From a public-health perspective, our survey raises some issues for discussion and potential topics for future work.
First, for example, the local government, local CDC, primary health care institutes, and other public health institutions, need to find a solution to the imbalanced diet and consequent prevalence of NCDs within the community, possibly using a “positive deviance” approach (Baxter et al., 2016). “Positive deviance” is based on the observation that in every community there are certain individuals or groups whose uncommon behaviours and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges (Positive Deviance Collaborative, 2017).
The key question here is, what enables some members of the community (the “positive deviants”) to have more balanced diets and better health outcomes than others with the same resources. Interventions could be designed and implemented, drawing on the experience of the
“positive deviants” before the underlying causes are fully addressed. The “positive deviance” approach uses local assets available to most community members and is independent of external resources, thus potentially making the intervention programme sustainable (Baxter et al., 2016; Positive Deviance Collaborative, 2017).
Second, it is crucial that stakeholders work together with the local community. There is a growing body of evidence underscoring the importance of cultural sensitivity in health services. As the 2014 Lancet-University College London Culture and Health Commission wrote, “the systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest standard of health worldwide” (Napier et al., 2014). In the unique natural and cultural environment of the Tibetan Plateau, local involvement in programme design may help breed success (Schembri et al., 2016).
Third, local government, local non-governmental organizations (NGOs), research institutions and the community need to come together to find a solution to the deteriorating dietary habits of the indigenous population. Government support is the premise in a local context, while the local NGO is usually the most active body that connects others in the chain.
This model has been proved successful in the ecological conservation field in the Sanjiangyuan areas, with Green River and Shanshui good examples of effective NGOs. In the public health area, such working models need to be explored further.
The food environment (and its wider system) is not just a tool for or determinant of nutritious and healthy foods. It also serves as a connection point to the environment and to the continuity of local culture. Together, food systems have added immensely to the overall picture of health determinants and to the environmental and cultural sustainability of Tibetan pastoralists – as they have for many other indigenous populations in food-environment transition.
ACKNOWLEDGEMENTS
The author is deeply grateful to Prof. Elliot M. Berry for his encouragement and invaluable suggestions and revisions in preparing this work. The author would also like to thank the local Green River NGO, its staff and volunteers, for their considerable help in conducting fieldwork, particularly in accessing the very remote areas in question and meeting the people there. The author is also thankful for Prof.
Yuexin Yang and Prof. Duo Li for their encouragement and help in initiating the project; for Prof. Yongnian Liu, Prof. Rong Wang and Prof. Zhaofen Wang for their help in coordinating the work.
FUNDING
This work was partly funded by the Pears IMPH Alumni Seed-Grant Program and a grant from Qinghai University Medical School (2017-KYZ-06). The Pears IMPH Seed-Grant Program aims to promote public health research, which is the result of a continuing partnership between the Braun School of Public Health, the Hebrew University of Jerusalem-Hadassah and the Pears Foundation. The Amity Foundation contributed to the funding of health check-ups on pastoralists in a 2018 field survey.
NGO/GREEN RIVER
References
Archer, E. 2018. In Defense of Sugar: A Critique of Diet-Centrism. Progress in Cardiovascular Diseases, 61(1): 10–19.
Baxter, R., Taylor, N., Kellar, I. & Lawton, R. 2016. What methods are used to apply positive deviance within healthcare organisations? A systematic review.
BMJ Quality & Safety, 25(3): 190–201. (also available at https://qualitysafety.
bmj.com/content/25/3/190.long).
Berry, E.M. 2011. The role of the sociotype in managing chronic disease:
integrating bio-psycho-sociology with systems biology. Medical Hypotheses, 77(4): 610–613.
Bessho, Y. 2015. Migration for ecological preservation? Tibetan herders’
decision making process in the eco-migration policy of Golok Tibetan autonomous prefecture (Qinghai province, PRC). Nomadic Peoples, 19(2):
189–208.
Chinese Center for Disease Control and Prevention (China CDC). 2015.
Report on nutrition and non-communicable diseases among Chinese residents, 2015. First edition [in Chinese]. Beijing, China, People’s Health Press.
Fan, Y. 2014. An investigation on the effects of ecological migration project in Qinghai Province. School of Economics, Central University for Nationalities.
MSc Dissertation. (also available, in Chinese only, at http://www.wanfangdata.
com.cn/details/detail.do?_type=degree&id=Y2616734).
FAO. 2016. Influencing food environments for healthy diets. Rome, FAO. 154 pp.
