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A letter to the editor is presented in response to the article about witchcraft and psychotherapy published in the August 1986 issue.

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth 1 . Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months., (© 2023. The Author(s).)

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival 1,2 . Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions., (© 2023. The Author(s).)

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards) 1,2 . Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

The objective of this study was to assess the relationship between public protests and county-level, novel coronavirus disease (COVID-19) hospitalization rates across California. Publicly available data were included in the analysis from 55 of 58 California state counties (29 March-14 October 2020). Mixed-effects negative binomial regression models were used to examine the relationship between daily county-level COVID-19 hospitalizations and two main exposure variables: any vs. no protests and 1 or >1 protest vs. no protests on a given county-day. COVID-19 hospitalizations were used as a proxy for viral transmission since such rates are less sensitive to temporal changes in testing access/availability. Models included covariates for daily county mobility, county-level characteristics, and time trends. Models also included a county-population offset and a two-week lag for the association between exposure and outcome. No significant associations were observed between protest exposures and COVID-19 hospitalization rates among the 55 counties. We did not find evidence to suggest that public protests were associated with COVID-19 hospitalization within California counties. These findings support the notion that protesting during a pandemic may be safe, ostensibly, so long as evidence-based precautionary measures are taken.

Background: It is estimated that vaccinating 50%-70% of school-aged children for influenza can produce population-wide indirect effects. We evaluated a city-wide school-located influenza vaccination (SLIV) intervention that aimed to increase influenza vaccination coverage. The intervention was implemented in ≥95 preschools and elementary schools in northern California from 2014 to 2018. Using a matched cohort design, we estimated intervention impacts on student influenza vaccination coverage, school absenteeism, and community-wide indirect effects on laboratory-confirmed influenza hospitalizations., Methods and Findings: We used a multivariate matching algorithm to identify a nearby comparison school district with pre-intervention characteristics similar to those of the intervention school district and matched schools in each district. To measure student influenza vaccination, we conducted cross-sectional surveys of student caregivers in 22 school pairs (2017 survey, N = 6,070; 2018 survey, N = 6,507). We estimated the incidence of laboratory-confirmed influenza hospitalization from 2011 to 2018 using surveillance data from school district zip codes. We analyzed student absenteeism data from 2011 to 2018 from each district (N = 42,487,816 student-days). To account for pre-intervention differences between districts, we estimated difference-in-differences (DID) in influenza hospitalization incidence and absenteeism rates using generalized linear and log-linear models with a population offset for incidence outcomes. Prior to the SLIV intervention, the median household income was $51,849 in the intervention site and $61,596 in the comparison site. The population in each site was predominately white (41% in the intervention site, 48% in the comparison site) and/or of Hispanic or Latino ethnicity (26% in the intervention site, 33% in the comparison site). The number of students vaccinated by the SLIV intervention ranged from 7,502 to 10,106 (22%-28% of eligible students) each year. During the intervention, influenza vaccination coverage among elementary students was 53%-66% in the comparison district. Coverage was similar between the intervention and comparison districts in influenza seasons 2014-2015 and 2015-2016 and was significantly higher in the intervention site in seasons 2016-2017 (7%; 95% CI 4, 11; p < 0.001) and 2017-2018 (11%; 95% CI 7, 15; p < 0.001). During seasons when vaccination coverage was higher among intervention schools and the vaccine was moderately effective, there was evidence of statistically significant indirect effects: The DID in the incidence of influenza hospitalization per 100,000 in the intervention versus comparison site was -17 (95% CI -30, -4; p = 0.008) in 2016-2017 and -37 (95% CI -54, -19; p < 0.001) in 2017-2018 among non-elementary-school-aged individuals and -73 (95% CI -147, 1; p = 0.054) in 2016-2017 and -160 (95% CI -267, -53; p = 0.004) in 2017-2018 among adults 65 years or older. The DID in illness-related school absences per 100 school days during the influenza season was -0.63 (95% CI -1.14, -0.13; p = 0.014) in 2016-2017 and -0.80 (95% CI -1.28, -0.31; p = 0.001) in 2017-2018. Limitations of this study include the use of an observational design, which may be subject to unmeasured confounding, and caregiver-reported vaccination status, which is subject to poor recall and low response rates., Conclusions: A city-wide SLIV intervention in a large, diverse urban population was associated with a decrease in the incidence of laboratory-confirmed influenza hospitalization in all age groups and a decrease in illness-specific school absence rate among students in 2016-2017 and 2017-2018, seasons when the vaccine was moderately effective, suggesting that the intervention produced indirect effects. Our findings suggest that in populations with moderately high background levels of influenza vaccination coverage, SLIV programs are associated with further increases in coverage and reduced influenza across the community., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: The following authors report grant support from the Flu Lab to the University of California, Berkeley for the conduct of this research: JBC, BFA, KM, NP, AN, WJ, AEH, AR, JMC. EP reports grant support from the Shoo the Flu organization to the Alameda County Public Health Department. KH reports paid employment from the Shoo the Flu organization. CK reports paid employment from Kaiser Permanente Northern California, Division of Research. PDK and TL report grant support from the U.S. Centers for Disease Control and Prevention to the California Emerging Infections Program.

