking
P R E FAC E xix
 ∙ Updated statistics on alcohol use disorder and suicide;
drunk driving; binge drinking and heavy alcohol use;
fetal alcohol syndrome; arrests for drug and alcohol-­
related offenses; and the contribution of alcohol use to
murders, assaults, and rapes
Chapter 11: Tobacco Use
∙ New and updated information on e-cigarettes, tobacco
additives, tolerance and withdrawal, and economic
costs of cigarettes
∙ Updated statistics on annual deaths from tobacco-­
related causes, deaths among nonsmokers due to
­environmental tobacco smoke, demographics of smokers,
American teen smokers, quitting smoking, total health
care costs of smoking, and state rates of smoking
∙ Updated Critical Consumer feature: Tobacco Advertising
Chapter 12: Nutrition Basics
∙ New section on the Dietary Guidelines for Americans
2015–2020
∙ Updated information on added sugars, dietary fat, e­ nergy
needs, building and supporting healthy eating patterns,
how the U.S. diet compares to recommendations, the
DASH eating plan, biotech crops, and food safety
∙ New information on calorie labeling for restaurants and
vending machines
∙ Updated information on the Social-Ecological Model
for food and physical activity decisions
∙ New Take Charge feature: Positive Changes to Meet
Dietary Guidelines; updated Take Charge feature: Fats
and Health; and updated Critical Consumer feature:
Using Food Labels
Chapter 13: Exercise for Health and Fitness
∙ New information on the health benefits of exercise, the
risks of sedentary time, core training, and managing
athletic injuries
∙ New Take Action feature: Move More, Sit Less and up-
dated Critical Consumer feature: What to Wear
∙ Updated information on target heart rate range, core
muscles, and differences in muscular strength between
sexes
Chapter 14: Weight Management
∙ Updated information on energy intake, dietary patterns,
and sleep as lifestyle factors for weight management
∙ Updated information on environmental factors in
weight management, safety and effectiveness of
xx    P R E F A C E
c­ ommon over-the-counter weight loss pills, and pre-
scription weight loss drugs
∙ New information on gut microbiota, eating disorders,
and positive body image
∙ Updated statistics on the prevalence of obesity in
America and on the amount of money spent on weight
loss efforts per year in America
∙ Updated Wellness on Campus feature: The Freshman
15: Myth or Fact?; Critical Consumer feature: Evaluat-
ing Fat and Sugar Substitutes; Take Charge feature:
Lifestyle Strategies for Successful Weight Manage-
ment; and Critical Consumer feature: Are All Calories
and Dietary Patterns Equal for Weight Loss?
Chapter 15: Cardiovascular Health
∙ New information on treatments for high blood ­pressure,
medications for high cholesterol, and e-cigarettes and
their relationship to cardiovascular d­ isease
∙ Updated statistics on the prevalence of overall
­cardiovascular disease, high cholesterol, diabetes and
­prediabetes, heart attack and stroke deaths, recurrent heart
attacks, heart failure, and cardiovascular disease deaths
­attributed to smoking and environmental ­tobacco smoke
Chapter 16: Cancer
∙ New information on genomic research
∙ Updated information on early detection of cancer, foods
that increase risk of colorectal cancer, ­recommendations
for mammography, skin cancer treatments, biological
therapies/immunotherapy, and cancer vaccines
∙ Updated statistics on the number of annual cancer cases
and deaths; five-year survival rates; and cancer deaths
caused by poor diet, exercise habits, obesity, and smoking
Chapter 17: Immunity and Infection
∙ New coverage of Zika disease, new information on
­climate change and allergies
∙ Updated information on HPV, Ebola, West Nile virus,
E. coli, and hantavirus
∙ Updated information on immunization
­recommendations, vaccination efficacy and rates, and
deaths due to infectious diseases worldwide
∙ Updated statistics on the H5N1 virus, tuberculosis,
­polio, tickborne infections, pertussis, HPV vaccination,
and antibiotic resistance
∙ Updated Diversity Matters feature: Poverty, Ethnicity,
and Asthma
Chapter 18: Sexually Transmitted Infections
∙ Updated information on HIV diagnosis and treatment
∙ Updated information and statistics on hepatitis B,
syphilis, and trichomoniasis
∙ Updated Diversity Matters feature: HIV/AIDS around
the World; Wellness on Campus feature: The Riskiest
Sexual Behavior Is Becoming More Common; and
Critical Consumer feature: Getting an HIV Test
∙ Updated statistics on new STI cases; direct medical costs
of STIs; number of Americans living with HIV;
­percentage of HIV-infected Americans who do not know
of their infections; and rates of chlamydia, gonorrhea,
­human papillomavirus, genital herpes, and syphilis
Chapter 19: Environmental Health
∙ New information on pesticides, preventing air and
chemical pollution, the 2015 UN Climate Change
­Conference, and the effects on children whose mothers
were exposed to air pollution while pregnant
∙ Updated information on carbon dioxide levels in the
­atmosphere, climate change, and the hole in the ozone
layer
∙ Updated statistics on world population growth, energy
consumption of selected countries, renewable energy
use, deaths from air pollution per year, and trash and
compost generated in America
Chapter 20: Conventional and Complementary ­Medicine
∙ New information on integrative health, evaluating
­complementary and alternative therapies, and
­acupuncture
∙ Updated statistics on the number of Americans using
complementary and alternative therapies
∙ New information on types of research studies, the
­placebo effect, recognized medical specialties,
­choosing a specialist, and key concepts in health care
insurance coverage
∙ Updated Critical Consumer feature: Health Care
­Reform with the ACA
Chapter 21: Personal Safety
∙ New information on head injuries in contact sport
∙ New and updated information on preventing
­acquaintance rape
∙ Updated Wellness on Campus feature: Cell Phones and
Distracted Driving and Diversity Matters feature:
­Injuries among Young Men
∙ New and updated statistics on deaths and costs of
­injuries, leading causes of deaths from unintentional
injuries, deaths from motor vehicle crashes in the
United States, use of seat belts, bicycle helmet laws,
pedestrian injuries, gun ownership, sexual assaults,
­arrests, and violent crimes
Chapter 22: Aging: A Vital Process
∙ Updated statistics and information on the number of
older Americans, life expectancy, poverty rates, living
arrangements of people 65 and older, and Social
­Security benefits
Chapter 23: Dying and Death
∙ Updated information on defining and learning about
death, physician-assisted death and voluntary active
euthanasia, the shortage of organs among some racial
or ethnic groups, autopsies, and helping children cope
with loss
∙ Updated Critical Consumer feature: A Consumer’s
Guide to Funerals
∙ New Take Charge feature: Surviving the Violent Death
of a Loved One
∙ Updated statistics on people who die in hospice and on
people waiting for an organ transplant and the number
of people who die waiting for one
P R E F A C E     xxi
 YOUR COURSE, YOUR WAY
McGraw-Hill Create® is a self-service website that allows
you to create customized course materials using McGraw-
Hill Education’s comprehensive, cross-disciplinary content
and digital products. You can even access third-party content
such as readings, articles, cases, videos, and more.
∙ Select and arrange content to fit your course scope and
sequence
∙ Upload your own course materials
∙ Select the best format for your students—print or
e­Book
∙ Select and personalize your cover
∙ Edit and update your materials as often as you’d like
Experience how McGraw-Hill Education’s Create empowers
you to teach your students your way:
http://www.mcgrawhillcreate.com.
xxii    P R E F A C E
McGraw-Hill Campus® is a groundbreaking service that
puts world-class digital learning resources just a click away
for all faculty and students. All faculty—whether or not they
use a McGraw-Hill title—can instantly browse, search, and
access the entire library of McGraw-Hill instructional re-
sources and services, including eBooks, test banks, Power-
Point slides, animations, and learning objects—from any
Learning Management System (LMS), at no additional cost
to an institution. Users also have single sign-on access to
McGraw-Hill digital platforms, including Connect, Create,
and Tegrity, a fully automated lecture caption solution.
INSTRUCTOR RESOURCES
Instructor resources available through Connect for Connect
Core Concepts in Health include a Course Integrator Guide,
Test Bank, Image Bank, and PowerPoint presentations for
each chapter. A static PDF version of the interactive ­Wellness
Worksheets offered in Connect is also available.
 ACKNOWLEDGMENTS