(also available at http://www.fao.org/3/a-i6484e.pdf).
Kuhnlein, H.V. & Receveur, O. 1996. Dietary change and traditional food systems of indigenous peoples. Annual Review of Nutrition, 16: 417–442.
Kuhnlein, H.V., Receveur, O., Soueida, R. & Egeland, G.M. 2004. Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity. The Journal of Nutrition, 134(6): 1447–1453. (also available at https://academic.oup.com/jn/article/134/6/1447/4688754).
Monteiro, C.A., Mondini, L., Medeiros de Souza, A.L. & Popkin, B.M. 1995.
The nutrition transition in Brazil. European Journal of Clinical Nutrition, 49(2):
105–113.
Moreno, L.A., Sarría, A. & Popkin, B.M. 2002. The nutrition transition in Spain:
a European Mediterranean country. European Journal of Clinical Nutrition, 56(10):
992–1003. (also available at https://www.nature.com/articles/1601414).
Napier, A.D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., Guesnet, F., et al. 2014. The Lancet Commissions: Culture and health. The Lancet, 384(9954): 1607–1639.
Peng, W. & Berry, E.M. 2019. The Concept of Food Security. In P. Ferranti, E.M.
Berry & J.R. Anderson, eds. Encyclopedia of Food Security and Sustainability, pp. 1–7. New York, Elsevier.
Peng, W., Dernini, S. & Berry, E.M. 2018. Coping With Food Insecurity Using the Sociotype Ecological Framework. Frontiers in Nutrition, 5: 107. (also available at https://www.frontiersin.org/articles/10.3389/fnut.2018.00107/full).
Peng, W, Liu, Y.N., Liu, Y., Zhao, H. & Chen, H.R. (forthcoming). Major dietary patterns and their relationship to obesity among urbanized adult Tibetan pastoralists. Paper accepted for Asia Pacific Journal of Clinic Nutrition.
Positive Deviance Collaborative. 2017. What is Positive Deviance? In:
The Positive Deviance Collaborative [online]. [Cited 5 March 2019]. https://
positivedeviance.org.
Ptackova, J. 2011. Sedentarisation of Tibetan nomads in China:
Implementation of the Nomadic settlement project in the Tibetan Amdo area;
Qinghai and Sichuan Provinces. Pastoralism: Research, Policy and Practice, 1:
4. (also available at https://link.springer.com/article/10.1186/2041-7136-1-4).
The State Council Information Office of the P.R.C. 2018. The insurance policy will protect the ecological guards in the Sanjiangyuan National park.
In: The State Council Information Office of the P.R.C. [online, in Chinese]. [Cited 15 May 2019]. http://www.scio.gov.cn/32344/32345/37799/39124/39131/
Document/1639498/1639498.htm
Singh, R.K., Pretty, J. & Pilgrim, S. 2010. Traditional knowledge and biocultural diversity: learning from tribal communities for sustainable development in northeast India. Journal of Environmental Planning and Management, 53(4): 511–533.
Schembri, L., Curran, J., Collins, L., Pelinovskaia, M., Bell, H., Richardson, C.
& Palermo, C. 2016. The effect of nutrition education on nutrition-related health outcomes of Aboriginal and Torres Strait Islander people: a systematic review.
Australian and New Zealand Journal of Public Health, 40 (suppl. 1): S42–S47. (also available at https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12392).
Turner, C., Aggarwal, A., Walls, H., Herforth, A., Drewnowski, A., Coates, J., Kalamatianou, S. & Kadiyala, S. 2018. Concepts and critical perspectives for food environment research: A global framework with implications for action in low- and middle-income countries. Global Food Security, 18: 93–101. (also available at https://www.sciencedirect.com/science/article/pii/S2211912418300154).
Wang, Z., Song, K. & Hu, L. 2010. China’s largest scale ecological migration in the Three-River Headwater region. Ambio, 39(5-6): 443–446. (also available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3357714/).
Xinhua News Agency. 2014. The pastoralist-settling project benefited 530,000 people within 5 years in Qinghai. In: Xinhua News Agency [online, in Chinese]. [Cited 9 January 2019]. http://www.gov.cn/xinwen/2014-11/12/
content_2777481.htm
Zhang, B., Zhai, F.Y., Du, S.F. & Popkin, B.M. 2014. The China Health and Nutrition Survey, 1989-2011. Obesity Reviews, 15 (suppl. 1): 2–7. (also available at https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12119).