Zika and associated microcephaly among newborns were reported in Brazil during 2015. Zika has since spread across the Americas, and travel-associated cases were reported throughout the United States. We reviewed travel-associated Zika cases in California to assess the potential threat of local Zika virus transmission, given the regional spread of Aedes aegypti and Ae. albopictus mosquitoes. During November 2015-September 2017, a total of 588 travel-associated Zika cases were reported in California, including 139 infections in pregnant women, 10 congenital infections, and 8 sexually transmitted infections. Most case-patients reported travel to Mexico and Central America, and many returned during a period when they could have been viremic. By September 2017, Ae. aegypti mosquitoes had spread to 124 locations in California, and Ae. albopictus mosquitoes had spread to 53 locations. Continued human and mosquito surveillance and public health education are valuable tools in preventing and detecting Zika virus infections and local transmission in California.

The aim of this article is to present a summarizing overview on ethnomedical aspects of koro (in Chinese called suo-yang), the panic anxiety state in which affected males believe that the penis is shrinking and/or retracting, and perhaps disappearing. While reduction of penile volume occurs physiologically due to vasoconstriction in cold temperature and intense anxiety, it is believed in certain cultures that genital shrinking leads to impotence and sterility, and eventually to death. Traditional Chinese medicine treats suo-yang, the reduction of the male principle yang, as a dangerous disturbance of the life-sustaining yin-yang equilibrium of the organism. Koro has therefore been held to be a Chinese "culture-bound" condition. However , the koro phenomenon is also known among diverse ethnic and religious groups in Asia and Africa, typically in cultures in which reproductive ability is a major determinant of a young person's worth. Koro epidemics of panic anxiety due to widespread fears of losing one's genitals, procreative ability, and even one's life, are triggered by rumors of genital disappearance supposedly caused in China by female fox spirits, in Singapore and Thailand by mass poisoning, and in Africa by sorcery, usually in the context of socioeconomic or political tension. Today, in contemporary Western societies, ideas of genital disappearance are not culturally endorsed. But historically, it should be remembered that in the late Middle Ages in Europe, a man could lose his membrum virile through magical attacks by witches. The conclusion is that the psychological disappearance of the penis is a universal syndrome that was described recently in Asia and Africa and already in Medieval Europe.

