The Elderly on Gozo:Healthy Traditions and Preventative Healthcare

Sabrina L. Consiglio

Submitted to Faculty in the Sociology and Anthropology DepartmentUniversity of La Verne

In fulfillment for the degree ofBACHELOR OF SCIENCE IN ANTHROPOLOGY

Advisor: Kimberly Martin

May 2013

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ABSTRACT

This paper focuses on the health and wellness of the elderly on Gozo in the Republic of

Malta. The aged population on Goza seems to be healthier than the elderly in other

countries. They particularly had low rates of dementia, which has become a global health

crisis. Data were collected through participant observation and semi-structured interviews

with Gozitan elderly men and women, health professionals and a traditional healer. The

research showed that, for the elderly, traditional healing is still an active practice that cures

and prevents diseases. There is also a strong tendency for elders to reject consumption of all

chemicals that were introduced to the island within the last 30 years, whether found in

medication or in food products. The younger generation are criticized by the elders for

consuming “chemicals”, smoking, and eating large quantities of processed foods that are very

different from the traditional Mediterranean diet.

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INTRODUCTION

There is a rare and unique perspective that can be gained through studying the elderly

because they take a very special place in every society. The role that the elderly fill within a

culture can be an indicator of how the culture treats those who no longer serve the roles they

previously did, as well as those who are terminally ill. Research of the elderly also provides

the ability to examine different past commonalities and determine positive and negative

associations. This can even lead to possible preventative care techniques and understanding

of different causes of disease.

The elderly from the island of Gozo specifically merit further study because over the

course of their lifetime, the population and the island of have undergone significant changes.

In thirty years the island went from a completely rural and traditional life to a technological,

globalized society. The progression from isolation to interaction is reflected in the health of

the oldest generation as well as the health of the younger generations.

The existing ethnographic research provides detailed information on the economic

and social changes from the impact of tourism on the island of Gozo. However, there is a

substantial gap in the literature, in terms of recent research on the changes that health has

undergone as a result. There is limited research on the effect that joining the European Union

has had on the culture with the exception of increased tourism. As such, the existing

literature will be examined, and the current state of affairs will be researched in order to

appreciate the changes that have occurred and the overall health of the elderly.

LIFE ON GOZO:

The Republic of Malta is a collection of three islands in the Mediterranean Sea with a

combined total population of 419,000 people. Known as the archipelago, the islands are

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Malta, Gozo, and Comino. The largest in size and population is Malta, and the second largest

island, also known as Malta’s sister island, is Gozo with a population of about 31,000 people.

Gozo is appreciably more rural than its larger counterpart. This geographic isolation allowed

for the Gozitan culture to be virtually untouched by global changes for many years, and made

it a desirable location for research. Despite the entire island being only 25.9 square miles,

Gozo has 46 Roman Catholic churches. With approximately 98% percent of Maltese people

being Catholic, the country’s national religion is Catholicism (Conrad, Christie, and Fazey

2011). Despite this conservative heritage, there is an unprecedented, major cultural

transformation taking place on the Maltese island of Gozo.

In her article, “Carnival on Gozo: Waning Traditions and Thriving Celebrations,”

Cremona (1995) discusses the transformation of cultural rituals to economic endeavors. The

different villages’ traditional Catholic fiestas have become large tourist attractions. This

separation from the initial ritual significance is important because it demonstrates the

changes that occur from tourism. Although parishes were historically competitive with one

another over their fiestas, the line between religious ceremony and economic endeavor has

become blurred. Many people are not in favor of the traditional practices having escalated to

parties, which creates a division between the older and younger generations.

Traditional and progressive values are colliding throughout the Maltese Archipelago,

but especially on Gozo, and globalization is dramatically impacting the public’s health. Their

experience merits further research. In order to understand this impact, it is crucial to

appreciate the preexisting culture as well as the conditions which led to the current changes.

Evolving cultural, economic, geographic, and international influences will be explored with

their impact on overall health. The Maltese healthcare system is a socialist system like most

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of those in Europe, and operates in the public sector. However, the Catholic Church still

maintains influence over a large portion of governmental decisions, and thereby controls

many healthcare decisions as well.

In 2004, The Republic of Malta joined the European Union, and in 2007, adopted the

euro as their national currency. This was an extremely dynamic change that introduced a

progressive European influence in contrast to Malta’s incredibly traditional way of life.

There was a growth in tourism because of the increased ease of travelling between Europe

and the islands. The economy also improved through the use of the Euro because of the

international connections that the Euro enabled. Using the Euro and having a new important

industry changed the economic structure on Malta and Gozo. The primary industry because

tourism, and Malta and Gozo became dependent upon the number of people who travel there

each year (Chaperon 2013).

Although Malta has become a significantly more attractive destination for European

tourists, Gozo is still limited in its popularity due to the difficulty of traveling there.

Boissevain studied the impact of tourism on a dependent island, in 1979 when tourism to

Gozo first occurred regularly. Initially, only Europeans visited the islands, and even today, it

is still nicknamed “Europe’s best-kept secret” because so few non-Europeans visit the

islands. The tourist industry was especially important because in addition to bringing an

exciting revenue stream that far out-earned anything else that the Gozitans produced, it also

eliminated the isolation of the Gozitan culture. An influx of change resulted from the

introduction of the outside contact that came with tourism (Boissevain 1965 and 1979). This

meant that foreign foods became available to Gozitans, and transportation on the island was

forced to improve.

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The transportation improvements that occurred as a result of the increased tourism

have many negative effects on the health of the populations of Malta and Gozo. First and

foremost, especially on Gozo, sedentary lifestyles have become more common since people

are no longer required to walk everywhere. Furthermore, there is another negative effect in

regard to the respiratory health of the Maltese. The major studies that have been completed

suggest that the traffic has led to an increase in asthma and other breathing issues. Within the

last two to three decades, there has been not only an increase in both traffic and asthma, but

in the increase in a sedentary lifestyle, and the health related issues that relate from said

lifestyle. Studies suggest that those who have been diagnosed with asthma are less active

than those who have not been. This means that in addition to the number of people who have

already stopped the day-to-day physical activity of walking from place to place in favor of

public and private motorized transportations, those who continued the traditional walking as

their primary form of transportation may be at risk for having to stop as well. This would

cause an even higher rate of obesity and unhealthy aging (Schembri 2007).

Another important cultural change that has occurred since tourism to Gozo became

popular in the last two to three decades is the fact that the tourist-based economy has brought

foreign foods. Multinational restaurant chains, such as McDonalds, which is located at the

Arkadia Mall, are now popular within the Gozitan community. In his study on the intrusion

of American culture into the previously untouched society, Melaragno (2010) examined the

resulting Americanization that occurred. People in Gozo have changed their traditional

behavior of eating mostly locally and home-grown foods and instead eat out on average three

to four times a week. Additionally, even the traditional restaurants are now using foreign,

imported foods. The food that is being served is no longer being grown by the local farms

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and sold to small businesses. There are large corporations bringing in their own food, and

changing the dietary patterns of the locals. This provides competition for locally owned

farms and restaurants, and has the potential to significantly decrease the healthy options on

the island. This impact is negative because agriculture has always held cultural and economic

significance in Gozitan culture (Henriet 1973).

Agriculture is an extremely important industry for Gozitians because its culture is

based on farming, which has traditionally provided most of the opportunities for direct

employment and subsistence. Practically all of Maltese farms are family owned and

operated. Over the course of the last ten years since Malta joined the European Union, it is

one of few traditional industries that has maintained an upward trend. This is partially due to

the Farmer’s Aid Program that provides funding to fruit and vegetable farmers from the

Agricultural Department for Community Supported Agriculture (Troonbeeckx 2008).

There has recently been a health-based movement to return to pesticide-free farming.

The introduction of organic farming has been encouraged, but it is yet to become popular

among the small farms owners who received little to no formal agricultural education. Since

the familial practice of farming is learned via tradition, new practices for farming brought in

by outsiders are not trusted. Organic crops are more expensive than inorganic crops, yet

throughout Europe the organic farms are more lucrative than regular farms. The increased

profit possibilities are expected to increase farmer interest in the practice of organic farming.

If this occurs, the restaurants and supermarkets will be encouraged by the Maltese

government to support the local growers. The expectation is for Organic Farming to become

as popular in Malta as it is throughout the rest of Europe, and the health of the people will

benefit from this modification (Troonbeeckx 2008).

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All of the changes on Gozo have occurred during the oldest generations’ adulthood.

They have witnessed firsthand the impact that globalization has had on the island, and they

have the ability to compare themselves to the younger generations who are living in the

globalized Gozo. Their experience merits further study because of the difference between

their generation and the younger generations. Through understanding how the elderly stayed

healthy while changes were bringing in unhealthy practices has the potential to show what

lifelong practices that should be implemented.

THE AGING PROCESS

Being elderly is generally accepted as merely those who are of a greater age than 65

years. However, the aging process is an extremely complicated and variable process that is

still not yet fully understood. There are many factors including genetics, nutrition, exercise,

and overall life experience that completely alter how a person ages. Therefore, being elderly

is not simply reaching a certain age, but is also an association with age related issues. There

is a strong association between aging and cardiovascular disease, mental illnesses, and a

lower financial status because of either a decreased or fixed income. Given that about ten

percent of the world is currently over the age of sixty, the opportunity to study what is

referred to as successful or healthy aging is available in a way that it was not previously.

