Williams, Cicely (1893–1992)

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Williams, Cicely (1893–1992)

British physician who discovered kwashiorkor (protein energy malnutrition) . Born Cicely Delphine Williams in Kew Park, Jamaica, on December 2, 1893; died in Oxford, England, on July 13, 1992; daughter of Margaret (Farewell) Williams and James Rowland Williams; attended Bath High School for Girls, 1906–12; Oxford University, B.M., 1920; Oxford University, Ch.B., 1923; London University, diploma in tropical medicine and hygiene, 1929; never married; no children.

Awards:

gold medal, British Paediatric Association (1965); Joseph Goldberger Award, American Medical Association (1967); Companion of the Order of St. Michael and St. George (1968); honorary Ph.D., University of the West Indies (1969); Martha May Elliot Award, American Public Health Association (1971); Dawson Williams Prize for Pediatrics, British Medical Association (1972); honorary member of the American Academy of Pediatrics (1973); honorary Ph.D., University of Maryland (1973), Tulane University (1973); fellow of the American Pediatric Association (1976).

Traveled to England (1906); passed the Oxford University entrance examination (1912); death of James Rowland Williams (1916); interned at King's College Hospital (1920); appointed house physician, South London Hospital for Women and Children (1923); worked for the American Farm School, Salonika, Greece (1927); was the first woman appointed to the British Colonial Service, Gold Coast, Africa (1929); appointed head of the Princess Marie Louise Hospital for Children (1930); discovered kwashiorkor (1931); transferred to the General Hospital, Singapore, Malaya (1936); transferred to the Unfederated State of Trengganu (1941); interned by the Japanese, Changi Prison (1941); appointed commandant of the women's camp (February 1943); imprisoned by the Kempe Tai (October 1943); released by the Kempe Tai (March 25, 1944); served as head of the child health department, Oxford University (1948); was first head of the Section of Maternal and Child Health of the World Health Organization (1948); undertook research into vomiting sickness, Jamaica (1951); death of Margaret Williams (1953); was a senior lecturer in nutrition at London University (1953); studied toxaemia of pregnancy, University College (1955); joined the faculty of the American University of Beirut, Lebanon (1960); appointed advisor in Training Programs for the Family Planning Association of Great Britain (1964); joined the faculty of the University of Tulane (1971).

Selected writings:

"Deficiency Diseases in Infants," in Gold Coast Medical Report (Vol. 2, no. 93, 1931); "A Nutritional Disease of Children Associated with a Maize Diet," in Archives of Disease of Childhood (Vol. 8, no. 423, 1933); "Clinical Malaria in Children," in Lancet (Vol. 1, no. 441, 1940); "Teaching Health in the Tropics," in Health Education Journal (Vol. 8, no. 172, 1950); "Maternal and Child Health Services in Developing Countries," in Journal of Tropical Paediatrics (Vol. 1, no. 3, 1955); "Factors in the ecology of Malnutrition," in Report of the Western Hemisphere Nutrition Congress (1965); "The needs of a Hungry World," in American Association for Advancement of Science (1974).

Cicely Williams made a discovery of stellar significance while working with the natives of West Africa. In 1931, she uncovered an illness known locally as kwashiorkor, or protein energy malnutrition. The earliest reference to kwashiorkor occurs in Psalm 131: "I will refrain my soul and keep it low like a child that is weaned from his mother; yea, my soul is even as a weaned child."

Stemming from a long line of plantations owners, Williams' family arrived in Jamaica during the 17th century from Glamorgan, Wales. It was at Kew Park, a plantation in Westmoreland, that she was born on December 2, 1893, the fourth of six children of James Rowland Williams and Margaret Farewell Williams , daughter of Major-General W.T. Freke Farewell, late of the

Indian Army. James met Margaret while studying in England. In 1888, the young couple married and moved to the family estate in Jamaica.