Emil Kraepelin, well known as the principal designer of modern psychiatric nosology, is less well known for his pioneering work in comparative sociocultural psychiatry. This paper is trying to document Kraepelin's role as the inaugurator of systematic investigations into culture-dependent differences in psychopathology. Despite his many responsibilities as clinician, teacher, hospital administrator and scientific author, Kraepelin considered cross-cultural comparison of such importance that he spent considerable time on the preparation of then very cumbersome overseas expeditions. His first research journey in 1904 to Southeast Asia led to the programmatic formulation of comparative psychiatry as a scientific endeavour designed to contribute to the better understanding of psychopathological processes and to a comprehensive comparative ethnopsychology ("Voelkerpsychologie"). Kraepelin's main cross-cultural research project, planned to extend to seven non-European countries and to involve many foreign colleagues, was prevented by World War I and postwar complications. One year before his unexpected death, Kraepelin conducted comparative studies with American Indian, Afro-American and Latin American patients at psychiatric institutions in the United States, Mexico and Cuba in 1925. In his writings Kraepelin commented on certain differences in the incidence and presentation of psychopathological phenomena that he considered to be due to ethnic-cultural characteristics or social conditions. This paper discusses in detail Kraepelin's observations on the pathoplastic and pathogenic effects of cultural and social factors, and demonstrates the influence of his ideas on the development of modern social and transcultural psychiatry.

Starting from a critical review of the concept of 'culture-bound' disorders and its development in comparative psychiatry, the authors present the changing aspects of two so-called culture-bound syndromes as paradigms of transcultural metamorphosis (koro) and intra-cultural metamorphosis (Salish Indian spirit sickness), respectively. The authors present recent data on epidemics of koro, which is supposedly bound to Chinese culture, in Thailand and India among non-Chinese populations. Neither the model of Oedipal castration anxiety nor the model of culture-specific pathogenicity, commonly adduced in psychiatric and ethnological literature, explain these phenomena. The authors' data on Salish Indian spirit sickness describes the contemporary condition as anomic depression, which is significantly different from its traditional namesake. The traditional concept was redefined by Salish ritual specialists in response to current needs imposed by social changes. The stresses involved in creating the contemporary phenomena of koro and spirit sickness are neither culture-specific nor culture-inherent, as postulated for 'culture-bound' syndromes, rather they are generated by a feeling of powerlessness caused by perceived threats to ethnic survival.

Initiation ceremonials in traditional Papua New Guinea and North American Indian cultures serve important psychohygienic functions in establishing the youth's final identity and thereby warding off the frustration, anxiety, and depression which are associated with anomie and role confusion. Inititations in Papua New Guinea are presented as a process of social learning in which group consciousness and loyalty are established through revelation of ancestral secrets, testing by ordeals, and ego-stregthening rewards. Structually patterned archetypal collective symbols gain direct access to the young person's unconscious when skillfully transmitted in the initiatory psychodrama of death and rebirth. Medical complications occuring during initiation procedures are rare accidents which have to be weighed against the psychological and social benefits for individual and group. Initiation ceremonials help the young to achieve a sense of sexual and socio-cultural identity from which feelings of emotional security and social belonging are derived.

Koro, a psychogenic anxiety syndrome interfering with genital body image and sexual functioning, has hitherto been described as occurring mainly in isolated cases of South Chinese males. The present communication reports an epidemic outbreak in November 1976 in Northeastern Thailand where within a few days at least 200 patients, most of them Thai and two-thirds males, were treated at local hospitals. Main presenting symptoms were acute anxiety, in some cases leading to fainting, (subjective) shrinking of the penis and impotency in men, shrinking and/or itching of the external genitals and frigidity in women; further complaints included initial nausea and dizziness, abdominal pains, headaches, facial numbness. All patients recovered after brief symptomatic intervention. Popular opinion and news media echoed the patients' paranoid projection of viewing the epidemic as caused by Vietnamese food and tobacco poisoning in a hideous assault against the sexual vitality and general health of the Thai people, in the context of a specific socio-cultural and politico-historical situation. It appears that an adequate interpretation of Koro and of analogous hysterical symptom formation would have to go beyond the hitherto applied psychoanalytic models by considering the specific sociodynamic factors involved in the pathogenesis of such phenomena.