An interesting aspect of aging is negative ageist perceptions that discriminate against

all elderly persons. There is now a movement in research to show that not all elderly are

weak and incapable of self-determination or self-care, which has yielded data on healthy

aging. Aging is inevitable, and over the course of the natural lifetime, vulnerabilities are

inevitable. Due to aging, illness, or injury, the mind or the body may begin to fail. When this

happens, a need for intervention occurs, and a caretaker must aid the person (Mallia and

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Fiorini 2003). Part of the definition of healthy versus unhealthy aging is of the time at which

this occurs. Thus, the earlier that someone becomes incapable of independent care, the less

healthily they aged.

First and foremost, healthy aging must be defined. The Minnesota State Department

of Health (MDH) worked with the United States National Institute for Health and a variety of

rural organizations to come up with a working definition. From their study they decided that

“Healthy aging is the development and maintenance of optimal mental,

social, and physical well-being and function in older adults. This will most

likely be achieved when communities are safe, promote health and well-

being and use health services and community programs to prevent or

minimize disease. Healthy aging is a lifelong concept that encompasses the

mental, social and physical well-being of people and communities” (MDH

2006).

Thus, there are many factors that go into healthy aging, and in order for a population as a

whole to age well, there have to have been lifelong healthy practices. The MDH study

focused on four main factors that work cooperatively in order to enable healthy aging. These

four factors are addressing of basic needs, promotion of optimal health and well-being,

encouragement of civic and social engagement, and supporting the elderly to allow for

independence as a long as possible. As a result, healthy aging is not seen as an individual

effort, but as a collaborative and holistic endeavor. The all-encompassing perspective comes

from taking the individual, his or her family, local and large-scale policymakers, healthcare

professionals, businesses, and faith-based organizations. These four factors combine to

provide the basis for healthy aging from a personal and societal perspective.

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The first factor for healthy aging is addressing basic needs throughout an aging

population. The basic needs that need to be met include more than simply nutrition and safe

housing, but also access to healthcare and access to goods and services. The healthcare that

should be available must overcome cultural boundaries. As the elderly are more vulnerable to

exploitation, basic care should also include some form of protection from those who may

take advantage of them. This is particularly necessary for people who have dementia because

they are incapable of making fully functional decisions. Consequently, decision assistance,

when necessary, is also a basic need. Also, most elderly people no longer work like younger

adults do, so their income is generally fixed. In order for their basic needs to be met, they

need to have access to affordable goods and services. When all basic needs are met, a person

has the ability to age gracefully and healthily.

The second aspect of healthy aging is the optimization of health. Access to affordable

healthcare is the most basic step for this particular factor of healthy aging, but the study that

was completed in Minnesota argued that access to healthcare was not enough. In order for

wellness to be achieved, there must be a community based support system that provides

preventative care methods. Community is not just where someone lives, but also the

organizations through which they define themselves, such as religious, civil, or professional

groups. In terms of the elderly this not only means healthy nutrition and physical activity, but

also includes the support of caregivers. When the elderly become partially and completely

dependent on caregivers, if their caregivers are able to provide a higher level of care, they

will not require as much treatment after the fact from healthcare officials. This aspect of

healthcare focuses on the physical healthcare that is necessary for healthy aging.

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The third factor that is crucial for healthy aging is the mental health of the elderly.

Wellness is not only a physical state of being disease-free, but a state in which all basic needs

are met, which encompasses not only the physical needs but also social, emotional, and

spiritual needs. The National Institute of Health (2006) suggests that the best way to maintain

the mental health of the elderly is to encourage community involvement. The interpersonal

relationships that build as a result of the elderly’s community involvement provide a support

system and a large degree of socialization. Whether the aged person is involved in a faith-

based community or a civic community, as long as they are involved somehow, their mental

health state is greatly improved.

The fourth and final factor that the Minnesota State Department of health

cooperatively identified for the possibility of healthy aging was the supporting of

independent living for elderly residents. If aged people are able to live in their own home, or

at least within the society or environment with which they are familiar, their well-being will

be improved. Institutional arrangements should be a last resort when possible. Studies have

shown that living in a place in which people are supposed to be elderly or aged limits the

independent activities that the elderly do, and their dependency becomes more rapidly on-set.

The option for independence actually improves the outlook for the mental and physical

health of the elderly because they continue to do both physically and mentally stimulating

activities. In some cases, independent living may not be an option, and then a proper elderly

living environment is the next step.

A study conducted in nursing homes across Europe indicated that the nutritional

status of the elderly is reflective of the lifestyle they led in the past in addition to the

nutritional state of their nursing home. The discovery was made that the single most

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important in the way that people age is their lifestyle. A healthy lifestyle consists of a

lifetime of consistent physical activity and a low fat diet that wards off obesity and diabetes.

However, the life that is led within the nursing home also impacts the state of health. Many

nursing homes either over or under feed their residents, and that affects the overall health of

the individual. Additionally, people living in nursing homes that do not provide physical and

social activities have a lower the age at which age-related diseases occur. The increasing

number of older persons as well as the increasing number of people who are obese has

become a common health problem (Koh 2005).

The preventative research on heart disease and other coronary disease has provided

insight into the prevention of dementia because there is a correlation between an active

lifestyle and dementia prevention. A diet high in carbohydrates may have a detrimental effect

on patients. Coronary heart disease is a primary cause of premature disability as well as death

in developed and industrialized countries. The preventative measures that were put into effect

focused on diets that are high in carbohydrates versus those that are not. The result was that

traditional Mediterranean foods proved to be an ideal nutritional plan for decreasing rates of

diabetes and heart disease. The decreases in these diseases followed in parallel reduction of

dementia rates. It is now recommended by healthcare professionals that all cultures should

promote gastronomic exchanges to increase the prevalence of the traditional Mediterranean

diet (Riccardi et al 2003).

HEALTH AND AGING ON GOZO

The traditional Gozitan diet, which follows the Mediterranean diet, is one of the

primary influences on the health of the elderly on Gozo. Given that diet is such a crucial

factor of life expectancy and the state of health, the health of Gozitans is a result of their

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nutritional patterns. Vesa, Crisan, Macarie, and Teodorescu (2009) asserted that the most

beneficial diet for prevention of aging diseases is the Mediterranean diet. Through the

analysis of the preexisting data on the Mediterranean diet and health, they drew their own

conclusions and provided possible solutions. The Mediterranean diet is primarily known as

being associated with Italy and Greece, but the location of the Maltese archipelago aligns it

with Italian style cuisine, which is characterized by a high intake of fish, vegetables, fruit,

olive oil, and whole grains. It also includes very low of rates of fat, cheese, and red meat

(Ferro-Luzzi and Branca 1995). This diet has been known to play a preventative role and is

part of a treatment plan for cardiovascular diseases, but this study pursued the benefits that

the Mediterranean diet had for the prevention of Alzheimer’s. The study found a correlation

between the Mediterranean diet and lower rates of Alzheimer’s. Although there is yet to be

conclusive cause and effect data, their study argues that the correlation is strong enough that

the Mediterranean diet should be treated as a preventative measure for Alzheimer’s and

dementia (Vesa et al 2009).

Although the diet of the Maltese traditionally results in low obesity rates, that is not

the current situation. In 2008, the Maltese medical journal performed a study in order to

better understand the state of obesity and the complications that are associated with it. They

collected survey data on 5,500 random Maltese adults through their general practice doctors.

The survey consisted simply of the person being asked to record their height and weight. If a

person did not know it, his or her doctor’s staff was able to assist in finding out their height

and weight. Although this method was not necessarily the most thorough or accurate, their

large sample enabled decent generalizability. The Medical Journal research team discovered

that the Maltese population is on the upper end of the spectrum for population body mass

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index. This research was conducted on adults, not elderly, but the implications for the future

consequences of the rates obesity suggest that the next generation of elderly will be

significantly less healthy (Sammut et al 2012).

The health of the adult generation is further at risk because one of the most

preventable options for minimizing future health conditions is very common among the

Maltese. Cigarette smoking is incredibly prevalent on the Maltese Archipelago. However,

what was not foreseen in the study that the Malta Medical Journal performed was that the

findings indicated the elderly were not the most common smokers. The elderly who were

surveyed were not addicted to cigarettes regardless of the fact that the health concerns were

not as widely acknowledged when they were younger. Generally, the oldest generations have

the highest rates of smoking. The results of this survey further support the idea that the

elderly are actually healthier than their younger counterparts (Sant Portanier 2004). The

lower disease rates are found throughout the Mediterranean countries, and this is thought to

be a result of the Mediterranean diet. The decreases in dementia that resulted from the

Mediterranean diet have suggested at least one preventative measure.

DEMENTIA

As the number of the elderly increase around the world, the diseases to which the

elderly are prone follow the same patterns of increase. However, certain of these diseases are

present at higher rates on a per capita basis rather than just mirroring demographic patterns.

These diseases present a greater global threat because the number of elderly is expected to be

the highest it has ever been in the next ten to fifty years. If these diseases continue to rapidly

increase, while the population that they affect continues to increase, it has the potential for

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the situation to become a serious problem also increases. One of the foremost of these

diseases around the world is dementia (Kalaria et al .