Connect Core Concepts in Health, 15th edition, has bene- Kim McMahon, MS, RD, LD
fited from the thoughtful commentary, expert knowledge, Benedictine University and Logan College
and helpful suggestions of many people. We are deeply Weight Management
grateful for their participation in this project. Jonathan Schwartz, MD
Stanford University School of Medicine
Academic Contributors Cardiovascular Health
Steve Flowers, MA, LMFT
Somasundaram Subramaniam, MD, MS
Mindfulness Based Stress Reduction Program at Enloe
Swedish Cancer Institute
Medical Center
Cancer
Stress: The Constant Challenge
Martha Zuniga, PhD
Heidi Roth, MD
University of California—Santa Cruz
University of North Carolina–Chapel Hill
Immunity and Infection
Sleep Medicine
Candice J. McNeil, MD, MPH
Michael Joshua Ostacher, MD, MPH, MMSc
Wake Forest University Health Sciences
Stanford University School of Medicine
Sexually Transmitted Infections
Psychological Health
Robert Jarski, PhD, PA
Inge Hansen, PsyD
School of Health Sciences, Oakland University
Stanford University
Conventional and Complementary Medicine
Intimate Relationships and Communication
Christine Labuski, PhD Marcia Seyler, MPhil
Virginia Polytechnic Institute and State University Aging: A Vital Process
Sex and Your Body Nancy Kemp, MD, MA
Kamilee Christenson, MD Green Valley Hospice
Stanford University Dying and Death
Contraception
Anna Altshuler, MD, MPH Academic Advisors and Reviewers
California Pacific Medical Center for the 15th Edition
Abortion Ronald Baldwin, Beaufort County Community College
Kathy Bingham, Antelope Valley College
Jeroen Vanderhoeven, MD
Mia M. Botkin, Moreno Valley College
Swedish Medical Center
Paula Congleton, Santa Barbara City College
Pregnancy and Childbirth
Wendy Frappier, Minnesota State University Moorhead
Chwen-Yuen Angie Chen, MD, FACP, FASAM James Metcalf, George Mason University
Internal and Addiction Medicine, Stanford University Kristin Newton, Gardner-Webb University
Drug Use and Addiction Jodi Rees, Indiana State University
Johanna Rochester, PhD Scott Rogers, College of Southern Idaho
The Endocrine Disruption Exchange Richard Scheidt, Fresno City College
Tobacco Use Carol Sloan, Henry Ford College
Environmental Health Teresa K. Snow, Georgia Institute of Technology
Susan Stockton, University of Central Missouri
Melissa Bernstein, PhD, RD, LD B. Denise Stokich, University of Nevada, Reno
Rosalind Franklin University of Medicine and Science Robert O. Walsh, Utah Valley University
Nutrition Basics Heidi Wiedenfeld, Texas Tech University
Tom Fahey, EdD
California State University–Chico
Exercise for Health and Fitness
P R E FAC E xxiii
 CHAPTER

