SOME THINGS CAN'T BE TRUE BUT ARE:

RICE, RICKETS, AND WHAT ELSE?

Norman Uphoff and Jerry Combs

Cornell University

"If he [the scientist] sees a thing, he must say that he sees it, whether it was what he
thought he was going to see or not.... Otherwise you will only see what you were
expecting. Most scientists forget that."

Dr. Wonko, in Adams (1984: 165)

The common expression "I'll believe it when I see it" is not necessarily true. Indeed, the converse is

often more correct because we have a hard time seeing what we don't believe. The scientist, Dr.

Wonko, in Douglas Adams' concluding novel in his Hitchhiker's Guide to the Galaxy series feigned

madness to be able to work outside the confines of conventional science because he found them limiting

his observation and exploration of nature.

Most people are by now familiar, perhaps too familiar, with the term "paradigm." We share the

widespread feeling that the word has been used so frequently, and often so pretentiously, that it burdens

more conversations than it enlightens. However, some of our work overseas with colleagues on behalf

of the Cornell International Institute for Food, Agriculture and Development (CIIFAD) has shown us

how important it is not just to understand this concept, but to appreciate how paradigms can limit our

vision rather than inform it.

Paradigm Problems in the Developing World

A paradigm is a set of concepts, linked by some specified set of relationships, that dominates and thus

shapes thinking in a field of endeavor. This sounds abstract, and it is. But paradigms can have very real

consequences, as we learned from experiences at grassroots levels in Bangladesh and Madagascar.

We found ourselves in situations where a significant problem or a remarkable solution was being

overlooked or dismissed by scientists and other professionals because of what can best be described as

"paradigm blockage." In both cases, something that could be seen, literally in broad daylight, was being

discounted and even denied because, according to standard ways of thinking, it was not possible.

Here we would like to share what we have learned about a serious disease among children and

a promising opportunity to improve both food security and rain forest protection, starting with the latter.

Both stories are interesting in themselves; but they also show how the way that we organize and

communicate our knowledge can keep us from responding to significant needs and opportunities.

In Madagascar, we learned in 1993 about a simple set of practices for growing rice that could

increase crop yields by multiples, not just increments, and without requiring costly inputs of genetically

improved seeds or chemical fertilizer. However, this system of intensified rice production was being

rejected by agricultural scientists who gave it only cursory consideration despite reports that the

methods could double grain output or more. Why? Because this system did not fit prevailing beliefs

about how rice is supposed to be cultivated, and because its results were perceived as "too good to be

true."

Then in Bangladesh two years ago, we heard about the spread of rickets among many

thousands of children. Rickets is a dreadful malformation of growing bones that can cripple people for

life, robbing them of the chance to be self-supporting and the basic need of self-respect. If rickets were

a communicable disease, this would have been considered an epidemic since it was affecting one in 10

children in the Chakaria subdistrict of that country. Yet the medical establishment was ignoring this

health problem. It is "well known" that rickets does not occur in the tropics. Children there are

regularly exposed to sunshine so their skin should be able to synthesize enough Vitamin D, which it was

discovered in the early part of this century can prevent rickets. Nevertheless, in Chakaria we found
many florid cases of the disease, which were subsequently confirmed by radiological as well as

biochemical evaluations.

The Need Sometimes to Unlearn

Our intent here is not to criticize paradigms in general. Certainly, we need them to perceive and make

sense of the world, to construct and share knowledge. We rely on them necessarily, and usually

unwittingly. Without common understandings about how things work, we cannot comprehend the

world. Lacking paradigms, communicating with others would be even more complex and cumbersome

than it already is.

In the situations presented here, we have found ourselves in the middle of scientific

controversies and, we hope, advancement of knowledge. In each case the paradigms being challenged

had contributed to some remarkable progress. The "Green Revolution" based on manipulating the

genetic potentials of cereal varieties and adding nutrients to the soil through chemical fertilizers has

helped double food production and reduce hunger and poverty in the world (Conway 1997). Vitamin

D supplements and the fortification of foods such as milk and breakfast cereals have helped eradicate

rickets as a public health problem in the industrialized world. Nevertheless, we now see how these

paradigms impede further advance of knowledge. The challenge is how to get the benefits of paradigms

without becoming their prisoners.