Dementia has become a global health crisis, because of its morbidity and mortality

rates. Morbidity is the incidence of a disease within a population, and mortality is the

incidence of death because of a disease. Dementia is completely incurable, and therefore

fatal. There have been experimental treatments, but to-date there is no way to reverse the

effects of the neurodegeneration that characterizes dementia. Once someone is afflicted with

dementia, their mental and physical state will decline, and eventually they will result die.

Dementia is not a quick death sentence, it is a prolonged affliction that may not always be the

direct cause of death, but will always be a factor (Ferri et al 2006).

Dementia, although technically a group of diseases, is considered by public health

officials as one disease that is still neither fully understood nor fully preventable. However,

the working definition is that it is an acquired condition and is characterized by a significant

decline in memory. The memory loss must also be coupled with another form of cognitive

domain decline, which includes all regulatory and control functions (executive functions).

This decline can also include failures in language and communication, visual and auditory

skills, and social skills. Most people who suffer from dementia eventually lose their social

functionality and experience verbal outbursts, uncontrollable mood changes and disorders,

issues with eating, and sexual extemporaneity. Alzheimer’s, the most severe form of

dementia, progresses at a particularly rapid pace. While previously viewed as its own disease

separate from dementia, Alzheimer’s is now seen as a type of dementia. Dementia is a

disease that requires those who are affected by it to be cared for on a constant basis. (Magri,

Ferri, and Abela 2007).

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From a global perspective, dementia is extremely prevalent and very expensive. In

2010, according to European research, dementia cost the world 435 billion euros. In other

words, approximately one percent of the world’s gross domestic product was spent purely on

dementia treatments (Scerri and Scerri 2012). This also does not take into account the

amount of money that would be spent if not for familial caregivers and housing. According

to the World Health Organization, people with dementia live for an average of 11 years in

which they are disabled and need care. The socio-economic consequences are grave, and it is

necessary to understand that there is not a large-enough younger generation to care for the

growing number of patients with dementia (Abela, Mamo, Aquilina, and Scerri 2007). As a

result, caring for the elderly who are afflicted with dementia is an immense drain on the

health care system because treatment of people with dementia costs more than the treatment

of cancer and heart disease combined (Kukull 2006).

DEMENTIA ON GOZO

In 2007, the first study of dementia in the Maltese Archipelago transpired as a result

of the European Demographic (EURODEM ) study asserting that the prevalence of dementia

was going to increase dramatically. The study consisted of data collection from eleven

countries, eight of which were from in European Union. They gathered data about the

prevalence of dementia within the population. In order to make population estimates, they

drew from the overall population estimates were previously collected by the United Nations.

As an analytical epidemiological study, they collected data from the different healthcare

databases throughout the eleven countries and made comparisons of age, gender, and whether

the country was developed or developing. Their research showed that rates throughout

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Europe are expected to double every twenty years, and for an aging population like Malta,

that has the potential to be detrimental for the society.

Consequently, this awareness generated the need to begin an examination of the

elderly on Malta, Gozo, and Camino in order to understand what the future held for their

population. All of the data that was gathered on the rates of dementia in Malta were based on

of the EURODEM statistics. Despite the fact that the experience of the Maltese and Gozitans

is radically different from the rest Europe, they used the same percentages as the rest of the

European Union. The conclusions of the Malta Medical Journal based on this study,

examined the potential risks for the Republic of Malta.

From the EURODEM study, the medical researchers arrived at the conclusion that

there were approximately five thousand cases of dementia throughout the Maltese islands.

Their estimation was used to determine the base for which expected cases would occur over

the following twenty-five years. Initially, the expectation was that by the year 2050, two

percent of the entire (not just elderly) population would have dementia. They also concluded

that despite the fact that the number of elderly were increasing, the number of older people

dying from dementia was also increasing, so the percentage increase of dementia was even

higher than previously thought (Abela, Mamo, Aquilina, and Scerri 2007).

This initial projection was troubling, and so the research continued, and further

findings were published after another European project called EUROCoDe (European

Collaboration on Dementia) occurred from 2006 to 2008, with published results in 2010.

This project was aimed at increasing the generalizability of the findings on dementia to all of

Europe rather than to countries that were similar to those that were initially studied. This was

a significantly more in-depth study that worked from a collaborative perspective using

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different organizations and their data. Rather than just focusing on the dementia prevalence,

the follow-up study focused on six different dementia-related indicators and guidelines for

prevention and treatment. To develop these, the study collaborated with the Cochrane

Dementia and Cognitive Improvement Group, the European Alzheimer's Disease

Consortium, the European Association of Geriatric Psychiatry, the dementia panel of the

European Federation of Neurological Societies, the INTERDEM (Early Detection and

Timely Intervention in Dementia) group, the International Association of Gerontology

(European region) and the North Sea Dementia Research Group.

The six measures that were evaluated in the EUROCoDe Study were agreed-upon

prevalence rates, guidelines on diagnosis and treatment, guidelines on non-pharmacological

interventions, risk factors and risk reduction and prevention strategies, socioeconomic cost of

Alzheimer’s disease, and inventory of social support systems. The agreed upon terminology

that was chosen was consensual, which refers to the fact that they took all previous

epidemiological studies, and worked with their strengths and weaknesses in order to

understand what the actual dementia rates were. From unification of prevalence, the study

moved to the guidelines on diagnosis and treatment. They compared the preexisting

guidelines, and worked to unify the different organizations on a single process of diagnosing

through recognizing and diagnosing shown neurodegeneration rather than just assuming

forgetfulness was dementia. After diagnosis, the effects of non-medicinal treatments were

examined in a hope of understanding what sort of interventions could positively affect those

with dementia. The collaborative study also examined what lifestyles could beget a healthier

brain during aging thereby providing preventative care strategies. Another factor that was

taken into account was a more accurate analysis of the cost of Alzheimer’s in Europe.

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Finally, of the 25 members of the European Union, they took a survey of the options that

were provided including benefits and allowances. These analyses provided valuable insight

into the best way to handle the increasing demand that dementia is placing on the world.

The findings of EuroCoDe created a greater global awareness of dementia, because

they built on the strength of prominent organizations that gained media attention. EuroCoDe

determined that through their improved research techniques they had a more accurate and

generalizable study to all of Europe. The previous estimation that in 2050 two percent of the

world would have dementia was shown to be far too conservative. Through unification of

diagnoses, and the time passed in between studies their estimate is that two percent of the

population will be affected by 2025, which is 25 years earlier than previously expected.

In addition to prevalence, the EuroCoDe study also found that there were three

overarching positive correlations that they assert are preventative measures. According to

their study, diet, exercise and continued socialization are the most important determinants in

the prevention of dementia. However, their study was conducted on people who already had

a lifetime of varied experiences, and so there is no way to determine what other spurious

variables affected the affected people. Despite the fact that there have been correlations at the

population level between particular activities and decreases in dementia rates, these are

correlations are far from demonstrated cause and effect relationships. They are only

associations. Dementia is yet to be proven to be directly related to diet, exercise, or

socialization because there has not been the elimination of confounding variables. Thereby,

this does not provide a viable solution, but a possibility for future preventative measures.

(Ferri et al 2006),

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By 2012, the Malta Medical Journal did their own study on the island of Malta based

on of the new EuroCoDe findings, and concluded that there was a significantly higher

projection for the number of Maltese with dementia than previously thought. They found not

only changes in the incidence of the disease, but that one changing factor was the age at

which dementia is expected in the population. What was formerly considered an exclusively

older elderly disease is now being found at younger ages. This means that instead of

dementia setting in during at around the ages of 70, it can begin to progress as early as the

age of 60. The earlier on-set dementia was found to be more prevalent among the Maltese. It

is expected that the Maltese population will see an increase of people in the sixty-year-old

range with observable dementia, which means that their disease projections dramatically

increase. There is now discussion among medical health professionals to alter the definition

of early-onset dementia as prior to the age of 60 due to the increased incidence (Scerri and

Scerri 2012)

Another primary difference that was found in the EuroCoDe Study was that rather

than just plaguing developed countries, dementia is expected to be prevalent in developing

countries as well. This is particularly important for the Maltese island of Gozo that does not

share all of the technological advancements to which Malta, as a whole, has grown

accustomed. However, research was not performed to conclude whether this is the case or

not. It is merely a hypothesis with regard to Gozo. (Scerri and Scerri 2012).

There is a large gap in the Maltese research on dementia, given that there is no

research that focuses exclusively on Gozo. All of the Maltese Archipelago studies are

conducted exclusively on the largest island, Malta. There is a consistency among researchers

that generalize the findings on the Maltese population to include that of Gozitans. However,

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Gozo is significantly more rural and considered less developed than Malta and the rest of

Europe. Technology that is commonplace in Malta is nonexistent in Gozo. Also, the

healthcare that is readily available in Malta is not present in Gozo. Thus the generalization to

Gozo may not be an accurate representation of the population’s experience. Historically, on

multiple occasions during different occupations of Malta, Gozo became recognized as its

own independent nation. Furthermore, Gozo has encountered a great deal of change in the

last thirty years that has dramatically impacted the life experience of its inhabitants, and

changed their health situations as well. The difference between the life the elderly led in the

past and their lives today is significant (Baldicchio 2007). The generalization of Gozo as a

mere part of the Maltese Archipelago results in a lacking understanding of the Gozitan

dementia situation. There needs to be further research into the incidence of dementia on

Gozo rather than just on the big island of Malta.

