This article expresses alot of the same things that jerrilyn , our wonderful pediatrician , found when she did clinics last week on 400 of the Mayans in our region. This was esp. true of the children and the pregnant ladies.
Malnutrition in Third World Countries
by Sally Urvina
Ms. Urvina is a homemaker and free-lance writer living in Pullman, Washington. This article appeared in the Christian Century May 23, 1984, p. 550. Copyright by the Christian Century Foundation and used by permission. Current articles and subscription information can be found at www.christiancentury.org. This material was prepared for Religion Online by Ted & Winnie Brock.
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There is enough food to feed everybody in the world now; in the year 2000 there will still be enough food for everyone. And yet 500 million people are malnourished. The realities linking these statements are a relatively inconsequential part of our lives here in the United States, but in Third World countries these realities are part of the shape of living. It is primarily in the third World that protein energy malnutrition (PEM) affects 500 million people and kills 10 million every year.
At the Sixth Assembly of the World Council of Churches in Vancouver, the problems of hunger and malnutrition that deeply divide the Third World from the First and Second Worlds were seen to extend into the body of Christ. Peoples in the Third World struggle every hour with the effects of hunger and malnutrition while the main concern of peoples of the First and Second Worlds is the possibility of nuclear war. The difference evident in these priorities is a reflection of a difference in attitudes, which is, in turn, a reflection of differences in culture and experience.
Another gap is that, though churches and church-affiliated groups in the US. are the largest private givers of overseas food aid, the problem is not a world shortage of food. Thus, what we hope to accomplish with our aid -- to keep people from starving -- is not being achieved. The problem of malnutrition in the Third World is a complex one that most Americans have no experience with and thus do not understand well. But only through better understanding lies any hope for a solution and for more effective use of the money and energy devoted to overseas food aid.
Last fall Michael Latham, director of the Program in International Nutrition at Cornell University, delivered a series of lectures at Washington State University in Pullman. Washington. The material in this article is based on those lectures and on a subsequent interview.
Born and raised in Tanzania, Dr. Latham attended an English boarding school in South Africa and went on to university and medical school studies in Dublin. Then he returned to serve in the town where he had been born. Over the years most of his work has been in the Third World.
Early in his career, Dr. Latham dealt with the case of a child suffering from kwashiorkhor, a form of malnutrition caused by a lack of both protein and energy-giving food in the diet. The child’s parents insisted that he was getting enough food, largely consisting of cassava. a root vegetable high in bulk but low in protein. The swelling of the body due to edema from the kwashiorkhor hid his malnourishment and it was difficult for the parents to understand that his diet was inadequate. When the condition did not improve, the family brought the child to the clinic again. The third time that Dr. Latham saw him he was better, probably because, being older, he was more aggressive at the table.
Many incidents similar to this underscored for Dr. Latham the value of the preventive, public-health approach to medical problems, rather than the traditional curative approach. Several years after this incident, the importance and influence of nutrition in preventing disease became clear.
Today, as Dr. Latham points out, death and disease in developing countries are often primarily a result of malnutrition. The so-called “big four” are: protein-energy malnutrition (PEM), with 500 million people affected and 10 million dying every year; vitamin A deficiency, causing xerophthalmia and blindness, which affect 6 million people a year and kill 750,000; endemic goiter, caused by iodine deficiency and affecting 150 million people a year; and nutritional anemia, affecting 350 million people a year.
One of the most important adverse effects of malnutrition is that the body becomes unable to defend itself. People with kwashiorkhor are unable to produce antibodies after being given various vaccines, including typhoid and diphtheria. The formation of the white blood cells, essential in fighting infection, is reduced in severe PEM, and the ability of white blood cells to engulf and consume bacteria is decreased.
Infectious organisms are also more likely to enter the body. Inadequate amounts of vitamin C cause small vessels in the body which bring nutrients to the skin to become fragile; the skin then breaks down more easily, facilitating the entry of infectious organisms. A deficiency of niacin, or vitamin 83, causes pellagra, with its associated skin breakdown.
Kwashiorkhor leads to fatty changes in the liver and swelling of the body due to excess fluid in the tissues. There is also a decrease in intellectual development.
For people in developing countries, the effects of malnutrition are drastically compounded by infection and by the decline of breast feeding. Dr. Latham’s lectures focused on both of these factors.