Paradigms are simplifications: simplified organizations of cause and effect, consensual boundings

of open systems to make them closed and, thus, more comprehensible. They are generalized

explanations that spare us the labor of crafting particular ones for specific instances. As teachers and

scientists, one social and the other biological, both of us depend every day upon various paradigms to

make clear to students and colleagues what we understand to be true, and to provide a basis for further
inquiry and collaborative advancement of knowledge.

Paradigms are important beyond academia. "The free market," for example, is a shared

conception of economic relationships and dynamics that enables analysts and policy makers to

communicate and to reach conclusions about preferable courses of action in daily life. In the field of

nutrition, the "recommended daily allowance" has been useful for raising consciousness about the need

for certain nutrients and for focusing research on what constitutes an adequate diet. But just as both of

these paradigms have facilitated better understanding of cause and effect and the prediction of

outcomes, they also have serious limitations that are increasingly understood. (See, for example, the

critiques offered by Ormerod (1994) and Combs (1998).)

There is an old Quaker admonition that one should hold one's material possessions lightly;

likewise, there is reason for us to hold our mental constructions for dealing with the realms of nature and

society both conditionally and critically. We should continually remind ourselves that there is always a

chance that any construct of what we think represents "reality" can be incomplete, may mislead, or will,

indeed, be wrong about important situations.

This is prologue for considering two real-world encounters with puzzling and dramatic realities

affecting tens of thousands of people and potentially millions who face dire hunger and disease. In each

case, paradigms that previously facilitated the achievement of more food and better health for people in

need made it difficult to comprehend problems and opportunities, and, indeed, even to see them.

An Unrecognized Opportunity for Growing More Rice

In December 1993, CIIFAD was invited by the U. S. Agency for International Development (USAID)

to join an ongoing integrated conservation and development project in Madagascar. This was designed

to protect 42,000 hectares of rain forest within the newly created Ranomafana National Park lying along
that country's still-forested eastern escarpment. The park contains an abundance of threatened

ecosystems that are home to dozens of endemic species of plants and animals -- lemurs, reptiles,

chameleons, butterflies and other precious creatures. Alison Jolly, a leading primatologist who has

studied the ecology of Ranomafana, considers it one of the biologically richest areas of Madagascar

because of the particularly wide diversity of ecological "niches" it provides for small mammals, birds and

reptiles.

When we first visited Madagascar, the State University of New York at Stony Brook was

already working to establish the park and promote conservation goals with staff from the national park

agency. Our task was to work with Malagasy colleagues in assisting thousands of people living on the

periphery of the park to change their farming systems in upland areas from shifting cultivation to more

productive and sustainable agriculture. Farmers had for generations cultivated hillside areas by cutting

down and burning vegetation at the start of the planting season. This practice releases nutrients

accumulated in the forest vegetation for crops planted in the burned-over soil.

It was clear to us that any strategy for saving the rain forest had to begin with raising the very

low yields of irrigated lowland rice, which were generally no more than two metric tons per hectare.

This compares poorly with the world average, about 3.6 tons per hectare. Malagasies are some of the

biggest consumers of rice in the world, as this staple grain provides over half of their daily calories.

With such low yields and very little valley-bottom land available for irrigated production around

Ranomafana, most households had little choice but to practice slash-and-burn agriculture in the upland

areas around the forest.

The traditional slash-and-burn technology for growing rice generally yields between 1 and 1.5

tons per hectare. It requires only about one-third as much labor as irrigated production because neither
weeding nor the operation and maintenance of canals is necessary. Thus, more and more forested area

is converted each year to non-permanent fields; these are cropped for a year or two and then

abandoned when their yields decline. Farmers generally return to them after 5 to 10 years, when

regrowth has renewed the supply of nutrients that can be exploited once more by burning the vegetation.

With enough time, soil fertility can recuperate; however, fallow periods have been getting shorter,

responding to the economic pressures of a growing population. Uncovered soil, exposed to heavy rain,

erodes easily. This lowers the productive potential of hillsides, so that secondary forest regrowth never

matches the original forest in either net primary productivity or biodiversity. Protecting the latter is now

a worldwide concern.

The farmers around Ranomafana, who are some of the materially poorest we have worked with

anywhere, have had few options. The soils in this region are some of the least fertile to be found

anywhere. The roads and marketing infrastructure are woefully underdeveloped, and educational levels

and health services are minimal.