THE ETHNOGRAPHIC PROJECT

The overarching question to be addressed through my ethnographic research is: What

is the life experience of the elderly like on Gozo? Life experience is the patterns of life that

are consistent among different people in a culture. The education, careers, and family

structures are all elements of the life experience. Through the combination of daily practices

and large life events, I intend to examine the lives of the elderly on Gozo with a specific

focus on their health.

Approximately 31,000 people inhabit the island of Gozo, and in the last 20 to 30

years, dramatic changes have transpired. The rapidly increased tourism to the island of Gozo

and joining the European Union in 2003 altered the economy, social structure, and lifestyle

of Gozitans. The subpopulation of the elderly will be the focus of research as they stand to

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have the most comprehensive perspective on these issues having experienced the social and

cultural changes firsthand. They were alive before Gozo was a popular tourist destination,

and have been a part of the changes that occurred due to globalization. Through the

understanding of cultural changes, the question of how the changing experience of Gozitans

has affected their health will be explored.

One particular aspect of the life experience of the elderly is their understanding of

their health status, specifically in regards to dementia. What do the elderly consider healthy

and what factors do they believe impacts health, and particularly dementia? How is that

different from medical personnel and the younger generations? Through the examination of

the health of the elderly and their beliefs and practices as to what helps and hinders health

allows for an improved understanding of the success and failures or their lifestyle. These

questions will be addressed through ethnographic interviewing and participant observation.

The conclusions will provide insight into the Gozitan life experience of the elderly and their

health.

METHODOLOGY

My field site was on the island of Gozo in the Republic of Malta. I conducted

research throughout the island, with specific focus on the elderly, and therefore with a focus

on the locations the elderly frequent. The population of Gozo is approximately 31,000, and

their population is aging with large numbers of elderly inhabiting the island. The entire island

is only 25.9 square miles, so travel anywhere on the island is feasible with a bus pass, which

they sell by the week for 12 euros. As a result, it is not was not difficult to get to any of my

field sites.

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The first site I studied was a church-run, private nursing home; their visiting hours

were from 11 am to 3 pm every day of the week. This particular nursing home only allows

females to live there, so needed other sites for a more comprehensive picture of the elderly

on Gozo. In order to gain access to both male and female participants, I also played bocce at

the bocce court and bar where the elderly men go every afternoon. I split my afternoons

between these two places with exceptions for other outstanding commitments, such as a day

at a Gozitan farm. Also, my previous experience in nursing homes enabled me to make a

better connection with the staff and the persons in the homes. Also, the field school with

which I worked, Off the Beaten Track, introduced me to contacts that proved to be beneficial

to me. As with most ethnographic research, participants led me to others in a snowball effect.

In order to gain other informants, I also attended mass at one of the local churches in the

center of the capital for Sunday Mass and went to the café across the plaza where the mass

attendees, particularly the elder members, congregated after church each Sunday. In addition,

during siesta, most Gozitans gather around the front of their houses with the windows and

doors open so that people can stop by and visit. Also, the traditional Gozitan practice is to do

laundry at the local wells early in the morning. I went to the wells at about seven in the

morning to visit with the women while they worked. Finally, the transportation of Gozo has

undergone dramatic changes in the last ten years with the introduction of a structured bus

system. People who inhabit Gozo are able to ride the buses for extremely discounted rates.

While riding the busses, I used the opportunity for informal interviewing and discussions.

The methods that I used to do ethnographic, descriptive research on the elderly on Gozo

were participant observation, interviews, and environmental observations. Participant

observations occurred every time I visited the Bocce courts, and when I am with informants

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for specific activities, such as wool washing at the wells. My interviews occurred both

formally and also informally, when an informant has time to answer my questions. My semi-

structured interviews will focus on the elderly, dementia, and how Gozo has changed over

the course of the last thirty years. Whenever informants let me, and in public places where

ethically possible, I took photographs. My documenting process included handwritten notes

during interviews, and typed research notes. However, there were times when writing down

notes was not feasible because of casual and spontaneous nature of conversations.

ENTERING THE FIELD

The island of Gozo is located in the Mediterranean Sea, and belongs to the Republic

of Malta. The entire island is about 25.9 square miles, and its population is approximately

30,000 people. Catholicism is the official religion of the island, and the Catholic Church is an

active part of Gozitan daily life (Conrad, Christie, and Fazey 2011). The island has one city,

Victoria, which is the capital of the Gozo. Other than Victoria, there are several villages and

towns scattered across the island.

Upon arriving in Gozo, I went with the intention of studying public health, but I was

not exactly sure how my project would unfold. I began by simply walking door to door in the

villages looking for informants. People who had time for interviews, spoke English, and

would be willing to answer questions about health were virtually non-existent. However,

people were almost always willing to discuss the changes on Gozo, the healthcare system,

and their distinction from the Maltese. Of the thirty homes (ten of whom answered the door),

only two were willing to have me interview them.

In order to gain more sources and interviews, I started frequenting St. Dominic’s

Home for the Elderly, which is privately owned and run by sisters of the church. The women

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in the nursing home were surprisingly healthy both physically and mentally. With permission

and help from the nuns who acted as translators when the patients only spoke Maltese, I

proceeded to interview the elderly women during the visiting hours. I also interviewed the

Sister in charge. Several other women talked with me informally while they played games or

watched television. They recommended to me that I find the traditional healer and weaver on

the island and provided me with her address. She became my key informant.

Through more than eight hours of in-depth formal interviewing with the traditional

healer we developed a relationship and she was willing to introduce me to other informants.

She took me to all the places that were important for healing including the wells where the

wool is to be washed, and the fields where the herbs are found. She also invited me to events

where people she knew would be beneficial to my research would be. I was able to meet and

interview doctors who work at the hospital at an art gallery opening. On outings, the

traditional healer and I also visited elderly people who lived with their families’ and

interviewed them with her acting as my translator when necessary.

During the hours of siesta when the nursing home was closed, and making visits to

people’s homes is not polite, I played Bocce with the elderly men. I interviewed them, played

with them, and learned from them. These afternoons introduced a male perspective into my

research. Both elderly men and a few younger men participated in the Bocce games, and they

were able to provide cross generational attitudes and information.

On my own in the mornings doing laundry, I visited the wells in Xlendi that still

serve as important cultural locations for the people Gozo. It is here that laundry is washed,

cars are cleaned, and farmers gather buckets of water to irrigate their crops. With the

traditional healer, I was also able to visit the lesser known wells that are on the border of

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Victoria. These secondary wells are cleaned and the wool that is used to make the traditional

blankets is washed there.

Finally, I rode the bus and hitchhiked every day that I was on Gozo, and informally

interviewed the people on the busses and those who drove me. On days when I only had a

few hours of interviews with the ladies at St. Dominic’s or the traditional healer, I would just

ride the busses for two or of three hours and talk to anybody who was willing to talk to me. It

was through these numerous, short interview sessions that I asked how Gozo had changed

over the last forty years, and whether the person had ever lived abroad. Before people would

speak with me, they asked which mass I went to on Gozo. I attended church at St. George’s

basilica in Victoria every Sunday morning and spoke with the parishioners after the service

in St. George’s square where they congregate. My attendance at mass enabled many

conversations that would not have otherwise possible due to the importance of the Catholic

faith on Gozo.

THE NURSING HOME

St. George’s Home for the Elderly is located in the capital city, Victoria, on Gozo. It

is located along the main bus route, less than a five minute walk from the major Basilica, the

main Bus station, and both large town squares. It is attached not only to a chapel, but also to

a home for sisters of the church, a convent. Directly across from the street from the entrance

is a health clinic. The nursing home, itself, is in the traditional Gozitan style of sandstone. It

is a long building that mirrors the length of the health clinic, which covers an entire block.

Along the length of the street from the convent to the nursing home is a black

wrought-iron gate that allows for about six feet of gated, tiled walkway in between the street

and the front steps. The building is painted white, which is unusual for Gozo. Most buildings

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are left in (or have faded back to) their original sandstone, which is a tan color. As a result,

the white convent and nursing home with their black gate stand out against the wash of

brown buildings.

The door to the nursing home is flanked by a carved wooden sign identifying it as St.

George’s Home for the Elderly. On the right window of the door to the nursing home,

visiting hours are posted on a white typed sheet of paper. It reads,

“Hinijiet tad – dhul [Hours of Entry]

Xitwa [Winter]

Minn 9.30 sa 11.00 3.30 sa 07.00 [From 9:30 am to 11:00 am and from 3:30 pm to

7:00 pm]

Sajf [Summer]

Minn 9.30 sa 11.00 3.30 sa 07.30” [From 9:30 am to 11:00 am and from 3:30 pm to

7:30 pm]

Gozitan people observe a siesta, and the majority of stores, restaurants, and tourist attractions

are closed anywhere from 12 to 4:30. Likewise, the home for the elderly maintains this

tradition, and visiting hours are not during the early afternoon. Most signage is either done in

English or English and Maltese. The lack of English on the hours at the nursing home is

indicative of the fact that it is not for English speakers, but for native people.