Taking Charge
of Your Health 1

© Tom Stewart/Getty Images

CHAPTER OBJECTIVES
■■ Define wellness as a health goal
■■ Explain two major efforts to promote national health
■■ List factors that influence wellness
■■ Explain methods for achieving wellness through lifestyle management
■■ List ways to promote lifelong wellness for yourself and your
environment
T EST YOUR K NOWL E D G E
1. Which of the following lifestyle factors influence wellness?
a. Managing your finances
b. Cultivating a support group
c. Exercising regularly
2. The terms health and wellness mean the same thing.
True or False?
3. What is the leading cause of death for college-age students?
a. Alcohol misuse
b. Motor vehicle accidents
c. Cancer
4. A person’s genetic makeup determines whether he or she will develop
­certain diseases (such as breast cancer), regardless of that person’s
health habits.
True or False?
T
he next time you ask someone, “How are you?”
and you get the automatic response “Fine,” be
grateful. If that person had told you how he or
she actually felt—physically, emotionally, men-
tally—you might wish you had never asked.
Your friend might be one of the too many people who live
most of their lives feeling no better than just all right, or so-
so, or downright miserable. Some do not even know what
optimal wellness is. How many people do you know who
feel great most of the time? Do you?
WELLNESS AS A HEALTH GOAL
Generations of people have viewed good health simply as
the absence of disease, and that view largely prevails today.
The word health typically refers to the overall condition of a
health The overall condition of body or mind T ERMS
and the presence or absence of illness or injury.
T ERMS
wellness Optimal health and vitality, encompassing all the
dimensions of well-being.
2 CHAPTER 1 TA K I N G C H A R G E O F YO U R H E A LT H
A NS W E RS
1. ALL THREE. All of these practices affect
your sense of well-being.
2. FALSE. The term health refers to the overall
condition of the body or mind and to the
presence or absence of illness or injury. The
term wellness refers to optimal health and
vitality, encompassing the dimensions of
well-being.
3. B. Motor vehicle accidents are the leading
cause of death for people aged 15–24 years.
4. FALSE. In many cases, behavior can counter
the effects of heredity or environment. For
­example, diabetes may run in families, but this
disease is also associated with controllable
factors, such as being overweight and inactive.
person’s body or mind and to the presence or absence of ill-
ness or injury. Wellness expands this idea of good health to
include living a rich, meaningful, and energetic life. Beyond
the simple presence or absence of disease, wellness can refer
to optimal health and vitality—to living life to its fullest.
Although we use the words health and wellness interchange-
ably, they differ in two important ways:
∙ Health—or some aspects of it—can be determined or
influenced by factors beyond your control, such as your
genes, age, and family history. Consider, for example, a
50-year-old man with a strong family history of early heart
disease. This factor increases this man’s risk of having a
heart attack at an earlier age than might be expected.
∙ Wellness is determined largely by the decisions you
make about how you live. That same 50-year-old man can
reduce his risk of an early heart attack by eating sensibly,
exercising, and having regular screening tests. Even if he
develops heart disease, he may still live a long, rich, mean-
ingful life. These factors suggest he should choose not
only to care for himself physically but also to maintain a
positive outlook, enjoy his relationships with others, chal-
lenge himself intellectually, and nurture other aspects of
his life.
 FIGURE 1.1 The wellness continuum.
Low level Physical, mental, Change High level The concept of wellness includes vitality in
of wellness emotional symptoms and growth of wellness a number of interrelated dimensions, all of
which contribute to wellness.
INTELLE SS
CTU NAL LNE
AL E RSPOH WEL WE
EMOTIO
NA RP YS WELLNE LL
L TE IC SS NE
IN WE A SS
CU L LN L
LTU ESS
EN RA WELLNESS
VIR L A L S
L U S S W S
O N M E N TA S P IRI T W E LL NE ELL N E W
ELL
O C C UPATI O N AL W E L LN ESS NES
S
FIN A
N CIAL

Malaise Vital, meaningful life

Wellness, therefore, involves conscious decisions that affect
risk factors that contribute to disease or injury. We cannot
control risk factors such as age and family history, but we
can control lifestyle behaviors.
Dimensions of Wellness
The process of achieving wellness is continuing and
­dynamic (Figure 1.1), involving change and growth. Well-
ness is not static. The encouraging aspect of wellness is
that you can actively pursue it. Here are nine dimensions of
wellness:
∙ Physical ∙ Spiritual
∙ Emotional ∙ Environmental
∙ Intellectual ∙ Financial
∙ Interpersonal ∙ Occupational
∙ Cultural
These dimensions are interrelated and may affect each
other, as the following sections explain. Figure 1.2 lists spe-
cific qualities and behaviors associated with each d­ imension.
Physical Wellness Your physical wellness includes not
just your body’s overall condition and the absence of disease
but also your fitness level and your ability to care for your-
self. The higher your fitness level, the higher your level of
physical wellness. Similarly, as you develop the ability to
take care of your own physical needs, you ensure greater
physical wellness. The decisions you make now, and the
habits you develop over your lifetime, will determine the
length and quality of your life.
acceptance is your personal satisfaction with yourself—it
might exclude society’s expectations—whereas self-esteem
relates to the way you think others perceive you; self-confi-
dence can be a part of both acceptance and esteem. Achiev-
ing emotional wellness means finding solutions to emotional
problems, with professional help if necessary.
Intellectual Wellness Those who enjoy intellectual
wellness continually challenge their minds. An active mind
is essential to wellness because it detects problems, finds
solutions, and directs behavior. Throughout their lifetimes
people who enjoy intellectual wellness never stop learning.
Often they discover new things about themselves.
Interpersonal Wellness Satisfying and supportive re-
lationships are important to physical and emotional well-
ness. Learning good communication skills, developing the
capacity for intimacy, and cultivating a supportive network
are all important to interpersonal (or social) wellness. Social
wellness requires participating in and contributing to your
community and to society.
Cultural Wellness Cultural wellness refers to the way
you interact with others who are different from you in terms
of ethnicity, religion, gender, sexual orientation, age, and
customs (practices). It involves creating relationships with
others and suspending judgment on others’ behavior until
you have lived with them or “walked in their shoes.” It also
includes accepting, valuing, and even celebrating the differ-
ent cultural ways people interact in the world. The extent to
which you maintain and value cultural identities is one mea-
sure of cultural wellness.