When we started looking for ways to establish more sustainable agricultural systems, our first

priority had to be raising the yields obtainable from lowland irrigated rice production. In our search, we

made contact with a small Malagasy non-governmental organization (NGO), Association Tefy Saina,

which was already working to improve rice production. The response of its officers to our challenge

was simple: “Pas de problem.” They said that with their system of rice intensification (SRI), farmers

could achieve yields of 5, 10, even 15 tons per hectare -- without having to buy either new seeds for

higher-yielding rice varieties or chemical fertilizer!

This was a fantastic claim. A first response was to thank and dismiss the Tefy Saina leaders as

con-men. After all, thousands of excellent rice scientists all over the world have been working for

decades to achieve yield increments of 20, 30 or 40 percent. Their collective efforts produced the
improved varieties that, coupled with substantial investments in seeds, fertilizer and irrigation

infrastructure, doubled rice yields globally over the past three decades. The proposed new method

relied on neither of the Green Revolution's two "pillars" -- enhanced genetic potentials and "modern"

inputs. This made the alternative system hard to comprehend and thus nearly impossible to accept.

Despite his skepticism, Uphoff decided to put SRI to the test in farmers' fields. The system

combines a number of practices for managing plants, soil and water that evoke, we believe, productive

potentials that have always been present in the rice plant's genetic make-up, but were not fully realized

by conventional cultivation techniques. The new system starts by transplanting rice seedlings just 8 to 12

days after sowing when they are still very young, instead of after 3 to 4 weeks when plants are taller and

more mature. This contributes to a dramatic increase in seedlings' potential to produce more tillers,

stalks with grain-bearing potential.

The SRI system of management also induces much greater growth of the plant's root system,

which can support a larger number of tillers. The tiny seedlings are planted singly rather than in clumps

of 3 or more and are planted less densely, planted in a square pattern with 25 cm or more between

plants. The most radical innovation is to keep rice fields only moist during the plants' growth phase,

even dried intermittently. SRI fields are never flooded so that the soil becomes saturated. Once the

tillers begin to flower and form grains, only a thin layer of water is kept on the fields, reducing total

water requirements by about half.

Irrigated rice has almost always been grown under flooded conditions with five or more

centimeters of water kept standing on the field. This practice has been favored by farmers for several

thousand years partly because it controls weeds. But Tefy Saina is convinced from its experience with

rice that saturated soils cut off the availability of oxygen to the plants' roots and thus impede both rooting

and tillering. To control weeds, SRI fields must be weeded several times, but this can be done
reasonably efficiently using a simple mechanical hand weeder that costs less than $10. The small metal-

toothed wheels of this "rotating hoe" aerate the soil as they churn up weeds. Also, compost made from

any available biomass, including rice straw, is added to the field before plowing to enhance the soil's

nutrient supply.

These practices require 40 to 60 percent more labor than with conventional cultivation methods,

but the added cost is repaid by substantially increased harvests, giving farmers two to four times more

rice per day of work invested. Indeed, we observe that once SRI management techniques have been

mastered, the labor required can be considerably reduced.

None of this was known to us in 1993, however, when we asked Tefy Saina to introduce SRI

to farmers around Ranomafana. We reasoned that if SRI could deliver even part of what it promised, it

could make a major contribution to improving the lives of rural people while helping to save treasured

ecosystems. We told Tefy Saina that if the rice yields around Ranomafana could be raised to just 3 or 4

tons per hectare, that would considered a success.

Before starting to test SRI, Uphoff visited the office of the International Rice Research Institute

(IRRI) in Antananarivo to find out what its experts knew about the method. The program leader had

heard about SRI but had not investigated it. Why not? When some Malagasy government scientists

had tried the method on an experiment station, they had not gotten yields in the 10 to 15 ton range

claimed to be possible with the new system. So SRI was not considered credible, even though the trials

had produced yields twice the national average without requiring any purchased inputs. Since yields in

the 5 to 10 ton range could be obtained with IRRI's high-yielding varieties using Green Revolution

techniques, its scientists saw no need to investigate the method. At the time Uphoff was not convinced

that SRI could produce very great yield increases, so he did not pursue with IRRI why it did not

evaluate a technology that needed no new inputs, only different management. Like them, he thought it
unlikely that any technology using unimproved seeds could significantly increase rice production.