Cicely's childhood was one of privilege, surrounded by servants and the idyllic calm of sunshine and sea. The living conditions of the workers on the plantation, however, contrasted sharply with her own. Injuries were common, and from an early age Williams was taught the basics of first aid to help with emergencies. Margaret Williams founded a clinic for young mothers, and although she had no formal training she consulted frequently with local doctors. Thus, early in life Cicely Williams was confronted with the health-care concerns of an impoverished population.

In 1906, Williams was sent to school in England, where she attended the Bath High School for Girls. After graduating in 1912, she wrote the Oxford University entrance examination and passed. A devastating hurricane in the same year, however, did considerable damage to Kew Park. Due to financial constrains, Cicely returned to Jamaica, where she took a position teaching Montessori in Kingston. Though the financial situation at Kew Park gradually improved, in early 1916, James Rowland Williams died.

We worry a great deal about the persons we want to liberate from political tyranny, and we ignore those we could and should liberate from the tyrannies of dirt, ignorance, and hunger.
—Cicely Williams

Due to a shortage of doctors caused by the First World War, Williams was admitted to the school of medicine at Oxford University, arriving in England in October 1917. On October 14, 1920, she received a degree in medicine and found a position at King's College Hospital, where she was introduced to pediatrics by Sir George Frederick Still, a pioneer in the field of children's medicine. Traditionally, Oxford graduates were required to return and write final examinations for a medical degree. Williams did so in 1923.

That same year, she was appointed house physician at the South London Hospital for Women and Children, one of the few English hospitals which employed female doctors. There, her mentor became Dr. Helen MacKay , who was the first female fellow of the Royal College of Physicians and a pioneer in preventive and curative health services.

In 1927, after two years at South London and unable to find a permanent position, Williams moved to the American Farm School, near Salonika, Greece. There she instructed local farm boys in the rudiments of health and nutrition, and on the infectious diseases which could be transmitted from livestock to humans. In Greece, she met Dr. Andrija Stampar , who forever influenced her concept of community health care.

Returning to England in 1929, Williams earned a diploma in tropical medicine and hygiene from London University. The day after graduating, she was offered a position with the British Colonial Service. Williams was the first woman to be appointed to the British Colonial Service in the Gold Coast (now Ghana). In 1929, the population of the Gold Coast numbered some 3 million inhabitants. There were roughly 60 physicians, 30 nurses, and 10 technicians to serve the entire population. The Gold Coast was known as "The White Man's Grave," due to the epidemics of plague, smallpox, yellow fever, malaria, typhus, and sleeping sickness which swept the region.

Although disease control programs had been implemented, by the time of Williams' arrival new efforts were underway to initiate preventative health-care programs which targeted mothers and children. As Williams noted: "Hippocrates says that the physician 'must look after the patient's regimen while he is yet in health.'" After spending three months in Accra and Kumasi, she was transferred to the remote outpost of Koforidua. In 1930, she was appointed to head the Princess Marie Louise Hospital for Children. There she organized the out-patient services.

Williams identified a condition known as kwashiorkor in 1931. Her research was published in the Gold Coast Colony Annual Medical Report of 1932. The report included photographs, and charts measuring the weight of four children with the illness. The syndrome mainly affects infants and children, and if left untreated can result in death. As William J. Darby wrote, "the importance of her early descriptions of this syndrome and related concepts cannot be overestimated…. [Kwashiorkor] may well be the world's most appalling cause of early death and morbidity."

Her next publication in the Archives of Diseases of Childhood, published with the assistance of MacKay, hinted that an "amino acid or protein deficiency" might be responsible for the illness. Since kwashiorkor means "the disease of the deposed baby when the next one is born" it was a distinct possibility, as kwashiorkor is linked to the early weaning of children without adequate provision for protein.

Williams' hypothesis was not met by universal approval. She remembered the resistance of some of her colleagues. The controversy centered on whether or not kwashiorkor was a distinct disease or associated with pellagra, a syndrome which causes niacin deficiency. As late as 1954, Dr. Alvar Carrillo Gil wrote:

The inconsistency and futility of Dr. Williams' arguments to establish a differential diagnosis between Kwashiorkor and Infantile Pellagra, are evident from the very first moment…. A greater carelessness and deceit cannot be conceived in each and every one of the propositions presented by Dr. Williams. Taken as a whole they are the best argument to sustain the identity between Infantile Pellagra and Kwashiorkor.