Emotional Wellness Trust, self-confidence, optimism,
satisfying relationships, and self-esteem are some of the
qualities of emotional wellness. Emotional wellness is dy-
namic and involves the ups and downs of living. No one can
achieve an emotional “high” all the time. Emotional well-
ness fluctuates with your intellectual, physical, spiritual,
cultural, and interpersonal health. Maintaining emotional
wellness requires exploring thoughts and feelings. Self-­
Spiritual Wellness To enjoy spiritual wellness is to
possess a set of guiding beliefs, principles, or values that
give meaning and purpose to your life, especially in difficult
times. The spiritually well person focuses on the positive
TER MS
risk factor A condition that increases your
chances of disease or injury.
TER M

W E L L N E S S as a H E A L T H G O A L 3
 PHYSICAL WELLNESS EMOTIONAL WELLNESS INTELLECTUAL WELLNESS
• Eating well • Optimism • Openness to new ideas
• Exercising • Trust • Capacity to question
• Avoiding harmful habits • Self-esteem • Ability to think critically
• Practicing safer sex • Self-acceptance • Motivation to master new skills
• Recognizing symptoms of disease • Self-confidence • Sense of humor
• Getting regular checkups • Ability to understand and accept • Creativity
• Avoiding injuries one’s feelings • Curiosity
• Ability to share feelings with others • Lifelong learning

INTERPERSONAL WELLNESS CULTURAL WELLNESS SPIRITUAL WELLNESS

• Communication skills • Creating relationships with those • Capacity for love
• Capacity for intimacy who are different from you • Compassion
• Ability to establish and maintain • Maintaining and valuing your own • Forgiveness
satisfying relationships cultural identity • Altruism
• Ability to cultivate a support system • Avoiding stereotyping based on race, • Joy and fulfillment
of friends and family ethnicity, gender, religion, or sexual • Caring for others
orientation • Sense of meaning and purpose
• Sense of belonging to something
greater than oneself

ENVIRONMENTAL WELLNESS FINANCIAL WELLNESS OCCUPATIONAL WELLNESS

• Having abundant, clean natural
resources
• Maintaining sustainable development
• Recycling whenever possible
• Reducing pollution and waste
• Having a basic understanding of
how money works
• Living within one’s means
• Avoiding debt, especially for
unnecessary items
• Saving for the future and for
emergencies
• Enjoying what you do
• Feeling valued by your manager
• Building satisfying relationships
with coworkers
• Taking advantage of opportunities
to learn and be challenged

FI GURE 1 . 2 Qualities and behaviors associated with the dimensions of wellness. Carefully review each dimension and consider
your personal wellness strengths and weaknesses.

aspects of life and finds spirituality to be an antidote for
negative feelings such as cynicism, anger, and pessimism.
Organized religions help many people develop spiritual
health. Religion, however, is not the only source or form of
spiritual wellness. Many people find meaning and purpose
in their lives through their loved ones or on their own—
through nature, art, meditation, or good works.
Environmental Wellness Your environmental wellness
is defined by the livability of your surroundings. ­Personal
health depends on the health of the planet—from the safety of
the food supply to the degree of violence in society. Your phys-
ical environment can support your wellness or diminish it. To
improve your environmental wellness, you can learn about and
protect yourself against hazards in your surroundings and work
to make your world a cleaner and safer place.
Financial Wellness Financial wellness refers to your
ability to live within your means and manage your money in
morbidity rate The relative incidence of disease T ERMS
among a population.
T ERMS
mortality rate The number of deaths in a population in a
given period; usually expressed as a ratio, such as 75 deaths
per 1000 members of the population.
infectious disease A disease that can spread from person to
person, caused by microorganisms such as bacteria and viruses.
a way that gives you peace of mind. It includes balancing
your income and expenses, staying out of debt, saving for the
future, and understanding your emotions about money. See
the “Financial Wellness” box.
Occupational Wellness Occupational wellness refers
to the level of happiness and fulfillment you gain through
your work. Although high salaries and prestigious titles are
gratifying, they alone may not bring about occupational
wellness. An occupationally well person enjoys his or her
work, feels a connection with others in the workplace, and
takes advantage of the opportunities to learn and be chal-
lenged. Another important aspect of occupational wellness
is recognition from managers and colleagues. An ideal job
draws on your interests and passions, as well as your voca-
tional skills, and allows you to feel that you are making a
contribution in your everyday work.
New Opportunities for Taking Charge
Wellness is a fairly new concept. One hundred and fifty
years ago, Americans considered themselves lucky just to
survive to adulthood. A boy born in 1850, for example, could
expect to live only about 38 years and a girl, 40 years. Mor-
bidity and mortality rates (rates of illness and death, re-
spectively) from common infectious diseases (such as
pneumonia, ­tuberculosis, and diarrhea) were much higher
than Americans experience today.