Tefy Saina was pleased to accept the challenge to raise rice yields around Ranomafana. In May

1994, it put four young and energetic field staff into peripheral-zone villages. They worked alongside

the field staff whom CIIFAD had recruited from the communities and had trained to work as facilitators

for experimentation, demonstration and change in the areas of agriculture, health, education and

conservation. The first season, only 38 farmers were willing to experiment with SRI on small trial plots;

the method seemed quite risky. Yields, however, averaged an impressive 8.2 tons per hectare on the

5.6 hectares cultivated with SRI methods that first season. This was promising enough to continue the

work, but still we did not know what to believe about SRI.

This new method, we learned, had been developed by a French Jesuit priest, Fr. Henri du

Laulaníe, who came to Madagascar in 1961 and spent the remaining 34 years of his life working with

farmers to improve their livelihoods. In 1980, he established a small school at Antsirabe on the high

plateau where he and his students worked in the school's fields, experimenting with new agricultural

methods while applying accepted techniques. In 1983, they discovered accidentally the value of early

transplanting, which led to dramatically improved cropping potential when combined with other

practices Laulaníe and his farmer-students had been assembling.

Four of the six practices that SRI integrates diverge sharply from what farmers growing irrigated

rice around the world have done for over two thousand of years. These standard practices -- planting

mature seedlings, in clumps, close together, in flooded fields -- appeared to reduce the risk of crop

failure. This explains why alternative practices had not been tried before, and certainly not all of them

together at one time, which is SRI's innovation.

Farmers' understandable aversion to risk can account for their not having experimented with

SRI practices. But why have scientists not investigated them? Researchers have apparently accepted
too readily the practical paradigm of how to grow irrigated rice and have tried to improve output only

within that framework.

An explanation that should be of scientific interest is that SRI's benefits appear to derive from

the synergistic effects of its set of practices. That each of the individual components of SRI can raise

production is now accepted by IRRI (memo to Norman Uphoff, August 29, 1998). But researchers

have not addressed the possibility that the components may contribute interactively to greater output.

Evaluating SRI practices separately, assessing only ceteris paribus effects, misses any multiplicative

rather than simply additive effects on root development, tillering, nutrient transport, grain filling and other

parameters. Reductionist methods of analysis might not reveal what a priest and his farmer-students

discovered.

As has been frequently seen in the history of science, serendipity played an important role in that

discovery. In 1983, when Fr. de Laulanie and his students found that their seedling nursery was too

small to provide enough plants for their school's rice field, they transplanted seedlings after only 15 days,

instead of the usual 30; this way another batch could be raised quickly to plant the rest of the field. To

no one's surprise, the tiny seedlings looked spindly and weak for several weeks, but they erupted with

impressive growth in the third month. Rather than dismiss this as merely an aberration, the group tried

early transplanting again the next year, with similar results. After seeing this, they experimented with still

younger seedlings, transplanting some just 8 days after emergence and continuing to get excellent

harvests this way.

In 1988, Fr. de Laulanie discovered earlier research done on rice tillering by a Japanese

scientist, T. Katayama. This work, conducted before World War II, was published in 1951 but never

translated into English. As a result, Katayama's analysis of phyllochrons is, unfortunately, not widely

known among researchers outside Japan, although there has now been a whole issue of the professional
journal of the Crop Science Society of America publishing the papers from a symposium on this subject

(see Crop Science, 1995, Vol. 35, No. 1). Phyllochrons are repeated intervals of plant growth in

which one or more sets of a tiller, a root and a leaf are produced. This patterning of growth is seen in all

grasses, including wheat and barley as well as rice. The length of phyllochrons is affected by factors

such as temperature, light intensity, plant spacing and soil conditions. If rice plants are transplanted

before the fourth phyllochron, usually before the 15th day, they can produce many more tillers than if

they experience the trauma of later transplanting.

The increased tillering that results from SRI methods is easy to see when comparing it with rice

cultivated by standard methods, but the greater density and extension of roots is not visible. An

accepted proxy measurement of root development is the amount of force that is required to pull a plant

out of the soil. We have found that a single SRI plant requires on average about twice as much force

(53 kg) as an entire clump of three rice plants grown by traditional methods (28 kg). This difference

appears to come from the better aeration of the soil root zone, resulting from not keeping standing water

on the field, and from weeding in a manner that aerates the soil.