Resistance to her diagnosis occurred largely because "many physicians have been dominated by ideas related to the study of infections," wrote Williams. "But nutritional disorders are an entirely different matter…. Disorders can exist as defi ciencies, or as excesses or as imbalances. They can co-exist with any other form of disease."

After several years in Africa, Cicely Williams was transferred to the Far East in 1936. Thus, her research on kwashiorkor came to an abrupt end. As a pediatrician at the General Hospital in Singapore, she saw many cases of malnutrition, mainly related to beri beri and rickets. The prevalence of rickets came as a surprise, for Williams had been told that rickets was impossible only five degrees from the Equator.

While in Singapore, she fought the practice of feeding condensed milk to infants, and took on the Nestlé company in a highly controversial paper "Milk and Murder." She emphasized breast feeding and the education of mothers in family planning. As Herbert Ratner commented, "This defense of maltreated babies was probably the first salvo in the battle of breast versus bottle."

By early 1941, Williams was practicing in the Unfederated State of Trengganu when the Japanese invasion interrupted her work. She fled the territory ahead of the Japanese army, only to be trapped in Singapore when the city fell on February 15, 1942. She was interned in Changi Prison. Ironically, her cousin John Farewell had supervised the construction of the facility only a few years previous. The prison was designed to accommodate 700 prisoners. By the end of the war, it held 6,000.

During her two-year internment, Williams saw patients regularly, and was appointed commandant of the women's camp from February to June 1943. When a spy scare swept the prison, Williams was taken away for questioning on October 23, 1943, by the Kempe Tai, the Japanese secret police. She was not released until March 25, 1944, having endured terrible hardships at their hands. Of the treatment of fellow prisoners by the Kempe Tai, she wrote, "It is impossible to describe the courage of some of these men, who maintained their detachment and dignity in spite of hours of torture and threats and months of degradation." Mrs. Freddy Bloom, a fellow inmate, wrote of Williams: "She was tremendous fun. In the toughest situation, she could still see the ridiculous. Even in the Kempe Tai 'cages' there were moments of uncontrolled hilarity. Later, in better times, the giggles were even worse when the pomposity and blatant vanity of 'authority' were evident."

Immediately following World War II, Williams spent several months in the United States as a postgraduate student at Johns Hopkins University. She had a lot of catching up to do. During the war, numerous medical advances had been made. But Williams eagerly plowed through the latest literature. She learned that serum analysis had been developed, and that her assumption about kwashiorkor, based on necropsy, was proven correct. As well, a treatment for pellagra had been developed which incorporated nicotinic acid. When tried on kwashiorkor patients, they all died. One of Williams' harshest critics, Dr. Hugh Trowell of the Colonial Service in the Gold Coast, wrote in 1975:

Being a lady, and a very gracious lady at that, she arrived by instinct at the correct answer…. Experts nowadays tell me that I must call it Protein-Energy-Malnutrition (PEM), but never mind; probably they will change it again. Call it Energy-Protein-Malnutrition (EPM), but I will call it only and forever Kwashiorkor, in honor of Cicely, for she was right, and the experts had brought a needless dispute between us for more than a decade.

In 1945, the Colonial Office dispatched Williams to Malaya, where she reorganized health services. In 1948, she became the head of the child health department at the Institute of Social Medicine at Oxford University. After only five months at Oxford, the British Ministry of Health nominated her as the first head of Maternal and Child Health with the new World Health Organization. The preamble to the constitution of the World Health Organization states: "Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development." The institutional bias of the organization towards large capital projects, rather than community-based health care, however, clashed with Williams' fundamental beliefs, which had been heavily influenced by Andrija Stampar. Sally Craddock summarizes these beliefs:

The need for supervision of families on a regular basis; the need to involve mothers in caring for children in hospital; the need to listen to the local people if health education were to be effective—all of these and Cicely's constant cry for the proper training of nurses and health visitors.