The adverse effects of malnutrition increase the body’s exposure to infection while at the same time decreasing its ability to fight the infection. When infection is present, loss of appetite occurs. The resulting decrease in food intake is compounded by traditional methods of treatment, such as “starving a fever.” The body loses increasing amounts of nitrogen into the urine, usually as a result of the breakdown of protein in muscle tissue. On recovery, more protein is needed to replace the lost amino acids.
In Third World countries, children suffer from many different infections, often having some kind of infection for 200 days of the year. With each infection, as protein is broken down and nitrogen lost, the nitrogen deficit grows, making it more and more difficult for the body to rebuild the amino acids needed for new protein formation. A slowing of the children’s growth rate and normal development is one result.
The nature of the relationship between malnutrition and infection is found in the fact that their interaction within the body is synergistic; that is, the effect of the presence of both of them at once is greater than the sum of the effects of malnutrition plus the effects of infection. Dr. Latham used the examples of diarrhea, measles and parasitic infestations to outline this synergistic relationship.
The most common cause of death in young children in developing countries is diarrhea (also a major fatal disease in New York at the turn of the century). In Indonesia it kills one out of ten children per year. The infections start after the time of weaning, from eating contaminated foods and from lack of hygiene. The cause of death is not the infection itself, but dehydration from the resultant water loss.
Some parasitic infestations are a direct cause of nutritional deficiencies. One-quarter of the world’s people are infested with roundworms. Hookworms, also prevalent in Third World countries, suck blood from the lining of the gut, thereby causing iron deficiency anemia. Another worm, the fish tapeworm, causes a vitamin B12 deficiency. It is common to have multiple infestations as well. In some parts of Kenya, 90 per cent of the children have hookworm, so it is not surprising that, in some of the country’s primary schools, 50 percent of the pupils were found to be anemic.
Measles, now considered a mild childhood infection in this country, has a death rate in Mexico 180 times higher than in the United States. In some African countries the death rate from measles is 400 times that of the U.S. In England, one person in 10,000 dies from measles; in West Africa, the figure is one in 20. The differences in these rates are attributable to the nutritional states of the people who contract measles. The disease severely affects those whose immune systems have already been eroded by malnutrition. Complicating the problem is the poorer response to vaccination in malnourished children.
Dr. Latham also reported on some solutions that have been found in dealing with these three infections. For diarrhea, oral rehydration has replaced the use of intravenous fluids. In what an English medical journal, the Lancet, has called one of the most important scientific findings in the past 20 to 30 years, the addition of glucose to the standard oral rehydration fluid of salt and water greatly increases the body’s ability to absorb needed water. Mothers can be taught to make oral rehydration fluids and to make sure that the child eats regularly during the illness. Further, within the next ten to 20 years. a vaccine against rotaviruses that cause diarrhea is expected to be developed.
Because some parasitic infestations are so common, Dr. Latham suggests regular, routine deworming projects until a community’s sanitation is improved sufficiently to eliminate the worm. With measles, studies have shown that the use of dietary supplements decreases both the death rate and the severity of infection.
Dr. Latham concludes that a community’s nutrition problems must be dealt with in conjunction with health care, sanitation and immunizations. Such a holistic approach has been shown to be the most effective. Just as the problems are synergistic, so are the solutions.
If a poor mother in a developing country chooses to bottle feed rather than to breast feed her infant, she thereby chooses greater chances of sickness and death for the baby. Four different influences can turn bottle feeding into a tragedy: economic, hygienic, nutritive and immunologic. The effects of these influences are threefold. First, the infants literally starve. Second, they are more exposed to infection. Third, they do not have the immunological protection that comes in breast milk. What follows is based on Dr. Latham’s analysis.
Formula is relatively expensive: for a three-month-old child, it can cost 50 to 60 per cent of the minimum wage in some developing countries, plus the price of the equipment. Because of the high cost there is a tendency to stretch the formula by overdiluting it. This practice leads to nutritional marasmus, a condition resulting from severe protein and calorie deprivation.
Breast feeding is cheaper and always nutritious; the only added cost is for the mother’s extra nutritive needs. Although the components of breast milk will vary depending on the woman’s health, even an undernourished mother is a remarkably efficient producer of nutritious human milk.
Contamination of the formula, the bottle or other equipment leads to infectious diarrhea. Breast milk comes sterile from the breast. And anti-infective properties cannot be put into formula, nor is there any indication that such a process will be possible in the near future. Conversely, at least a dozen anti-infective factors are found in breast milk, including antibodies, lysozyme, lactoferrin and interferon. Among the functions performed by antibodies are preventing bacterial invasion of the intestines, neutralizing toxins and killing viruses. Splitting the cell walls of certain bacteria is one function of lysozyme; this enzyme also aids the effectiveness of one of the antibodies. Lactoferrin binds iron that is essential for bacterial growth, and interferon provides early help in the body’s defense against viruses.