Because rice can survive when it is grown under submerged conditions, it has been inferred that

the plant thrives when grown this way. This is stated in leading textbooks (e.g., DeDatta, 1987: 41, 43,

297-298). Even though a recent publication of IRRI and the International Water Management Institute

has stated: "Numerous studies [one as early as 1967] . . . have demonstrated that continuous

submergence is not essential for obtaining high yields" (Guerra et al. 1998: 11), the belief persists that

rice should be grown in standing water. We see here a dramatic paradigm problem, as specialists (like

farmers) have difficulty conceiving of rice growing better with only intermittent applications of water than

when continuously submerged under water. If not correct, this fixation on maintaining standing water is

particularly unfortunate because the world's per capita supply of fresh water continues to decline year
by year.

Producing impressive results has not been enough to win acceptance of the new system for

growing rice. During 1992-94, before CIIFAD started working in Ranomafana, researchers from

North Carolina State University experimented with high-yielding varieties and chemical fertilizer to

improve rice production around the park. The handful of farmers cooperating in those trials got yields

up to an average of 3 tons per hectare, with a few farmers reaching 5 tons. In the same area, over 300

farmers have now used SRI on more than 50 hectares, with yields averaging 8.8 tons per hectare over

four seasons, with some farmers reaching levels between 10 and 14 tons. The good news for rice

scientists is that some of the best yields were achieved with the use of certain improved, high-yielding

varieties that appear particularly well-suited to local conditions.

Such impressive results have not been limited to Ranomafana. At Andapa in the north of the

country, trials with improved seeds and optimum applications of fertilizer produced 7.2 tons per hectare;

concurrently, 27 farmers using SRI methods averaged 10.2 tons (Tang-Po 1996). (Indeed, the four

farmers who used SRI methods with an IRRI variety, IR-46, reportedly averaged 13.7 tons per

hectare, and one of these reached 16.7 tons, a level normally considered unattainable; yet as far as we

know, this elicited no evident scientific interest.) In the northwest around Marovoay, where farmers got

average yields of 4.8 tons using "modern" methods, others in the same area produced 7.1 tons per

hectare with SRI methods (Rakotonirina 1996). An evaluation supervised by a French technician,

carried out with over 100 farmers on the high plateau in the center of the country where average yields

are higher (3.2 to 3.9 tons per hectare) due to better methods and soils, yields were roughly doubled

with SRI, averaging between 6.3 and 8.0 tons (MADR/ATS 1996).

These results are consistent with those from farmers' fields around Ranomafana. Still the

reaction of scientists and officials until recently has been to try to discredit the results rather than to try to
learn more about SRI and to evaluate it themselves. It is fair to ask why, if SRI produces such good

results, has it not been more widely adopted in Madagascar? The answer, we think, is that SRI raises a

paradigm problem for farmers as well as for scientists. SRI departs radically from past practices, which

are venerated by Malagasy farmers as "the ways of the ancestors." Moreover, for weeks after

transplanting, SRI fields are pitiful sights, with only tiny, sparsely distributed plants. There is no familiar

green color making the field look alive, no reassuring surface of water reflecting light to the eye, no

quick closure of the foliage canopy. Not until several weeks before the onset of flowering do the fields

practically explode with growth as exponential tillering kicks in. Such results are not easily believed; yet

after five years, there are 20 times more farmers using SRI around Ranomafana than were willing to try

it the first year.

As far as scientists are concerned, we have noticed that data on very large increases in yield,

instead of intriguing them, have turned most of them off. Such information gets categorized as quite

literally incredible and, thus, rejectable. When a single experiment by the government's agricultural

research agency did not produce phenomenal results, this was taken as justification for writing off SRI.

No interest was expressed in how yields more than twice the national average could be obtained

without using "miracle" seeds or applying chemical fertilizer. Rather than being curious, scientists

seemed relieved that their understanding of rice could be kept intact, not challenged by the findings of a

priest and experimenting farmers.

We would be more critical of this disinterest among scientists in Madagascar if some of our

Cornell colleagues had been more interested by our initial reports of SRI. Instead, we are struck by

how a paradigm can limit the vision and curiosity of even the best scientists, who are also well-motivated

human beings interested in benefiting humankind. Such is the power of a successful paradigm that it can

resist, at least for some time, exposure to contradictory evidence. Finally, this past year, seminars on
SRI have been given by Uphoff for rice scientists at universities and research institutes in China,

Indonesia and the Philippines, including IRRI, and there is now interest in evaluating this methodology

systematically. Thanks to e-mail, some active exchanges and debates are going on to try to figure out

where our previous understandings of rice production may have been incomplete.

