Anaemia in Women
Vitamin A Dispenser
Vitamin A, Zinc and Stomach Cancer
Doubly Fortified Salt Marketed for the First Time
XV IVACG Meeting
Controlling Vitamin A Deficiency - Policy Implications of Mortality Impact
Update on the UNICEF/WHO Baby-Friendly Hospital Initiative
Breastfeeding Trends in Cuba
Statement by the World Food Programme on Implementing the International Conference on Nutrition Plan of Action
Australia's Food and Nutrition Policy: Progress Report
Growth Patterns in Breastfed and Formula Fed Babies
Breastfeeding Protects Against Diarrhoea's Effect on Growth
New Bill Restricts Marketing of Infant Foods in India
Urinary Tract Infection and Breastfeeding - Evidence of Link
Global Eradication of Polio by the Year 2000 - an Achievable Goal?
Substance Abuse Amongst Street Children
Mortality Assessment in Somalia
Is Lead Damage Reversible?
Tropical Diseases - New WHO Research Targets
Dr Fernando Antezana Appointed Assistant Director-General of World Health Organization
Many Neighbours, One Earth - New Campaign to Transform US Foreign Aid
Co-financing Opportunities with the Asian Development Bank
WHO Division of Food and Nutrition
20 Years of Tanzania Food and Nutrition Centre 1973-1993
World Breastfeeding Week 1993 - Mother Friendly Workplace Initiative
Studies in Nutrition at the University of Queensland
Master of Community Nutrition (MCN)
Research training (MMedSc and PhD)
Dr J E Dutra de Oliveira Selected Fellow of the Third World Academy of Sciences
World Conference on Natural Disaster Reduction
Oxfam Launches New Campaign for Africa
Second Asian Conference on Food Safety
ECSA Micronutrient Symposium
Training Materials in Basic and Applied Nutrition
IUNS Awards - Correction
First Report of WHO'S Micronutrient Deficiency Information System (MDIS) - Goitre Rate Now Assessed at 655 Million Worldwide
WHO began to compile information on micronutrient deficiencies and on control programmes in 1991, in collaboration with the Community Systems Foundation in the USA. The System is also supported by UNICEF and ICCIDD. Now the first report, on iodine deficiency disorders (IDDs) has been issued. Further reports on vitamin A deficiency and iron are expected in due course, and in particular the tracking of control programmes worldwide will be an important feature of the system.
This first report starts with a major revision in the worldwide estimates of goitre - now given as 655 million people affected, based on a careful assessment country by country. This assessment triples the earlier estimates of WHO, which gave values of 211 million people with goitre1.
1. WHO (1990). Infant and Young Child Nutrition, Progress and Evaluation Report. 43rd World Health Assembly document A43/4, agenda item 17, 1 March 1990, page 14.The associated prevalence is now estimated as 12% worldwide, the highest being nearly 23% in the Eastern Mediterranean. The map shows WHO'S estimate of the distribution of goitre worldwide. The figures given earlier p. 11, table 1, already need revision.
At the same time, the estimated number of people at risk has also risen sharply, in this case in part due to a change in the threshold goitre rate used to define at risk populations - now set at 5% rather than the 10% used in the past. The total number of people worldwide considered to be at risk exceeds 1570 million people, 29% of the world's population.
As pointed out in the Executive Summary by Dr G Clugston, Chief of WHO'S Nutrition Unit, “In absolute terms, Southeast Asia (which includes India, Bangladesh and Indonesia) and the Western Pacific (which includes China) together account for more than 50% of the world's total population at risk of IDD. Moreover, there is still a non-negligible IDD problem in most countries in Europe (even Western Europe, including 10 million people at-risk in Germany), necessitating continuing control measures and vigilance... There are some increases in the numbers of persons at-risk and those affected by goitre in each of the WHO regions when compared with data presented to the World Health Assembly in 1992. The largest increases in populations-at-risk are in the American, Eastern Mediterranean, European and Southeast Asian Regions. The number of subjects affected by goitre is now estimated to be 655 million, and at least 110 countries are known to have an IDD problem.