4 CHAPTER 1 TA K I N G C H A R G E O F YO U R H E A LT H

Researchers surveyed nearly 90,000 college students about
their financial behaviors and attitudes. According to results
released in 2016, a large percentage of students feel less
prepared to manage their money than to handle almost any
other aspect of college life. They also express distress over
their current and future financial decisions. Front and center in
their minds is how to manage student loan debt. Financial
wellness means having a healthy relationship with money.
Here are strategies for establishing that relationship:
Follow a Budget
A budget is a way of tracking where your money goes and
making sure you’re spending it on the things that are most
important to you. To start one, list your monthly income and
expenditures. If you aren’t sure where you spend your money,
track your expenses for a few weeks or a month. Then orga-
nize them into categories, such as housing, food, transporta-
tion, entertainment, services, personal care, clothes, books
and school supplies, health care, credit card and loan pay-
ments, and miscellaneous. Knowing where your money goes
is the first step in gaining control of it.
Now total your income and expenditures and examine
your spending patterns. Use this information to set guidelines
and goals for yourself. If your expenses exceed your income,
identify ways to make some cuts. For example, if you spend
money going out at night, consider less expensive options
like having a weekly game night with friends or organizing an
occasional potluck.
Be Wary of Credit Cards
Students have easy access to credit but little training in fi-
nances. The percentage of students who have access to credit
cards has increased from 28% in 2012 to 41% in 2015. This
increase in credit card use has also correlated with an increase
in paying credit card bills late, paying only the minimum
amount, and having larger total outstanding credit balances.
Shifting away from using credit cards and toward using
debit cards is a good strategy for staying out of debt. Familiar-
ity with financial terminology helps as well. Basic financial lit-
eracy with regard to credit cards involves understanding
terms like APR (annual percentage rate—the interest you’re
charged on your balance), credit limit (the maximum amount
you can borrow), minimum monthly payment (the smallest
payment your creditor will accept each month), grace period
(the number of days you have to pay your bill before interest
or penalties are charged), and over-the-limit and late fees (the
amounts you’ll be charged if you go over your credit limit or
your payment is late).
Manage Your Debt
A 2015 study indicated that graduating college students of-
ten had debts of $35,000—and this amount is expected to
rise. When it comes to student loans, having a direct, personal
plan for repayment can save time and money, reduce stress,
and help you prepare for the future. However, only about 10%
TAKE CHARGE
Financial Wellness
of students surveyed feel they have all the in-
formation needed to pay off their loans. Work
with your lender and make sure you know
how to access your balance, when to start re-
payment, how to make payments, what your
repayment plan options are, and what to do if you have trou-
ble making payments. Information on managing federal stu-
dent loans is available from https://studentaid.ed.gov/sa/.
If you have credit card debt, stop using your cards and
start paying them off. If you can’t pay the whole balance, try to
pay more than the minimum payment each month. It can take
a very long time to pay off a loan by making only the minimum
payments. For example, paying off a credit card balance of
$2000 at 10% interest with monthly payments of $20 would
take 203 months—nearly 17 years. Check out an online credit
card calculator like http://money.cnn.com/calculator/pf/debt
-free/. If you carry a balance and incur finance charges, you
are paying back much more than your initial loan.
Start Saving
If you start saving early, the same miracle of compound inter-
est that locks you into years of credit card debt can work to
your benefit (for an online compound interest calculator, visit
http://www.interestcalc.org). Experts recommend “paying
yourself first” every month—that is, putting some money into
savings before you pay your bills. You may want to save for a
large purchase, or you may even be looking ahead to retire-
ment. If you work for a company with a 401(k) retirement plan,
contribute as much as you can every pay period.
Become Financially Literate
Most Americans have not received any basic financial train-
ing. For this reason, the U.S. government has established the
Financial Literacy and Education Commission (MyMoney.gov)
to help Americans learn how to save, invest, and manage
money better. Developing lifelong financial skills should begin
in early adulthood, during the college years, if not earlier, as
money-management experience appears to have a more di-
rect effect on financial knowledge than does education. For
example, when tested on their basic financial literacy, stu-
dents who had checking accounts had higher scores than
those who did not.
SOURCES: Smith, C., and G. A. Barboza. 2013. The role of trans-generational
financial knowledge and self-reported financial literacy on borrowing prac-
tices and debt accumulation of college students. Social Science Research
Network (http://ssrn.com/abstract=2342168); Plymouth State University.
2013. Student Monetary Awareness and Responsibility Today! (http://www
.plymouth.edu/office/financial-aid/smart/); U.S. Financial Literacy and Educa-
tion Commission. 2013. MyMoney.gov (http://www.mymoney.gov);
­Sparshott, J. 2015. Congratulations, Class of 2015. You’re the most
­indebted ever (for now). Wall Street Journal, May 8, 2015 (http://blogs.wsj
.com/economics/2015/05/08/congratulations-class-of-2015-youre-the
-most-indebted-ever-for-now/); EverFi. 2016. Money Matters on Campus:
Examining Financial Attitudes and Behaviors of Two-Year and Four-Year
College Students (www.moneymattersoncampus.org).
W E L L N E S S as a H E A L T H G O A L 5
 Control of Recognition of Affordable Care Act
infectious Safer tobacco use as a Implementation
Vaccinations diseases workplaces health hazard
for childhood 77.9 78.8
diseases 75.4 76.9
73.7
Fluoridation of 69.7 70.8
drinking water 68.2

62.9
59.7

54.1 Decline in deaths

50.0 from heart disease
47.3 and stroke
Motor Healthier
Safer and vehicle safety Family planning mothers
Life
healthier foods and babies
expectancy

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2014
Year

FI GURE 1 . 3 Public health, life expectancy, and quality of life. Public health achievements during the 20th century are credited with
adding more than 25 years to life expectancy for Americans, greatly improving quality of life, and dramatically reducing deaths from infectious
diseases. Public health improvements continue into the 21st century, including greater roadway safety and a steep decline in childhood lead
poisoning. In 2013, the government mandated that all Americans be covered by health insurance, a protection already long established in most
other industrialized countries.
SOU RCE S:Kochanek, K.D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4); Centers for Disease Control and Prevention. 2011. Ten
great public health achievements—United States, 2001–2010. MMWR 60(19): 619–623; Centers for Disease Control and Prevention. 1999. Ten great public health
achievements—United States, 1900–1999. MMWR 48(50): 1141.