In 1949, Williams was appointed to head the Maternal and Child Health department of the World Health Organization in South East Asia, a welcome reprieve from her administrative duties in Geneva. As well, South East Asia was a region of the world with which she was intimately familiar. From her headquarters in New Delhi, she set about implementing her theories, instituting a system of joint nursing to combat malaria, and encouraging doctors to visit people's homes. She also fought against the distribution of skim milk by UNICEF, because it is deficient in vitamin A and can cause xerophthalmia.

In October 1951, Williams resigned from the World Health Organization to care for her mother in Jamaica. Never one to remain idle for long, however, she soon applied for a position at the University of the West Indies, although she was turned down. When a serious outbreak of vomiting sickness swept the island, Williams set about investigating its causes, and discovered that a popular fruit, ackee, was responsible. She found that the fruit produced a toxic effect in malnourished children, which could be counteracted with a large dose of sugar.

In 1953, Margaret Williams died, and Cicely Williams returned to England as senior lecturer in nutrition at London University. After her contract expired, she moved to University College, where she studied toxaemia of pregnancy until 1957. In 1960, she traveled to Lebanon, where she joined the faculty of the American University in Beirut. She enjoyed teaching in Lebanon, and found the country "the most beautiful, exciting yet relaxed" that she had ever lived in.

Williams was appointed to the position of advisor in training programs for the Family Planning Association of Great Britain in 1964. She lectured and traveled extensively, visiting 70 countries on five continents. In 1968, she was made a companion of the Order of St. Michael and St. George, and introduced to Queen Elizabeth II at a ceremony at Buckingham Palace. The queen reputedly remarked: "I can't remember where you've been." To which Williams replied, "Many places." "Doing what?" asked Her Majesty. With typical modesty, Williams replied, "Mostly looking after children."

In 1971, Cicely Williams joined the faculty at Tulane University. At the time, she was 78 and still going strong. She also lectured in Canada, Haiti, Mexico, and Colombia. While in America, Williams testified before the Committee on Public Welfare of the U.S. Senate, advising its members on development policy in the Third World.

Cicely Williams died in Oxford, England, on July 13, 1992. She was 98. A firm advocate of a more holistic approach to health care, Williams urged an integration of preventive and curative health services. She also sought to bridge the gap between health-care practitioners and their patients, particularly in the Third World. Today her model has been applied in many countries.

Williams was always an advocate of birth control and family planning. She argued that the surest way to curb overpopulation was to insure the survival of living children through the education of mothers, thus eliminating the need for large families. During her travels, she also witnessed many cases of female circumcision, a practice she abhorred. Her controversial ideas were often the target of criticism by her peers, but she took the criticism well, noting that "one of the most difficult things is to educate the educated."

Cicely Williams held honorary degrees from various universities, and was the recipient of numerous prizes and awards. Her accomplishments were many and varied. She is best remembered, however, for her identification of kwashiorkor as a primary cause of early mortality. Wrote William J. Darby, "It is through such rare practitioners of medicine as Cicely Williams … that the modern world repays its heritage from the early greats like Hippocrates and Galen."

sources:

Craddock, Sally. Retired Except on Demand: The Life of Dr. Cicely Williams. Oxford: Green College, 1983.

Darby, William J. "Cicely D. Williams: Her Life and Influence," in Nutrition Reviews. Vol. 31, no. 11. Boston, MA: The Nutrition Foundation, 1973.

Farnes, Patricia. "Women in Medical Science," in Women of Science. G. Kass-Simon and Patricia Farnes, eds. Bloomington, IN: Indiana University Press, 1993.

O'Neill, Lois Decker. The Women's Book of World Records and Achievements. Garden City, NY: Anchor Press, 1979.

Uglow, Jennifer S., ed. The International Dictionary of Women's Biography. NY: Continuum, 1982.