The main door to the nursing home is a wooden door. It has a large glass window

over the top half of the door. The lower half is completely wooden. The door is kept locked

at all times, and in order to enter you have to ring the bell, which is located to the left of the

door just above the handle. There is a three feet by two feet area in between the front door

and the second door, which leads into the home. The second door is a wooden door as well,

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but it is painted white, and does not have any windows. There is a black metal handle, and a

lock on both doors.

When a person arrives, and rings the bell, the nun who is in charge of the elderly

home opens the second door and closes it. She waits in the area between the doors, and

checks the person at the door. Entry into the nursing home is at her discretion, and she is very

serious the first time she meets you. Sister Mary asks who you are, what you are doing,

where you are from, and why you want to visit the nursing home. After the initial questions,

if she approves, you are invited into the home. However, if she were to not approve, or find

your answer unsatisfactory, you would not be invited in. The door is only answered during

visitor hours unless you have a previous appointment. On subsequent visits, just a visual

affirmation of who you are is enough to get inside, but entry is always subject to the approval

of the nun.

The entrance opens to the common room, which has a white and grey tiled floor, and

white and pink walls. The room itself is quite large, and is approximately 25 feet deep and

about 35 feet long. In one corner is an upright piano. There was a long row of chairs in the

middle of the room, each with a resident facing away from the door and towards an old

television set, which was in the middle of the room on the opposite side of the door. During

the afternoon hours, the residents have the option of watching television in the common

room. The residents not only watch the television, but change seats and carry on

conversations and socialize throughout their time after lunch and before dinner.

On the right side of the room is a hallway that leads to some of the private rooms of

the residents and eventually the cafeteria. On the left side of the room is a hallway with more

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resident rooms and other facilities including clinical rooms and offices. My interviews were

all conducted in this common room.

St. George’s home for the elderly is an ever-changing community with its own

subculture. Exclusively aged women live in the home, and it is a private home, which means

although it is run by the church, living there requires payment. This provides the members a

sort of exclusive membership. Multiple women expressed that their home is the nicest on the

island because it is funded by neither the government nor the church.

However, the fact that the women live in a home at all is indicative of a change in

Gozitan culture. Previously, the older members of a family would live with their children and

grandchildren on the island. The women of St. George’s claim that the number of nursing

homes that exist on Gozo is a new phenomenon, and only severe cases where an old person

had no family would have resulted in a nursing or convalescent home that was run by the

church. Even now, there are no exclusively private nursing homes. The private St. George’s

still only employs sisters of the church to take care of the elderly. This is believed to be a

result of the influx of outside cultures that are forcing their way into Gozitan daily life.

After being introduced by Sister Mary, the vast majority of my interviews

commenced with the woman I was interviewing asking me questions about my religion. Like

the people of Gozo, I am Catholic, and that helped me to find people who were willing to

speak with me. When told that I was Catholic, the immediate next question would be to ask

where I was attending mass. Throughout my time on Gozo, I went to Sunday mass at St.

George’s Basilica, and I told the participant that although English masses are advertised

throughout the island, there are no English masses on Gozo, and whoever was asking about

my church habits would check me on this discrepancy. Josephine asked how I liked mass on

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Gozo; Mrs. C asked if the priest had good English. These questions were a test to see if I was

actually going to mass because religion is extremely important to the elderly on Gozo.

Once I passed the initial Catholic test, the women of St. George’s were willing to

discuss their various beliefs with me, and were willing to share just how important their faith

is in all their decisions. I was amazed by how mentally and physically well all the women

were, and I asked directly, “How are you all so healthy?” The initial response was always

because God is good, or because God wills it so. Sylvia said, “God blesses Gozo.” Generally,

after this first answer, the woman would make the sign of the cross.

The primary spiritual leader who is called upon for the health of Gozo was a

traditional healer and political leader, Franc del Gharb. According to the women of St.

George’s he could cure anything from the common cold to marital troubles. In the town of

Gharb, there is a shrine to him, and you can buy anointed oil or treatments that he would

have prescribed. There is an on-going cry from the people of Gozo to have him canonized,

and many of the women pray to him as they would to any other saint. According to

Josephine, it is not unusual for a priest to go and pray for the sick, and end the prayer with

the statement, “Franc Del Arb pray for us.”

The most common comment people made about their health was that they had lived

on Gozo for their whole lives. Michelle was the only woman who had lived outside of Gozo

for an extended period of time. She had resided in White Plains, New York for more than a

decade, and she was forgetful. Whereas she may not have had full-fledged dementia, her age

had definitely caught up to her. This could have occurred for a myriad of reasons, yet when

she asked me if I was related to the Cremona’s on Gozo, Josephine whispered in my ear that

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she had left Gozo. It was as though leaving Gozo guaranteed disease, and staying on Gozo

would have preserved her health, and this was rude to say outright.

The Gozo that the women of St. George’s grew up and lived in was very different

from the Gozo of today, of which they heartily disapprove. Thirty or more years ago, Gozo

was an almost exclusively rural and isolated island. The food that was eaten was grown on

the island, and people walked everywhere that they needed to go. They were healthy because

they lived the Gozitan way, and did not have the outside forces making them sick. Medicine

was not necessary, and did not yield side effects.

All of the women were very concerned that I was drinking tap water rather than

bottled water. Although I had been previously informed that the water on Gozo should not be

consumed, I questioned why I should avoid it. Josephine said, “We had to stop drinking the

water because of the chemicals.” At a certain point, the government decided that water was

not sanitary, and it had to be treated. Participants disagreed over whether this was ten or

twenty years prior, but Josephine and Carmine firmly believed that it made people sick.

Chemicals, in general were the reason that so many people got sick. “Chemicals” was the

term used to explain everything from the treated water, to soda and processed food, and even

to medicines. Chemicals were the root of illness, and must be avoided.

My particular interest was in the study of dementia, and the lack there of in the

nursing home. The elderly believed that their Gozitan, chemical free lifestyle had prevented

all the diseases that plague other places. Dementia was not a topic that they were willing to

discuss in any context other than providing sympathy. They referred to both Dementia and

Altzheimers as “The Dementia,” which was generally followed by an expression of sorrow,

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sympathy, or the sign of the cross. Questions about the causes of Dementia were met with

tension and short answers.

One interview, which was conducted with the family of a woman in the home,

provided a look into the dynamics of the older and younger generations’ relationship. The

daughter and two granddaughters of Carmine were willing to talk to me not only with their

mother at St. George’s, but also again in a follow-up interview at their family home in the

town of Qala. Carmine’s daughter, Venice, said that people no longer remain on Gozo

throughout their lifetimes. The dream is to own a big house on Gozo and raise a family there,

but there are not the necessary jobs on Gozo. In order to be successful, you need to college,

and the closest college is on Malta, so immediately you leave for at least four years. Then to

make enough money to buy a house on Gozo you have to live somewhere that has jobs, so

most people go to America or somewhere in Europe. Venice had lived in Germany for four

years with her husband because with the European Union they were able to live in any

country in the union without paying additional taxes.

The discussion of traditional healing was particularly interesting. The women of St.

George’s were passionately supportive of using natural medicines and staying healthy rather

than taking medicine. Health was maintained through living the Gozitan way. More than

once, the comment was made that medicine is to cure, but it is just chemicals. Chemicals

make you sick. In addition to being chemicals with warnings and side effects, medicine from

doctors is foreign. Since the medical practices originate outside of Gozo, they are

automatically assumed to make people sick rather than heal them.

Venice informed me that the medical belief is unique to the oldest generation on the

island. She felt that medicine was crucial, and her oldest daughter had once had to be flown

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from Gozo to Malta for treatment because the ferry just was not fast enough, and proper

resources were not available. The younger generations are pushing to make Gozo more

globalized, and they have “improved the hospitals.” Up until recently there was only one

small hospital and a few doctors’ offices. Now there are clinics, a hospital, and doctor’s

offices with many more pharmacies. This is because the young people on Gozo return from

whatever place the lived abroad, “and know what they need.”

THE BOCCE COURTS

Bocce is a cultural phenomenon that is found throughout the Mediterranean area in

countries such as Italy, Greece, and Malta. Quite simply, it is a game played with metal balls.

The objective is for the participant to throw their metal ball closest to the smallest ball. It is

played on tightly packed sand in a rectangular shape, which is called a court. On Gozo, the

bocce court is a congregating place for the men of all ages, especially older men who are

retired and no longer work.

The Bocce Court on Gozo is located outside of the capital city in one of the smaller

neighboring villages. The surrounding neighborhood is predominately farms and family

homes in addition to community areas for children. Down the street to the east of the center

is a playground with brightly colored swings, a sand pit, and a jungle gym. There is an

incredibly large mural on the wall across the street from the bocce center that encloses a

church and school. It features eight cartoon children of different races and genders holding

hands on a bright blue sky and green grass background with butterflies.

The Bocce Center itself is not only a bocce club, but is also a bar that serves food, and

is attached to the main athletic field on Gozo. The whole structure is very open and is made

of the sandstone that is found throughout the island of Gozo. The front of the building is

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The Bocce Court Diagram:

plain sandstone, and on the left is a large window into the bocce court is completely open,

without glass or panes. It is more like a half wall upon which people sit to watch the games

of bocce, and opens up the entire left half of the building. The right side of the building from

the street is closed without windows, but is made of the same sand stone, but with a full wall

rather than the apparent half.