In 1997, Combs returned from Bangladesh with a story so similar that it begs being bracketed

with an account of SRI. In that country he encountered a problem that was going unnoticed and

unattended. It resembled the SRI situation in that the same cognitive and psychological dynamics

appeared to be at work. The similarities between the two cases made us wonder: how many other

problems and solutions in the world have we as well as others been turning blind eyes to? How many

are we presently overlooking? It has long been known that there are none so blind as those who will

not see, but we have been impressed that seeing itself is, anyway, not as simple a process as commonly

believed.

An Unseen Epidemic of Rickets

The story of rickets is not new. It has been recognized as a dreadful affliction since the early days of the

industrial revolution. This crippling disease of growing bones reached epidemic proportions in northern

latitudes during the previous century, particularly in urban centers where children had little access to

bright sunshine. By 1900, rickets was so prevalent in London that it had become known as “the English

disease.” Rickets prevention soon became a public health priority, and research directed toward

determining its etiology ultimately resulted in the discovery of vitamin D, the hormone-like, anti-rachitic

vitamin that the body can synthesize when the skin has at least modest exposure to sunlight.

That discovery led to what was thought to be the virtual elimination of rickets as a public health

problem, or so we thought. Children could be given cod liver oil or other fish oils rich in vitamin D; milk
could be irradiated to produce the vitamin in that food; and as the purified vitamin became available, it

could be included in nutritional supplements or added to processed foods. Today, in countries that

fortify milk with vitamin D, rickets has been relegated to a place in medical history, and that, ironically,

becomes a problem.

Deficiency of Vitamin D can certainly cause rickets, but it is not necessarily the only cause. The

vitamin helps prevents the disease by supporting and regulating the metabolism of the major minerals in

bones, calcium and phosphorus. It facilitates not only the absorption of these important minerals from

the diet, but also their retention in the body and their deposition and retention in bone. Therefore,

individuals who get very little sun and very little vitamin D from their diet are unable to use what calcium

and phosphorus they may consume.

Children are at particularly high risk, as their rapidly growing bones are quick to become

deformed if they are not adequately mineralized. If vitamin D is lacking in the diet, then either sunshine

or supplemental vitamin D will prevent rickets. But rickets can also be caused by dietary deficiencies of

calcium and/or phosphorus, the actual bone minerals. This latter point appears to have been lost to

many physicians and nutritionists, particularly those who do not work with livestock where they have

opportunity to see, from time to time, a variety of feed formulation errors including ones causing

shortages of calcium or phosphorus.

At first, Combs reacted quite skeptically to a report from a colleague, a wheat agronomist

stationed in Dhaka, that rickets was a problem in some parts of Bangladesh. Everyone knows that

rickets occurs where sunlight is limited -- certainly not in a sun-filled tropical place like Bangladesh! But

this verdict rejects, without examination, the possibility that we do not yet know all there is to be known

about rickets.

Fortunately, Combs was willing to go and see for himself, and what he saw shocked him: a
community in the southeastern part of that poor country where it appeared that nearly one in five

children had florid rickets, obviously deformed legs and/or arms. What was worse was that no efforts

were being made to deal with the disease, since it was not recognized officially as existing.

Institutions seldom make change; people do. Craig Meisner, an agronomist with the

International Wheat and Maize Improvement Center (CIMMYT), and Shahidul Haque, the director of

a local NGO, Social Assistance and Rehabilitation for the Physically Vulnerable (SARPV), drew

Combs's attention to the problem. Perhaps it was easier for them to see rickets because neither had

academic training that led them to conclude that children in the tropics with bowed legs, knock knees

and sabre tibiae (bending forward of the legs) must have some other ailment. Combs found himself

mentally combing through the list of alternative possibilities to explain these maladies, as if from the

syllabus of his own nutrition course. Once he realized that this was indeed rickets, he found other

nutritionists and physicians, many with wide international experience, quick to reject the obvious: that

rickets can occur in Bangladesh.

Combs, Meisner and Haque encountered a bewildering array of rebuttals to their hypothesis.