Another contribution of breast feeding is the decrease in fertility of a nursing mother, often adding nine to 12 months to the spacing between births. In India, breast feeding is more effective for birth control than contraception.
In light of the clear superiority of human milk for babies, it is very disturbing to note the decline of breast feeding in Third World countries. In Chile in 1960, 90 per cent of women were breast feeding their children after the first year: by 1968, that figure had dropped to less than 10 per cent. In the 20 years between 1950 and 1970, the percentages of Singapore women who breast fed beyond the first year dropped from 80 to eight or ten.
Dr. Latham attributes this decline largely to a desire to be chic or modern. Reversing the trend involves the difficult task of changing attitudes. A place to start this task is in the medical community. Instruction and texts in medical schools have emphasized formula feeding and de-emphasized breast feeding. Physicians in the Third World, often trained in Western schools. convey this emphasis in their patient care, and breast feeding appears to be second-best. Medical students need to learn more about nutrition, and in particular the role of breast feeding in infant nutrition.
Another approach to the problem lies in changing trade policies. Third World countries could import less formula, and advertising practices could be more closely regulated.
The root cause of malnutrition is inadequate distribution of the available food, for the world produced enough grain last year to provide 3,000 calories per person per day. However, we are not able to get the food to the people who need it most. This statement refers not to food handouts but to policies that influence purchasing power, food prices and distribution practices.
Economic gains measured by gross national product or industrial output are not reflected in improvements in the lives of the majority of people; their purchasing power does not increase. The peasant farmer in Kenya, Tanzania or any of the developing countries is having to work harder in 1984 than in 1954 or ‘64 to earn enough money to buy a hoe or a gallon of kerosene. And the people are inadequately paid for their agricultural products and minerals. Compare these prices in upstate New York: imported bananas cost 35 cents per pound, while a pound of locally grown apples costs 48 cents.
The inequity in such a system is reflected in the occurrence of malnutrition. Protein-energy malnutrition, anemia and blindness from vitamin A deficiency are very closely associated with poverty, only rarely occurring in the affluent population -- even in developing countries.
Food distribution -- the use of the food produced -- is linked to national policies. The United States raises 2,000 pounds of cereal grain per person per year; of that total, 150 pounds is used for human consumption, while 1,850 pounds is fed to animals to produce meat, eggs and dairy products. The U.S.S.R. imports grain to use as animal feed. In contrast, China produces 450 pounds of cereal grain per person per year; 350 pounds goes for human consumption and 100 pounds to feed animals. The Philippines exports calories in the form of sugar and coconut oil every day, while half of the country’s children are malnourished. India is self-sufficient in food production.
Dr. Latham concludes that the lack of food and micronutrients is due not to acts of nature but to acts of people. What is needed is change to improve the quality of life, not change to get people to be more like ourselves. If this change is to happen, better understanding between people and revolutionary shifts in attitudes and policies must prevail.
There is an urgent and immediate need for several improvements: more voice for the people in the national policies which directly affect them: withdrawal of U.S. support for undemocratic governments; and more adequate pay for people who live in developing countries.
A huge impact could be made right now on the death and disease attributable to the synergism between infection and malnutrition -- but not with fancy hospitals, such as those found in capital cities in many developing countries, or with elaborate manufactured foods or expensive infant formulas or over-trained doctors or advanced food technologies. Rather, the means could be relatively simple if the affluent nations resolved that the reduction of deprivation is an important goal, and if the governments of developing nations made it an important priority.
Dr. Latham’s sensitivity to the poor pervades all his comments. When asked how he had developed this sensitivity, he said that he had been shown a tremendous amount of loving-kindness and generosity by poor people. One particular incident that stands out in his memory occurred when the Rufiji River in southeastern Tanzania had flooded. Dr. Latham was flown in to give care to victims stranded by the floodwaters. During the following 36 hours, people approached him continuously to offer him whatever bits and scraps of food they had, even though their own need was much greater than his.
The loving-kindness shown in such giving reminds us that “Blessed are the merciful, for they shall receive mercy,” And their merciful acts are only dim images of God’s kindness and compassion. As the Holy Spirit leads us to consider the devastating, complex problem of malnutrition, let us do it prayerfully, asking that our hearts be prepared to bring forth the fruits of the Spirit: love and kindness.