The left side of the building is where the two bocce courts are found. The entire

structure, while covered by a roof, has four open walls. In fact, there is no wall, but a

concrete frame for a wall facing the right side of the structure. Attached to the back and front

of the wall are two half walls that are about four feet high and six inches thick. They serve to

separate the Bocce courts from the hallway, while still allowing the entire middle portion of

the room to be open for people to enter. The room itself is divided into two halves by a

concrete center that is three feet wide and three feet high that runs the length of the courts.

On the top of this concrete half wall is a bench that serves as two steps of bleachers for

people who want to watch the men play bocce. This bench is constantly adorned with beers

that belong to the players and the observers. Most of the beers are Cisk, which is brewed

locally, but there is the occasional Heineken or a bottle of water.

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On either side of the main bench are the actual courts for Bocce. They are rectangular

in shape, and about twenty-five feet long, and eight feet wide. Rather than being concrete, the

floors of the courts are made of tightly packed and compacted sand. The ground is soft

enough not to scratch the Bocce balls, but packed tightly enough so that the balls roll

uninhibited by the sand. However, the ground is not completely flat, there are periodic dips

and indentations from balls that are thrown with great force, and leave an imprint on the

ground. The bocce courts are six inches lower than the walkway in between the two sides of

the building. Directly in front of the front and back walls of the building on the sides of the

court, have is a landing that is about a foot higher than the courts. On top of this landing are

poles that are attached to a metal railing that is two feet higher than the landing. The railing

lines up with the front and back walls.

The right side of the first structure is the bar area. The lighting in the bar is fairly dark

with the only natural light coming in from the door to the hallway, and incandescent lights

light the room. On the north side of the room, which is the back wall, has a refrigerator and

the bar. The refrigerator is red, and has a Coca Cola label on both sides, and a clear glass

front. The handle and the frame of the front are black. Within the refrigerator are shelves of

beer, soda, and water. The prices are listed in Maltese, written by hand on a plain sheet of

white paper, which sits on the bar. There is a cash register on the side of the bar that is

farthest from the door, opposite of the refrigerator. There are two round tables, each with four

chairs across from the bar towards the front of the structure.

The walkway in between the Bocce side and the bar side of the center is about four

feet wide, and twenty feet deep. Entrance into the athletic center is through this hallway. On

the right side is a closed wall, except for the door to the bar. On the left is the Bocce court,

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and past the two courts, a small bathroom. The hallway continues past the first structure and

opens onto a patio with several tables and chairs that overlooks a full-sized soccer field.

There are bleachers to the right and left of the patio area. There are stairs in front of the

bleachers that lead down to the soccer field, which is located about ten feet below the patio

and bleachers.

Although there was one younger man who came to watch the Bocce game, the

majority of the men were in their sixties and seventies. There were no Gozitan women

playing Bocce, only men. Many men claimed that this was because they came to play Bocce

when their wives threw them out of the house during siesta. They had the option to either go

to a cafe, if they could find one that was open, or come play Bocce and have a couple beers.

All of the men were extremely welcoming to me on my own and when I was with the other

young male and female field school students interested in learning Bocce. We were divided

onto the two teams, and the older men shared their expertise on the game. Each man has his

own unique technique, and some of the men specialize in throwing their ball closest to the

little ball. Others have the more difficult skill of being able to launch their ball and knock

others out of position without disturbing the little ball. Every man said that he was good, but

recommended another man as better. After giving a few pointers, every man would say, “I’m

good, but if you really want to learn you should ask…” Through these introductions, I was

able to meet every person playing Bocce, which allowed them to become potential

informants.

They wore comfortable clothes including mostly t-shirts or button downs and loose-

fitting shorts. The younger men generally sported tank tops instead of button downs or t-

shirts, and they were often teased for this decision. The Bocce Court is overall an incredibly

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relaxed and casual setting. Contrasting with American sports, it is really not a competitive

atmosphere. Although there is a clear winner in every game, there is no sense of victory and

defeat, but merely an end to a game. The whole Bocce practice is a solidarity building

activity that promotes friendships and physical activity.

All of the Bocce Men were more than willing to be interviewed, but for the most part

they were not interested in discussing health. The fact that I was studying the elderly had an

overwhelmingly positive response, but rather than providing direct answers about health,

they discussed the changes on Gozo. Studying the elderly provided a look into what Gozo

used to be like, and there was reminiscent quality to all the discussions about the life

Gozitans used to live.

More than one time I tried for a direct answer in regards to my questions on health. I

asked directly, “Why is it that the elderly on Gozo are so healthy? Why don’t they have

dementia?” One of the older men, George, looked at me with clear exasperation. There was a

degree of mutual frustration, and a clear miscommunication. I wondered if it had something

to do with the fact that although most of the people on Gozo speak Maltese and English,

there was a language barrier, and something that I was just missing. However, after a

moment, he put his hand on my shoulder and asked if I had been listening. To the elderly

men to discuss health was to discuss the “Gozitan way.” To explain why people were so

healthy it was positively pivotal to understand the changes on Gozo because prior to these

changes, there was a society that lived in the best possible way.

The changes on Gozo were explained through one sentence: “Thirty years ago there

was one truck on all of Gozo.” This phrase was supposed to convey absolutely everything

that I needed to know about Gozo thirty years ago. However, for the men of Gozo it meant

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that over the course of the last thirty years, there was a large shift from walking everywhere

to other forms of transportation. People neither needed cars nor the busses that now run all

over the island. This fact was stated to me repeatedly, and it carried a weight that was far

more significant than just the number of vehicles that were on the island. By saying, there

was only one truck; they were conveying how much simpler life on Gozo was.

In order for there to be busses, cars, and trucks on the island the transportation from

Malta to Gozo had to improve, and this occurred when the large ferry started running

regularly. Once there was an easy and convenient way on and off the island, there was an

influx of outside forces and an exodus of Gozitans. It was at this point in time that it became

normal for people to leave Gozo and only come back when they were older. As a result the

oldest generation is proud to be the only generation who had lived their entire lives on Gozo.

Part of increased transportation meant that less expensive, processed foods were

brought to the island, and farms became obsolete. People could drive or ride the bus to the

supermarket in Victoria rather than going to the daily village markets for fresh produce.

Now, almost every village has corner stores that sell packaged food, but for the

supermarkets, Gozitans have to shop in the capital.

The bustling economy of the capital led to the building of a multiple story shopping

mall complete with a McDonalds that embodies the western influence on the island.

Additionally, only the larger villages still have neighborhood bakeries. A dietary staple in

Gozitan culture is a pastry called a “pastizzi.” They are shaped like a clam shell, wrapped in

very thin dough, and stuffed with savory cheese. While these used to be found all over the

island, they are now limited to the bakeries only found in larger villages and Victoria. From

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the Gozitan perspective, these changes all originated when there came to be more than one

truck on the island.

One of the Bocce players still owned and operated a farm with sheep and goats and

made the traditional Gozitan cheeses. The traditional Gozitan cheese he makes is still sold to

some of the local restaurants and bakeries, but it is no longer processed the Gozitan way. It

used to be processed with lemon juice, work, and time, but now the process is almost

instantaneously achieved through the use of chemicals. However, he still makes a small

amount of the cheese in the old fashioned way, and this is for his family because “chemicals

are bad for you.” Additionally, his wool is given away to traditional healers or just discarded

because there is no longer the demand for wool. People today on Gozo will purchase

synthetic materials because they are cheap. Even though, according to George, anyone who

was raised on Gozo knows that only fresh wool and cotton are good for you.

The lack of demand for local products has made him the first man in his family

lineage not to be subsisting on the land. His farm no longer sustains itself through the

production of cheeses and wools, but is not supporting his family through allowing tourists to

spend the day at the farm. He opened a secondary farmhouse, which serves as a rental for

tourists, and this is how he makes his living. On an interesting note, while his family house

has exclusively locally made sheets and blankets, his farmhouse rental uses synthetic sheets

and blankets. It is crucial to him that his family stays healthy, and this is only accomplished

through maintaining certain traditional aspects of life.

Whereas the Bocce men did not answer direct questions about health, they confirmed

the rejection of outside forces and chemicals. The diseases that are becoming problematic on

the island are the result of the changes on the island. The fact that people are not walking as

Consiglio 39

their form of transportation has negative consequences. Rather than living off the land,

people are consuming chemicals. These negative adjustments were not something that the

elderly had to deal with thirty years ago, and so they are healthy because they avoided them.

There is an important distinction that needs to be made. The men who play Bocce do not

discuss a sedentary lifestyle or a healthy diet, they discuss the Gozitan way and how it is

now. The current and future generations will suffer from illness and disease because they are

not living the Gozitan way.

THE MEDICAL DOCTOR

The traditional healer invited me to the opening of an art gallery that featured Gozitan

artists and craftsmen in the village of Gharb. This particular village is a small, affluent

community that features many culturally significant locations. Within the boundaries Gharb,

which is on the west side of the island are the cultural museum, the art gallery, and most

importantly the shrine to Frenc Ta L’Gharb. People from all over the island came to this

event, and it was a Gozitan event not intended or tourists. The people who attended had

predominately been invited through word of mouth. While all the items that were featured

were for sale, the sale was not openly advertised in order to preserve the integrity of the

event. It was honor to have been able to participate in this event, and to be closely affiliated

with the traditional healer who was one of the artists.