By 1980, life expectancy nearly doubled, due largely to
the development of vaccines and antibiotics to fight infec-
tions, and to public health measures such as water purifica-
tion and sewage treatment to improve living conditions
(Figure 1.3). But even though life expectancy has increased,
poor health will limit most Americans’ activities during the
last 15% of their lives, resulting in some sort of impaired
life (Figure 1.4). Today a different set of diseases has
emerged as our major health threat: Heart disease, cancer,
and chronic lower respiratory diseases are now the three
leading causes of death for Americans (Table 1.1). An obe-
sity epidemic, beginning in the late 1970s, has also spurred
predictions that American life e­ xpectancy will decline within
the next several decades (see box “Life Expectancy and the
Obesity Epidemic” on p. 8). Obesity and poor eating habits
can lead to all of the major chronic diseases.
The good news is that people have some control over
whether they develop chronic diseases. People make choices
every day that increase or decrease their risks for such dis-
eases. For example, each of us can take personal responsibil-
ity for lifestyle choices regarding smoking, diet, exercise,
and alcohol use. Table 1.2 shows the estimated number of
annual deaths tied to selected underlying causes. For exam-
ple, the estimated 90,000 deaths tied to alcohol includes
deaths due directly to alcohol poisoning as well as a propor-
tion of deaths from causes such as liver cancer and injuries.
Similarly, sexual behavior is linked to a proportion of all
Healthy life
69.0

life expectancy The period of time a member of T ERMS

a given population is expected to live. Impaired life
T ERMS 9.8
impaired life The period of a person’s life when he or she Life expectancy
may not be able to function fully due to disease or disability. 7 8.8 years
chronic disease A disease that develops and continues over FIGURE 1.4 Quantity of life versus quality of life. Years of
a long period, such as heart disease, cancer, or diabetes. healthy life as a proportion of life expectancy in the U.S. population.
lifestyle choice A conscious behavior that can increase or SOURCE: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National
decrease a person’s risk of disease or injury; such behaviors Vital Statistics Reports 65(4). National Center for Health Statistics. 2012.
include smoking, exercising, and eating a healthful diet. Healthy People 2010 Final Review. Hyattsville, MD: National Center for
Health Statistics.

6 CHAPTER 1 TA K I N G C H A R G E O F YO U R H E A LT H
 V I TA L S TAT I S T I C S
Table 1.1 Leading Causes of Death in the United States, 2013

NUMBER PERCENTAGE OF LIFESTYLE

RANK CAUSE OF DEATH OF DEATHS TOTAL DEATHS FACTORS
1 Heart disease 614,348 23.4 D I S A
2 Cancer 591,699 22.5 D I S A
3 Chronic lower respiratory diseases 147,101 5.6 S
4 Unintentional injuries (accidents) 136,053 5.2 I S A
5 Stroke 133,103 5.1 D I S A
6 Alzheimer’s disease 93,541 3.6
7 Diabetes mellitus 76,488 2.9 D I S
8 Influenza and pneumonia 55,227 2.1 D I S A
9 Kidney disease 48,146 1.8 S
10 Intentional self-harm (suicide) 42,773 1.6 A
11 Septicemia (systemic blood infection) 38,940 1.5 A
12 Chronic liver disease and cirrhosis 38,170 1.5 A
13 Hypertension (high blood pressure) 30,221 1.2 D I S A
14 Parkinson’s disease 26,150 1.0
15 Lung inflammation due to solids and liquids 18,792 0.7 A
All other causes 535,666
All causes 2,626,418 100.0

Key D Diet plays a part. S Smoking plays a part.

I Inactive lifestyle plays a part. A Excessive alcohol use plays a part.

NOT E:Although not among the overall top 15 causes of death, HIV/AIDS (6,721 deaths in 2014) is a major killer. In 2014, HIV/AIDS was the 13th leading
cause of death for Americans aged 15–24 years and the 8th leading cause of death for those aged 25–34 years.

SOURCE: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4).

V I TA L S TAT I S T I C S
Table 1.2 Key Contributors to Deaths among Americans

ESTIMATED NUMBER OF DEATHS PER YEAR PERCENTAGE OF TOTAL DEATHS PER YEAR
Tobacco 480,000 18.3
Diet/activity patterns (obesity)* 400,000 15.2
Alcohol consumption 90,000 3.4
Microbial agents** 80,000 3.0
Firearms 30,000 1.1
Illicit drug use*** 25,000+ 1.0
Motor vehicles 20,000 0.8
Sexual behavior**** 15,000 0.6

*The number of deaths due to obesity is an area of ongoing controversy and research. Recent estimates have ranged from 112,000 to 400,000.
**Microbial agents include bacterial and viral infections, such as influenza, pneumonia, and hepatitis. Infections transmitted sexually are counted in the “sexual
behavior” category, including a proportion of deaths related to hepatitis, which can be transmitted both sexually and nonsexually.
***Drug overdose deaths have increased rapidly in recent years, making it likely that this estimate will rise.
****Estimated deaths linked to sexual behavior includes deaths from cervical cancer and sexually acquired HIV, hepatitis B, and hepatitis C.

SOURCE S: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4), National Research Council, Institute of Medicine.

2015. Measuring the Risks and Causes of Premature Death: Summary of Workshops. Washington, DC: National Academies Press; Stahre, M., et al. 2014.
Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Preventing Chronic Disease: Research, Practice,
and Policy 11: 130293; U.S. Department of Health and Human Services. 2014. The Health Consequences of Smoking—50 Years of Progress: A Report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