Prevalence of Iodine Deficiency Disorders - Global Distribution
(Source: WHO (1993) Global Prevalence of Iodine Deficiency Disorders, MDIS Working Paper #1, WHO, Geneva.)The Micronutrient Deficiency Information System (MDIS) was established two years ago by the Nutrition Unit of the World Health Organization with one major goal being to provide updated estimates on the magnitude and distribution of micronutrient malnutrition, and the state and progress in development of national micronutrient control programmes. In addition, the MDIS aims to assist in the standardization of methodologies employed in the assessment of micronutrient deficiencies, as well as to provide direct support to countries in the implementation and monitoring of micronutrient deficiency control programme activities. This document represents the first publication of the MDIS, and will be followed by updates on the global distribution of Vitamin A Deficiency and Iron Deficiency Anaemia.”
A flyer giving some details of the report is included with this issue of SCN News. The report can be ordered from the WHO Nutrition Unit, World Health Organization, 20, Avenue Appia, CH-1211, Geneva 27, Switzerland.
(Source: WHO (1993). Global Prevalence of Iodine Deficiency Disorders. MDIS Working Paper No.1, WHO, Geneva.
According to a World Health Organisation report “The Prevalence of Anaemia in Women”, which draws on evidence from more than 500 studies worldwide, over half of all pregnant women, and a third of all non-pregnant women of reproductive age suffer from anaemia.
Parts of the developing world, such as Southern Asia, have levels of anaemia in pregnant women as high as 75%, whilst levels in North America and Europe are around 17%. And in the worst affected parts of the world, 5% of women suffer from severe anaemia.
Most anaemia results from a lack in the body of one or more essential nutrients; iron, folic acid, vitamins, trace elements and protein. This can arise from low intake, poor absorption or chronic blood loss, and leads to lowered levels of haemoglobin, a component of blood which serves the vital function of transporting oxygen to body cells. Anaemia is diagnosed when the concentration of blood haemoglobin is less than 11g/dl. Anaemia is severe when the concentration is less than 7g/dl.
In the early stages of anaemia, there may be no symptoms, but as oxygen supply to vital organs declines, weakness, tiredness, dizziness and headaches occur. Many of those women who are severely anaemic die of heart failure.
Women, in particular, are vulnerable to anaemia because their needs for nutrients are greater. During reproductive years women require twice as much iron as men, even when they are not pregnant. When pregnant, the growth of the fetus and placenta, and the larger amount of circulating blood, means that there is an increased need for nutrients, especially iron and folic acid.
According to WHO “Anaemia is a contributory factor in many of the 500,000 deaths which occur each year due to complications of pregnancy and childbirth.” A normal healthy woman can survive a blood loss of over a litre during childbirth, but for anaemic women, even the normal blood loss of 250cc can be fatal. Women who have many closely spaced pregnancies have little time to build up haemoglobin levels and are at particular risk.
The most immediate and cost-effective solution is to give all pregnant and lactating women oral iron supplements. The long-term solution, however, is to ensure that girls and young women have an adequate diet before becoming pregnant. Red meat or dark green leafy vegetables should be eaten regularly, or dried beans together with tubers or fresh fruits. Women should avoid drinking tea and coffee with a meal, which can hinder iron absorption. Fortification of foods is an alternative approach, and providing access to family planning methods can help avoid closely spaced pregnancies.
(Source: WHO Press Release, 5 March 1993)
Vitamin A used in oral, periodic dosing programmes is usually given in the form of gelatine coated capsules containing 100,000 IU or 200,000 IU vitamin A (retinyl palmitate or acetate) and vitamin E (d-1 alpha tocopherol) in purified peanut oil. India is the only country where vitamin A solution (100,000 IU per ml) is used, administered with a shared measuring spoon.
There is a potential need to provide an increased number of 100,000 IU doses, or even 25,000 IU doses, to infants. But in practice it is often impossible to accurately dose children with 100,000 IU vitamin A or less using the existing strength capsules available for country programmes. The main reason is wastage of vitamin A during the process of opening and delivery, especially at high ambient temperatures. One possible solution would be to manufacture vitamin A capsules of different strengths, colour coded for identification. However, it is widely agreed that, while technically feasible, it is undesirable to have several strengths of vitamin A capsules provided to health centres at the same time.