The opening of the art gallery was a high end event that featured live traditional

entertainment, and waiters in suits serving drinks and canapés. The gallery itself was divided

into two rooms. One was L-shaped with the entrance at the turning corner of the L. The walls

were painted white and the tile floor was a subtle beige color. The room was brightly lit, and

there paintings displayed on the walls across from the front of the gallery. Each painting

Consiglio 40

featured a brief note on the artist and the artwork. Throughout both the front of and the

middle of room there were pedestals that had local artist’s sculptures resting on them. The

back room was rectangular in shape and the craftsmen and their work were located in this

room. On one wall was a flat screen television that showed a documentary of the traditional

healer’s process for creating wool and wool products. She had blankets and other beautiful,

hand-woven items for sale. In the opening between the two rooms was a traditional band that

featured an accordion, a small mandolin-like guitar, drums, and a singer.

As a result of the status of this event, there were many highly educated people in

attendance. Like many other societies, including America, doctors hold high esteem within

their respective communities. At the art gallery opening, there was one particular Gozitan

doctor who was willing to talk to me for the whole evening, and offered further

communication both on Gozo and via electronic communications after I left. Having been

raised on Gozo, attended medical school on Malta, and returned directly to Gozo, he held a

unique position in the Gozitan medical field. Dr. John informed me that he was the only true

Gozitan doctor on the island. While there is only one hospital on the island, there is also a

clinic in Victoria, which staffs doctors. He further informed me that doctors have a higher

salary in other countries, so Gozo is not the most popular location for doctors to practice.

Additionally, it is small and does not have the facilities to care for a lot of emergencies.

I spoke to the doctor for a couple of hours, and I was eager to understand his

perspective on the elderly. Confirming, my observations, he informed me that the elderly,

especially elderly women, “have the right idea.” Stressing the importance of the healthy

Mediterranean diet, he argued if everyone had the practice of walking everywhere they

needed to go, people would be much healthier. This was furthered by his assertions that the

Consiglio 41

younger people that he treats are obese, drink to excess, and smoke. In his opinion, the

elderly are the “healthiest people on the island.” He even went on to say that the elderly were

healthier than he is. However, this was followed up by the fact that they grew in a different

time, a different place. Although, they lived the “right” way, Dr. John believes that this is no

longer possible.

Dr. John is also a practicing Catholic, and confirmed that the elderly view their

treatments as secondary to their prayers. The first and foremost thing to do when ill is to

pray. When asked about the traditional healer, he spoke of Alda with an almost reverence. He

recounted how she managed to prevent her double amputee father from having bedsores

through hand-woven blankets and daily care. Apparently, she has been so successful in her

cures that they wanted her to work with the doctors.

It is important to note that when discussing his work as a doctor, he used the word

“treat” in order to describe the care that he prescribed. However, when discussing Alda, he

always said, “cure” or “heal.” This distinction is important because it indicates the way that

he views both his professional interventions and the traditional healing. Heal and cure both

serve as a final act. When someone is healed or cured, their ailment is alleviated. Treatment

has a different connotation. It serves as something that needs to be done repeatedly in the

hope of making something better, but not making it go away.

THE PHARMACY

On one of my many days of going door to door around Gozo, because it was not

visiting hours at the nursing home in which I was doing my field work, I decided that I would

go from pharmacy to pharmacy and see if I could talk one of the healthcare professionals into

giving me an interview or at least allowing me to visit. Pharmacies in Europe are controlled

Consiglio 42

by the government, like hospitals and doctor’s offices. Their symbol is a green cross, and

these crosses are neon lit so that people can see them from far away, day or night. They refer

to pharmacists as “chemists,” and there are generally only one or two people who handle all

of the medication, sales, and paperwork. Pharmacies on Gozo, like much of the world, sell

over the counter medicine and basic supplies in addition to prescription drugs.

The pharmacy in which I chose to do fieldwork was one of the many located in the

capital city of Victoria. It was housed on the bottom floor of a building filled with tourist

shops, travel agencies, and a realty office. The front of the pharmacy was a large glass

window with the name printed on it in bold white lettering. Hours posted to the left of the

door indicated the store observed siesta and was open from 7:30 to 11:00, and then from

15:00 to 19:00. Various medicines and personal products like soap were visible through the

window, and contrary to the other stores in the building, there was not a window display.

Nothing was placed to show a special price nor was there a poster plastered on the front

window. The window merely allowed you to see into the store.

Inside the pharmacy, the store was rectangular, and was about 25 feet deep and 20

feet wide. The walls were painted a stark white with white shelves and a white ceiling.

Across the back of the store was a thick glass counter that divided the front of the store from

the back. Behind that counter was about four feet for the pharmacist to walk around. Lining

the wall behind her are shelves filled with filled prescriptions in alphabetically arranged

boxes. There were also boxes of allergy medicine and eye drops on the shelves behind the

counter. In the middle of the shelving was a full size door that went to the back room where

only the employees were allowed. Inside the glass counter that divides the two sections of the

store are more over the counter medicines, gauze, and bandages in neat lines.

Consiglio 43

When I entered the store the first time it was about 9:15 in the morning. The

pharmacist was standing in what is generally recognized as the customer’s side of the class

counter. Her hair was dark brown and pulled back into a loose bun at the bottom of her head

above her white pharmacist’s coat. There was neither nametag nor identification of who the

pharmacist was nor were her credentials posted anywhere in the store.

The pharmacist was standing less than a foot away from a man who was at least 75.

He had grey white hair that was combed to the side, and he was about six inches shorter than

the pharmacist who was leaning towards him. She was waving the bag of pills in her left

hand and gesturing frantically with her right hand. Switching between Maltese and English,

she admonished him for not taking his pills correctly. With a raised voice and both hands

pointing towards the old man’s face and being raised lowered with each word, the pharmacist

literally yelled, “Every day! You must take every day!”

The older gentleman took the bag from her, said, “Grazzi,” and slowly walked to the

door. He nodded to me without a smile, and left.

The pharmacist was muttering under her breath and was clearly still angered and

frustrated. She asked if there was something I needed. While purchasing cough drops, I

enquired about the previous encounter. She whirled from the cash register to face me, and

proceeded to inform me that they think “everything else makes them sick!” It is not that the

elderly do not take their medicine each day, but for a myriad of other reasons. Apparently,

one of her clients was completely convinced that the Italian woman down the street had put a

curse on her. The manner that this was expressed by the pharmacist was sarcastic and critical

without belief. Other reasons included faith based explanations of needing to go to church

more, or having travelled to a place where diseases are prevalent. The pharmacist was proud

Consiglio 44

of her education, and believed that it placed her at a higher understanding and status than the

elderly who “make up” reasons illness.

Rather than sharing these beliefs, the pharmacist clearly disagreed and looked down

upon the practices of the older gentleman. This introduced the idea that perhaps medical

professionals disagreed with the traditional beliefs of the elderly. My research at the nursing

home had introduced me to a very healthy population of aged individuals, but also their

opinions. The pharmacist’s utter opposition represents a different attitude about the health of

the elderly. not only did she feel that the elderly were unaware of proper strategies for

healthcare, she also asserted that they were not as healthy as the Nursing Home women

appeared. According to the pharmacist, the large number of prescriptions filled was contrary

to the elderly rejecting the chemicals in medicine. She opined that the elderly are not actually

that healthy, and are sick because they fail to properly take their medicines.

THE TRADITIONAL HEALER

The traditional healer who was my key informant, my guide, and my best friend on

Gozo is somewhat of a celebrity on the island. She made a documentary on the traditional

Gozitan weaving practices, and is affiliated with just about everyone on Gozo. The famous

Frenc Ta L’Gharb who was a guiding light for the people, was Alda’s godfather, which is a

sacred role in the Catholic church. The elderly women at St. Georges professed her to be the

expert on traditional healing and traditional practices. The vendors in the main plaza in

Victoria, discussed her weaving as the highest quality and being healthier even than their

products. People in Gharb knew that Frenc Ta L’Gharb’s goddaughter still lived on the

island, and continued the great work that he started. All of the advisors of the field school

had attended her classes on weaving because she is the authority on natural products and the

Consiglio 45

sustaining of traditional practices. Before I met her, I had heard so much about her from so

many different people, I was concerned she would not acknowledge me.

All of the necessary parts of the cures are found on the island of Gozo. While walking

around the island, Alda would point to certain plants growing on the side of the road and

indicate what they were used for, and the purposes that they could serve. Her knowledge of

the island and its plants and animals is phenomenal. The primary ingredients in all the

traditional remedies that Alda taught me were olive oil and fresh chamomile. Olive oil is a

product of the Mediterranean region, and stores all over the island sell Gozitan olive oil.

Also, as chamomile grows wild on the island, it is a usual behavior to go out and find the

chamomile that is used in the curing processes. Most of the natural remedies were built from

these two simple ingredients, and are accepted because of their effectiveness.