Expert opinion, it seemed, took two tacks. One group rejected the report of rickets outright, although

the rejection came wrapped in the comfortable blanket of scientific language, full of such phrases as

“can cause similar signs,” “needs experienced diagnosis,” and the definitive dismissal, “is not supported

in the literature." The other group suggested alternative explanations: the widespread use of dark

clothing as had been reported as causing sporadic cases of rickets in Cairo; fluorosis, which causes

another disease of bone growth; or aluminum poisoning, which has been reported to precipitate rachitic

signs in calcium-deficient rats. Even the most encouraging found it convenient to label the problem as

“local,” not widespread in Bangladesh or elsewhere. Because the Ministry of Health's monitoring

system had no category for reporting rickets, there was no evidence in the public record of the disease
occurring anywhere else in the country.

But then Combs came across research by Dr. Phil Fischer, then at the University of Utah

Medical School and now with the Mayo Clinic in Rochester, Minnesota. Together with colleagues in

Nigeria, he had described some 200 cases of apparent calcium-deficiency rickets in that country.

Fischer put Combs in communication with Dr. John Pettifor of the University of the Witwatersrand in

South Africa, who had described similar cases in parts of that country. Combs took Fischer to

Chakaria in October 1997 and used that occasion to invite prominent physicians from the Bangladesh

Institute of Mother and Child Health, the International Center for Diarrheal Disease Research-

Bangladesh, UNICEF, and an American missionary hospital in that locality. In broad daylight, everyone

recognized the disease and the need for action. All were touched by the plight of children whose

disability had been overlooked for over 15 years.

This led to an informal commitment of individuals from various national, international and local

organizations to work on behalf of children stricken by, or vulnerable to, rickets in Chakaria -- and who

knew where else? Subsequently, a more formal Bangladesh Rickets Consortium was constituted, with

financial assistance from the U.S. Agency for International Development mission in Dhaka.

Now, some half dozen visits to that country later, Combs can pull off the Internet a Reuters

story reporting how rickets is affecting nearly a third of the children in Chakaria, figures compiled from a

diagnostic survey conducted by Consortium members. He can review via e-mail the draft instruments to

be used in a country-wide, community-based survey that will be carried out by two prominent

Bangladeshi civic institutions, the Bangladesh Rural Advancement Committee (BRAC) and the Grameen

Bank. He can point to efforts currently underway to compare the food production and use and the

child-care practices of households having rachitic children with neighboring ones whose children have

been spared. This effort should yield clues to the disease’s risk factors. Half a dozen times a day
messages appear on Combs's computer screen from Dhaka, Grenoble, Rochester (Minnesota),

government agencies, and university departments furthering the work that the Consortium has taken on.

Today one can read in the Dhaka Daily and on the BBC wire service that rickets is a public

health problem in Bangladesh which was previously under-diagnosed. It is now accepted that the

disease, apparently due to deficiencies of calcium and not lack of vitamin D or sunlight, also occurs in

Nigeria, South Africa and Ethiopia. No longer is the question: “Can there be rickets in sun-drenched

areas?” Now, given the wide prevalence of low-calcium intake among the children of poor families

throughout the developing world, the questions are: “How widespread is the disease?” "Why is there not

more?" and “How can it be prevented in sustainable ways?” During a visit to Dhaka in January 1999, a

reporter asked Combs, “Why did you not let us know about this disease sooner?” Well, nobody was

seeing it. There needed to be a change in paradigm before people could see something right before

their eyes.

Closer to Home: Paradigms Blocking Health Advances

These two cases show the reality and the risks of paradigms as they have held back progress, at least

for a while, in developing countries. But paradigm traps are not limited to far-away situations. In the

field of medicine, simple but dramatic cures for peptic ulcers and heart disease were delayed for many

years because of paradigm blockages. The careers of scientists who had brilliant insights and

conducted systematic laboratory tests to support their conclusions were stalled, and in one case

practically ruined. Proponents of the dominant paradigm resisted the truth of the innovative ideas even

when these were supported by solid scientific evidence. These cases have been reported in Monmaney

(1993) and Stacey (1997).

For many years, the cause of peptic ulcers was believed to be psychological stress, which led to
excessive secretion of acid in the stomach which consequently injured its lining. A variety of methods

were used to counter this process, including even removal of part of the stomach. In 1979, an

Australian pathologist, J. R. Warren, discovered a bacterium, Helicobacter pylori, in the stomach

tissue of patients who had been diagnosed with various digestive ailments. This was considered

anomalous and generated little interest, however, because it was believed at the time that the gastric

environment is basically free of bacteria due to its high concentration of acid.