A pump dispenser for vitamin A solution has been developed delivering 0.5ml of solution via a trigger operated mechanism. The pump mechanism operates in a horizontal axe improving accuracy of delivery into the mouth of the infant, and is designed to fit comfortably into the palm of the hand. A nozzle closure device is attached incorporating a trigger closure guard for use during transport. The dispenser is used in the inverted position (see illustration) to reduce wastage. The vitamin A solution is in a 60 ml glass bottle and can be supplied at different concentrations, for example, 200,000 IU per ml (dose delivered with each push of the pump 100,000 IU) or 50,000 IU per ml (dose delivered 25,000 IU). The pump has been laboratory tested by the Consumer Research Laboratory (UK) and stroke volume is accurate within the range 0.43-0.53 ml over a wide range of temperatures. The pump can be reused with up to 5000 cycles in test situations and can be boiled at temperatures up to 121°C.
The vitamin a dispenser has been field tested in Bangladesh. Guatemala, India and Malawi. Reports emphasise acceptability for both mothers and health workers, as well as easier dosing of infants as compared with capsules. Leakage of the oily solution at high temperatures, and during transport, appears to be the main problem. Cost of the pump units is around $2, depending on the size of the order. For first orders, one pump is being supplied per four bottles of vitamin A solution. On this basis, the cost per dose delivered with the dispenser should work out slightly less than with the capsules, currently around US cents 1.6. If the pumps are reused many times, the cost per dose will obviously fall correspondingly. Orders should be placed through UNICEF country offices or through UNIPAK, Copenhagen.
(Source: Nicholas Cohen, Expanded Programme on Immunisation (EPI), WHO, Geneva)
In the rural Linxian province of China the incidence of cancer of the upper stomach and oesophagus is one of the highest in the world. 760 of every 100,000 people in Linxian die from oesophageal cancer, a rate more than 150 times higher that that in white Americans.
Among the factors suspected of contributing to Linxian's high cancer rate is a chronic lack of several important nutrients, and a team of Chinese and American researchers has conducted a trial to find out the effects of supplements of different combinations of vitamins & minerals on incidence of these types of cancer.
Almost 30,000 people took part in the trial. Healthy adults aged between 40 and 69 took a daily dose of one of four combinations of vitamins and minerals, or a placebo. The four combinations were: vitamin A and zinc; the B vitamins riboflavin and niacin; vitamin C and molybdenum; and an “antioxidant” cocktail of beta-carotene, vitamin E and selenium.
450 of the people from the trial as a whole, selected at random, were examined, and it was found that in those who had taken the vitamin A and zinc supplement, the expected number of cancers of the upper stomach was reduced by two-thirds. The other three nutrient combinations had no significant effect.
It is thought that vitamin A may prevent the cancers because it encourages cell differentiation, which may help curb the wild, undifferentiated growth seen in tumour cells. Zinc enhances the transport of vitamin A in and out of cells.
Presenting the team's results at the Fourth International Conference of Anticarcinogenesis and Radiation Protection in Baltimore in April 1993, Philip Taylor, Chief of Cancer Prevention Studies at the US National Cancer Institute emphasised that “the results do not mean people should rush out and start taking handfuls of vitamin A and zinc supplements. First, the stomach cancer seen in Linxian is a different type from that which usually strikes Westerners, affecting the upper part rather than the body of the stomach. Secondly, dietary supplements may work better in the undernourished Chinese population than in generally well-nourished Westerners.”
However, despite urging caution, he believes that the findings of this trial “confirm the broad hypothesis that diet really does have a legitimate relationship to cancer.”
(Source: New Scientist, 22 May 1993)
Food Fortification Consultant, Venkatesh Mannar, has reported that salt fortified with iron and iodine is now being sold in Tamil Nadu along with iron-alone fortified salt - which is now being used in a large “Mid-Day Meals” programme in the State. A recent study in Tamil Nadu has revealed that intake of iron-fortified salt resulted in similar improvements in nutritional status as iron-tablets over a 100-day period.
(Source: World Bank Office Memorandum, April 26, 1993)
The XV IVACG meeting was held in Arusha, Tanzania, in March of this year. The theme was “Toward Comprehensive Programmes in Reducing Vitamin A Deficiency.” The following is extracted from an IVACG Press Release issued after the meeting.
“Representatives from 51 countries were among the 294 policy makers, implementors, and scientists in health, nutrition, agriculture and development participating in the meeting. Throughout the five-day programme, numerous speakers presented research concerning progress in changing dietary behaviours related to vitamin A, newer methodologies for assessing subclinical vitamin A deficiency, consequences for human health and disease, and physiological functions of vitamin A.