Alda instructed me on the traditional remedies that cure everyday ailments. Olive oil

on its own can be used as a conditioner to cure a scalp that itches or has dandruff as well as

moisturizing dry hair. For Gozitans, it also serves a lotion that is applied directly to the skin

as a remedy for irritated and dry skin. When fallen victim to allergies or the common cold,

olive oil applied directly to the sinuses and rubbed in a straight line downward will help clear

them. When someone has an upset stomach, a natural wool cloth warmed with olive oil

placed on the stomach will eliminate some or all of the discomfort experienced. Also, in the

case of constipation upsetting the stomach, olive and parsley mixed together and consumed

will naturally remedy that issue. There are small bugs like mosquitos all over the island, and

people are plagued by bites. Alda’s response was an cold mixture of water and olive oil

applied directly to the bite. Lastly, chamomile is used as an astringent applied with all natural

Consiglio 46

cotton, to the cut, scrape, or born. After cleaned with chamomile, olive oil is applied also

directly to the wound and expedites the healing process.

There are products out that are designed to eliminate all the discomforts, diseases, and

ailments. I asked directly why natural medicine is needed. She argued that people are not

receiving the necessary care from western medicine. Although there are a variety of

treatments, people are not cured. If people can be “cured” by placebos, how good are the

actual medicines that are being given? Treatments are administered that cause more problems

that require more treatments, and vicious cycle of healthcare is created. Traditional healing

actually allows the person to heal, and that is why it is preferential to western medicine.

First and foremost, the traditional healer asserted that people have a completely blind

trust in doctors and are afraid to question. They are prescribed medicines they neither need

nor are helped from taking. Rather than curing illness, doctors give medicines that cause

more problems. Natural medicine recognizes that every single body is a unique entity.

Women react differently depending on their hormones and the time of the month, so

consequently they will respond differently to medicine and chemicals. Alda believes that

doctors, hospitals, and big companies assume that people will all take a medicine and the

same thing will happen. That is just a not a possibility. She used the many instances of bodies

rejecting medicine and treatment as evidentiary support for the problems with medicines.

Furthermore, the body really needs to cure itself. God designed the body to take care

of itself and to maintain its status of health. It is through interfering with chemicals and

medicines that the body becomes incapable of curing itself. The body releases toxin and

things that make you sick through sweating. Sweat that gets trapped against skin and

becomes cold causes sickness. Natural materials allow for the toxins to escape and stay

Consiglio 47

outside of the body, but synthesized materials do not breathe and therefore trap the toxins. If

people were to wear exclusively naturally made materials and their skin was allowed to

breath the way it needs to, there would be fewer illnesses and fewer infections.

Finally, the most important thing that was reiterated over and over again by the

traditional healer was that doctors’ medicine does not embrace preventative care. With

natural healing, there are a myriad of preventative measures that are always employed.

Hydration and self-care are the hallmarks of traditional medicine, and that the body is cared

for first so that it might heal itself. In order to build the immune system, people should drink

chamomile tea and use olive oil for the cooking. People need to wear pure wools and cottons,

rejecting the synthetic materials that make them sick. If people use all natural materials, like

pure wool or cotton, everything from the common cold to asthma will be better.

Unlike the elderly, Alda was also willing to discuss dementia, and the fact that the

elderly on Gozo were not plagued by this incapacitating disease. She asserted that people on

Gozo had lived “right,” and this had allowed them to maintain their health in all capacities.

Rather than consuming chemicals and medicines, they used natural remedies. These

prevented dementia. While she did still provide sympathy on behalf of all people who had

dementia, it was a somewhat foreign concept to her, and she did not have suggested cures,

which was a unique circumstance.

FINAL THOUGHTS

Throughout my research period on Gozo, there were many reoccurring themes that

permeated the different subpopulations I spent time with. It is the overarching ideas that I

feel require further addressing because they provide a larger, cultural perspective. It is

equally as important to pursue the differences between the older generations that were my

Consiglio 48

primary subjects and the younger generations who I interviewed. Their experiences will

shape the Gozitan culture and it is necessary to understand that their perceptions will

eventually replace those of the elderly. Their life experiences are dramatically different, and

it is these oppositions that are so crucial to the changes on Gozo.

Not only were the changes on Gozo consistently referenced by almost all my

participants, they were discussed in an incredibly negative way. There was an overwhelming

remorse for the changes that had occurred over the previous years, and that Gozo had taken a

turn for the worse. Benefits of becoming a part of the European Union were never discussed,

and the infiltration of a global community was the predominate explanation for the changes.

While tourism has become a staple of the Gozitan economy, it came at an extremely high

price. Agrotourism replaced actual agriculture, which was the rural islands primary means of

subsistence. Bays that were used for fishing were replaced with hotels and apartment

buildings. People stopped walking to get to their destinations and started driving or taking the

busses. All of these changes occurred over the last thirty years, and most rapidly since Malta

joined the European Union in 2003. The Maltese want to build a bridge or tunnel that would

connect Gozo to Malta and make transportation much easier. People would no longer have to

take the ferry and have limited access. As the Gozitans are not happy with the changes that

have occurred, they asserted that this would be detrimental to Gozo and Gozitan culture.

Another topic that was discussed in a sentimental fashion were the Wells in Xlendi

and just outside of Victoria. Although each day people are still found using the wells for

hand laundering their clothes and linens, washing their cars, and watering crops, they are no

longer pure. The water has been treated and the wells in Xlendi were “restored” by the

European Union with plaques advertising the rebuilding. As a result, this cultural location

Consiglio 49

became tainted. People can no longer drink the well water, and there a sense that the clean

wells are missed.

From the shrine in the village of Gharb to the heartfelt stories repeatedly told, Frenc

Ta L’Gharb, is a cultural icon that is truly beloved. He lived from 1892 to 1967, and his time

on Gozo was spent acting as a healer because at the “at the age of 35, he received the healing

charisma.” As an extremely devout Catholic, he promoted faith based healing with the

Blessed Virgin interceded, healing, and curing. His faith was so strong that he was able to

simply “look at a person or touch her nails” to diagnose the nature of the illness. From their

he could cure the illnesses after boiling certain herbs, ointment with bees wax and oil, lard

with Linaspoon, oil mixed with a few drops of ammonia, and a variety of olive oil cures.

These treatments were never exclusively ointments; they were always coupled with prayers

to the Virgin Mary.

Frenc Ta L’Gharb stressed that health and well-being could only be achieved through

a strong faith and activism in the church. People went to this village leader not only for

health problems, but also for family trouble, marital issues, division of wills and estates,

spiritual difficulties, career guidance, and animal illnesses. His primary response was always

to pray: to the Blessed Virgin, rosaries, or to a particular saint. As a healer, he attended to the

wellbeing of all his patients, and is still prayed for guidance and help. The people (mostly the

elderly) on Gozo still frequently pray to Frenc Ta L’Gharb like they would to any other saint

for intercession on their behalf. There is a movement that prays and hopes for the

canonization of Frenc Ta L’Gharb as he fills the role of the patron saint of Gozo.

The difference between the generations on Gozo is absolutely paramount. The older

generation grew up in a culture that is extremely different from the younger generations.

Consiglio 50

While the elderly first pray, practice traditional remedies, and try to live healthy lives, the

young people on the island do not. The younger people on the island drink to excess, smoke,

and consume large quantities of chemicals. These differences outline the experiences and

values that are held. These differences are resulting in higher disease rates among the

younger and middle-aged people on the island, and mark the end of a particular way of life.

The last distinction that arose among my informants was healing and curing instead

of treatment. The traditional healer explained all of her processes as “I cured him” through

this course of action. When any of the populations talked about the traditional healer or Frenc

Ta L’Gharb, it was in the context of healing and curing. On the contrary, when discussing

doctors, medication, or hospitals it was always with the word treat. This was not a conscious

distinction, but ingrained in the approach to disease therapy. However, the young people on

the island did not use the words cure or heal. This was another generational separation that

arose because the young people on the island do not practice the traditional remedies.

My research on the island of Gozo is with a population that will not exist in a matter

of five to ten years. The elderly on Gozo are still extremely healthy because they lived the

“Gozitan way.” After the infiltration of the outside world over the last thirty years through

tourism and joining the European Union, the “Gozitan way” no longer exists. The life

experience of the elderly show what a healthy lifestyle can result in, and the promise that

preventative healthcare holds.

FURTHER RESEARCH

The island of Gozo is an excellent location for further research because of the ability

to examine the effects of globalization and resultant lifestyle changes. The most important

thing that would be helpful would be a longer duration of time on Gozo. I felt limited by the

Consiglio 51

amount of time that I had to do research, and I think that a much greater depth could be

achieved through a longer period of study. If there were more time, multiple nursing homes

could be studied and compared in conjunction with the elderly who either live on their own

or with their families. Health of people in different living situations could be evaluated for

effectiveness, and pursued. Also, it would be beneficial to have time with elderly men that

are not active in the Bocce culture, because they most likely have a different health status

than the men who are still actively involved in daily physical activity.

One beneficial study would be a long term comparison between the aging of the

oldest generation on the island, and the younger generations who lived in a very different

way. It would also be preferable for people to have medical personnel involved in the

research so that the actual medical status could be thoroughly documented rather than just

observations and opinions. The health could be compared between and among the

populations from an official medical perspective. The health of the elderly on Gozo has the

potential to provide insight into preventative measures for multiple chronic diseases.

Consiglio 52

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