W E L L N E S S as a H E A L T H G O A L 7
 TAKE CHARGE
Life Expectancy and the Obesity Epidemic
Life expectancy consistently increased each
decade in the United States since 1900 (see
Figure 1.3). But is this trend continuing? Will
children today live longer and healthier lives
than their parents? The upward trend has
slowed, and some researchers point to the significant in-
crease in obesity among Americans as a potential cause. Ac-
cording to estimates released in 2016, 35% of American men
and 40% of American women are obese. The problem isn’t
confined to the United States: The World Health Organization
estimates that 2 billion adults worldwide are overweight
or obese.
Along with increases in obesity come increased rates
of diabetes, chronic liver disease, heart disease, stroke,
and other chronic diseases that are leading causes of
death. Of course, medical interventions for these condi-
tions have improved over time, lessening the impact of
obesity to date. Still, medical treatments may be reaching
their limits in preventing early deaths related to obesity.
Moreover, people are becoming obese at earlier ages,
­exposing them to the adverse effects of excess body fat
over a longer period of time. The magnitude of the obesity
problem has brought predictions that an overall decline in
life expectancy will take place in the United States by the
mid-21st century.
What can be done? For an individual, body composition
is influenced by a complex interplay of personal factors, in-
cluding heredity, metabolic rate, hormones, age, and d ­ ietary
and activity habits. But many outside forces—social, ­cultural,
and economic—shape our behavior, and some experts rec-
ommend viewing obesity as a public health problem that
requires an urgent and coordinated public health response.
A response in health care technology such as gastric b ­ ypass
surgery, medications, and early screening for obesity-­
related diseases has helped in the past, but if obesity trends
persist, especially among children, average life spans may
begin to decrease.
What actions might be taken? Suggestions from health
promotion advocates include the following:
• Change food pricing to promote healthful options; for ex-
ample, tax sugary beverages and offer incentives to farmers
and food manufacturers to produce and market affordable
healthy choices and smaller portion sizes.
• Limit advertising of unhealthy foods targeting children.
• Require daily physical education classes in schools.
deaths from HIV/AIDS and cervical cancer. As Table 1.2
makes clear, lifestyle factors contribute to many deaths in the
United States.
The need to make good choices is especially true for teens
and young adults. For Americans aged 15–24, for example,
8 CHAPTER 1 TA K I N G C H A R G E O F YO U R H E A LT H
• Fund strategies to promote physical activity by creat-
ing more walkable communities, parks, and recreational
­facilities.
• Train health professionals to provide nutrition and exercise
counseling, and mandate health insurance coverage for treat-
ment of obesity as a chronic condition.
• Promote expansion of worksite programs for improving
diet and physical activity habits.
• Encourage increased public investment in obesity-related
research.
In addition to indirectly supporting these actions, you can
directly do the following:
• Analyze your own food choices, and make appropriate
changes. Nutrition is discussed in detail in Chapter 12, but
you can start by shifting away from consuming foods high in
sugar and refined grains.
• Be more physically active. Take the stairs rather than the
elevator, ride a bike instead of driving a car, and reduce your
overall sedentary time.
• Educate yourself about current recommendations and ar-
eas of debate in nutrition.
• Speak out, vote, and become an advocate for healthy
changes in your community.
See Chapters 12–14 for more on nutrition, exercise, and
weight management.
SOURCES: Flegal, K. M., et al. 2016. Trends in obesity among adults in
the United States, 2005–2014. JAMA 315(21): 2284–2291. Ludwig,
D. S. 2016. Lifespan weighed down by diet. JAMA (published online
April 4, 2016, DOI: 10.1001/jama.2016.3829); Olshansky, S. J., et al.
2005. A potential decline in life expectancy in the United States in the
21st century. New England Journal of Medicine 352(11): 1138–1145;
National Center for Health Statistics. 2016. Health, United States,
2015: With ­Special Feature on Racial and Ethnic Health Disparities.
Hyattsville, MD: National Center for Health Statistics; International
Food Policy Research Institute. 2016. Global Nutrition Report 2016:
From Promise to Impact: Ending Malnutrition by 2030. Washington,
DC: International Food Policy Research Institute; U.S. Department of
Agriculture. 2015. Scientific ­Report of the 2015 Dietary Guidelines
­Advisory Committee (http://www.health.gov/dietaryguidelines
/2015-scientific-report).
the leading cause of death is unintentional injuries (acci-
dents), with the greatest number of deaths linked to car
crashes (Table 1.3). Factors that influence wellness, includ-
ing the choices we can all make to promote it, are discussed
later in this chapter.
 V I TA L S TAT I S T I C S
Table 1.3 Leading Causes of Death among Americans Aged 15–24, 2014

RANK CAUSE OF DEATH NUMBER OF DEATHS PERCENTAGE OF TOTAL DEATHS

1 Unintentional injuries (accidents): 11,836 41.1
Motor vehicle 6,959 24.2
All other unintentional injuries 4,877 16.9
2 Suicide 5,079 17.6
3 Homicide 4,144 14.4
4 Cancer 1,569 5.4
5 Heart disease 1,199 4.2
All causes 28,791 100.0

SOURCE: Kochanek, K. D., et al. 2016. Deaths: Final data for 2014. National Vital Statistics Reports 65(4).

Coverage
Ask Yourself
QUESTIONS FOR CRITICAL THINKING AND REFLECTION
How often do you feel exuberant? Vital? Joyful? What makes you
feel that way? Conversely, how often do you feel downhearted,
de-energized, or depressed? What makes you feel that way? Have
you ever thought about how you might increase experiences of
vitality and decrease experiences of discouragement?
∙ Health plans can no longer deny or limit benefits due
to a preexisting condition.
∙ If you are under 26, you may be eligible to be covered
under your parent’s health plan.
∙ Insurers can no longer cancel your coverage because of
honest mistakes in your application.
∙ If your plan denies payment, you are guaranteed the
right to appeal.