In spite of this dogma, a young doctor in Perth, Australia, Barry Marshall, followed up the

discovery of H. pylori and accumulated evidence that it was a cause, if not necessarily the only cause,

of ulcers. But his results, based on studies with laboratory animal models, were ignored by others in the

medical profession. Finally, thinking of no other or better way to demonstrate his contention, he

ingested a dose of the bacteria himself after which he had his own gastrointestinal tract examined

endoscopically with a confirming biopsy. Thus did Marshall conclusively demonstrate that H. pylori

could cause ulcers in a healthy stomach. Subsequently, he was able to demonstrate in clinical trials with

ulcer patients the efficacy of antibiotic treatment against the disease, and a new paradigm for

understanding the cause and cure of ulcers was established.

A sadder story is that of Kilmer McCully, who observed in the mid-1960s that arteriosclerosis,

a major cause of heart disease, was associated with high levels in the blood of an amino acid,

homocysteine. These high levels could be lowered by remedying deficiencies of vitamins B6, B12 and

folic acid. However, at the time, the prevailing theories attributed arteriosclerosis to high levels of

cholesterol in the blood. With research proposals that ran counter to this paradigm, McCully found

himself unable to obtain research funding, which led to his being denied tenure at Harvard Medical

School and to being removed from the staff of Massachusetts General Hospital in 1979.

From a relatively anonymous base in a Veterans' Administration hospital in Providence, Rhode

Island, McCully persisted with his research during the 1980s. Eventually other researchers in the U.S.

and Europe confirmed his results in large-scale studies. Today, McCully's research was widely

recognized and praised, correct decades before its time. A more sophisticated paradigm now guides

research on heart disease, one that focuses on more than cholesterol.

Seeing "Impossible" Things

Michael Gershon, whose work on the neuroanatomy of the gastrointestinal system has helped to change

paradigms in neurology, recently commented caustically on how new idea in science get rejected: "A

herd instinct often grips the imagination of scientists. Like lemmings we are prone to charge over cliffs

when a large enough pack of us moves in that direction" (1998: 34). What else but a paradigm could

provoke such solidarity among persons who have been trained to question?

In how many other cases than those considered here has evidence that supported a new

explanation been ignored or rejected when it did not conform to the accepted way of thinking about a

particular problem? We will never know. Fortunately in the medical cases cited above, researchers

who persevered with their insights and convictions were able eventually to get others' cooperation in

assessing and accepting the new way of understanding biological relationships. Surely, however, many

other correct challenges to existing paradigms have not been as successful in getting attention and

evaluation, which means that we are today less enlightened than we might have been.

Paradigm traps are not restricted to any particular discipline, profession or era. It is instructive,

and appropriately humbling, to recall the confidence that previous generations have had, each in its turn,

in the correctness and sufficiency of their understandings of the world, being wiser, of course, than their

predecessors. Yet, do we not make the same assumptions about our knowledge, that it is not only

superior but relatively complete? Surely it, too, will be improved. How can anyone be certain that we

know the "biological ceiling" for rice production? How can we be sure that we understand fully the
etiology of any particular disease?

One should not be like the Red Queen in Lewis Carroll's Through the Looking Glass who

told Alice that she always believed "as many as six impossible things before breakfast." It is not

advisable to believe impossible things as a matter of course. But we should remain open to the

possibility that some things now incomprehensible will turn out, after more investigation, to be true.

While one cannot afford to chase after every wishful thought or explanation, unorthodox ideas that could

have high payoffs if correct deserve open-minded and thorough examination, maintaining appropriate

but not immobilizing skepticism.

It is clearer to us than it was five years ago that the adage "seeing is believing" is misleading. In

this respect, science is like magic; in both we are likely to see what we expect to see, as Dr. Wonko

warned. Conversely, we are unlikely to see what we do not or cannot yet understand or look for.

Paradoxically, even skepticism, an attitude essential for the advancement of science, can itself become a

belief so strong and pervasive that it blocks our ability to perceive new things.

How are paradigms changed? Our experience tells us that the process involves more than the

friction of data facing off against dogma. Paradigms can make correct but novel data unintelligible;

rationality is only part of our reasoning process. Changing paradigms thus seems to call for some

degree of personal engagement in solving important problems. We believe that engagement is

particularly important because it can engender the commitments that prompt one to become detached

from dogma in ways not possible otherwise. This should not be surprising since science remains always

a very human endeavor.

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