PROMOTING NATIONAL HEALTH
Wellness is a personal concern, but the U.S. government has
financial and humanitarian interests in it, too. A healthy
population is the nation’s source of vitality, creativity, and
wealth. Poor health drains the nation’s resources and raises
health care costs for all. The primary health promotion
strategies at the government and community levels are pub-
lic health policies and agencies that identify and discourage
unhealthy and high-risk behaviors and that encourage and
provide incentives for positive health behaviors. At the fed-
eral level in the United States, the National Institutes of
Health (NIH) and the Centers for Disease Control and Pre-
vention (CDC) are charged with promoting the public’s
health. These and other agencies translate research results
into interventions and communicate research findings to
health care providers and the public. There are also health
promotion agencies and programs at the state, community,
workplace, and college levels. Take advantage of health pro-
motion resources at all levels that are available to you.
The Affordable Care Act
The Affordable Care Act (ACA), also called “Obamacare,”
was signed into law on March 23, 2010, and upheld by the
Supreme Court in 2012 and 2015. The new law requires
most people to obtain health insurance or pay a federal pen-
alty. Here is a brief summary of the new law:
Costs
∙ Lifetime dollar limits are not permitted on most
­benefits you receive.
∙ Insurance companies must now publicly justify rate
hikes.
∙ Your premium dollars must be spent primarily on
health care—not administrative costs.
Care
∙ Recommended preventive health services are covered
with no copayment.
∙ From your plan’s network, you can choose the primary
care doctor you want.
∙ You can seek emergency care at a hospital outside your
health plan’s network.
Finding a Plan Under the ACA, health insurance market­
places, also called health exchanges, facilitate the purchase
of health insurance in every state. The health exchanges
provide a selection of government-regulated health care
plans that students and others may choose from. Those who
are below income requirements are eligible for federal help
with the premiums.
health promotion The process of enabling TER MS
people to increase control over their health and its
determinants, and thereby improve their health. TER M

P romoting N ational H ealth 9

 Table 1.4 Progress toward Healthy People 2020 Targets
BASELINE
(% IN 2008)
Increase proportion of people with health insurance
Help adults with hypertension get blood pressure under control
Reduce proportion of obese adults
Reduce proportion of adults who drank excessively in past 30 days
Increase proportion of adults who meet federal guidelines for exercise
Reduce proportion of adults who use cigarettes
SOURCE: U.S. Department of Health and Human Services. Healthy People 2020 data search (https://www.healthypeople.gov/2020/data-search/Search-the-Data).
Benefits to College Students The ACA permits stu-
dents to stay on their parents’ health insurance plans until
age 26—even if they are married or have coverage through
an employer. Students not on their parents’ plans who do not
want to purchase insurance through their schools can do so
through a health insurance marketplace.
If you’re under 30, you have the option of buying a “cata-
strophic” health plan. Such plans tend to have low premiums
but require you to pay all medical costs up to a certain amount,
usually several thousand dollars. The insurance company
would pay for essential health benefits over that amount.
Students whose income is below a certain level may qual-
ify for Medicaid. Check with your state. Individuals with
nonimmigrant status, which includes worker visas and stu-
dent visas, qualify for insurance coverage through the ex-
changes. You can browse plans and apply for coverage at
HealthCare.gov.
The Healthy People Initiative
The national Healthy People initiative aims to prevent dis-
ease and improve Americans’ quality of life. Healthy People
reports, published each decade since 1980, set national
health goals based on 10-year agendas. The initiative’s most
recent iteration, Healthy People 2020, was released to the
public in 2010 and envisions “a society in which all people
live long, healthy lives” and proposes the eventual achieve-
ment of the following broad national health objectives:
∙ Eliminate preventable disease, disability, injury, and
premature death.
∙ Achieve health equity, eliminate disparities, and im-
prove the health of all groups.
∙ Create social and physical environments that promote
good health for all.
∙ Promote healthy development and healthy behaviors
across every stage of life.
health disparity A health difference linked to T ERMS
social, economic, or environmental disadvantage that
adversely affects a group of people.
T ERMS
10 CHAPTER 1 TA K I N G C H A R G E O F YO U R H E A LT H
MOST RECENT TARGET PROGRESS
(% IN 2013–2014) (% BY 2020) TOWARD GOAL
83.2 86.7 100.0 Significant progress
43.7 48.9 61.2 Significant progress
33.9 37.7 30.5 Getting worse
27.1 26.9 24.4 Insignificant progress
18.2 21.3 20.1 Target met
20.6 17.0 12.0 Significant progress
In a shift from the past, Healthy People 2020 emphasizes
the importance of health determinants—factors that affect
the health of individuals, demographic groups, or entire pop-
ulations. Health determinants are social (including factors
such as ethnicity, education level, or economic status) and
environmental (including natural and human-made environ-
ments). Thus one goal is to improve living conditions in
ways that reduce the impact of negative health determinants.
Examples of individual health-promotion goals from
Healthy People 2020, along with estimates of how well
Americans are tracking toward achieving those goals, appear
in Table 1.4.
Health Issues for Diverse Populations
We all need to exercise, eat well, manage stress, and culti-
vate positive relationships. We also need to protect ourselves
from disease and injuries. But some of our differences—
both as individuals and as members of groups—have impor-
tant implications for wellness. These differences can be
biological (determined genetically) or cultural (acquired as
patterns of behavior through daily interactions with family,
community, and society); many health conditions are a func-
tion of biology and culture combined.
As described in the previous section, eliminating health
disparities is a major focus of Healthy People 2020. But not
all health differences between groups are considered health
disparities, which are those differences linked with social,
economic, and/or environmental disadvantage. They affect
groups who have systematically experienced greater obsta-
cles to health based on characteristics that are historically
linked to exclusion or discrimination. For example, the fact
that women have a higher rate of breast cancer than men is a
health difference but is not considered a disparity. In con-
trast, the higher death rates from breast cancer for black
women compared with non-Hispanic white women is con-
sidered a health disparity.
You share patterns of influences with certain others, and
information about those groups can help you identify areas
that may be of concern to you and your family. Healthy Peo-
ple 2020 tracks health status and behaviors in relation to a
number of demographic dimensions, including sex and gen-
der, race and ethnicity, income and educational attainment,
Another random document with
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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