“Several speakers presented evidence of substantial gains in meeting the goal of virtual eradication of vitamin A deficiency. A significant outcome is the reduction in childhood mortality from infections. The impact of vitamin A supplementation on mortality appears to be due to a reduction in the severity of infection rather than in the incidence of infection.
“Others referred to 'missed opportunities' in linking vitamin A with health care delivery systems such as immunization services and growth-monitoring programs. These are the 'windows of opportunity' for the future.
“A comprehensive approach to preventing vitamin A deficiency combines short-term strategies such as vitamin A capsule distribution with dietary diversification, a long-term strategy. Factors identified as essential for a successful vitamin a program include adequate political will; effective surveillance to guide policy formulation, program design, and implementation; and flexible training, supervision, and management systems.
“In closing the meeting, Dr Abraham Horwitz, Chairman of IVACG stated, 'The reduction of poverty, although essential, is not a prerequisite for the elimination of vitamin A deficiency. The process to reach this goal should start or be strengthened, and the sooner the better. The persistence of vitamin A deficiency anywhere in the world is cruel, because it exposes mothers and children to great risks. It is immoral, because it ignores basic human values. It is unacceptable, because it can be prevented.'”
For further information please contact: Laurie Lindsay Aomari, IVACG Secretariat, The Nutrition Foundation, Inc., 1126 16th Street, N.W., Washington, D.C. 20036, USA. Tel: (202) 659 9024 Fax: (202) 659 3617.
(Source: As quoted above)
In 1986, the Advisory Group on Nutrition (AGN) of the ACC/SCN reviewed the study from Aceh, Indonesia (subsequently published as Sommer et al. 1986) in the impact of vitamin A supplementation on childhood mortality, and concluded “that a reduction of childhood mortality may reasonably be expected from high dose vitamin A programmes”. This was one of the earlier public statements on the major effect of vitamin A on mortality. It continued “...confirmatory trials are in process, the results of which should be closely monitored to find out whether significant effects of vitamin A are to be found in populations of different patterns of morbidity and other conditioning factors, and where less severe deficiency of vitamin A exists”.
By 1991, around ten such studies were nearing completion. The AGN in 1990 developed a proposal, approved by the SCN in 1991, for “Assessment of the Research and Policy Implications of Recent Studies of Vitamin A and Morbidity and Mortality”. This was done in two separate phases. In the first, a meta-analysis was done of the results of eight trials of effects of vitamin A supplementation on mortality, and 20 on morbidity; the best-known results are those on mortality, which are also the most conclusive, indicating a 23% reduction under the circumstances studied. These are described in the article on page 17.
The second phase included establishing criteria to be applied in deciding whether a vitamin A intervention is warranted as a means to reduce mortality; providing age-specific estimates of the magnitude of benefits expected when vitamin A status is improved; identifying and critiquing alternative strategies for improving vitamin A status, including considerations of their relative cost-effectiveness, acceptability, sustainability, and complementarities with other strategies; recommending which approaches may be favoured, under given circumstances, over other competing alternatives, and the means of sequencing and phasing appropriate strategies over time. An overview based on the findings of some 46 evaluations was put together of “what has worked, where?”, based on the lessons of past experience.
The mortality outcome itself was no longer the issue as the link between vitamin A status improvement among 6-59 month children and mortality reduction was already demonstrated in the first phase (although there is no conclusive evidence yet regarding the under six month age group, or with populations with sub-clinical deficiency but no clinical signs). The outcome of concern for the comparative evaluation is thus vitamin A status. Another major conclusion of the first phase was that the mortality-reducing effect of vitamin A is biological and not pharmacological - that is, it is a function of vitamin A status itself. It does not depend on the mode of administration of vitamin A. Low dose, frequent administration of vitamin A by capsule or via fortified foodstuffs was shown to be associated with mortality reduction among xerophthalmic child populations in the mortality trials.
Based on the review, the interventions most often likely to be effective, under suitable conditions, seemed to be:
- targeted capsule distribution, and their medical use, as a quick-acting intervention;A consultation group meeting was organized by the ACC/SCN, hosted by the Micronutrients Initiative in Ottawa, Canada on 28-30 July. The preparation and meeting were supported by CIDA (Canada) and the Micronutrients Initiative. The background review provided one basis for the discussion, among some 46 participants, with focus on the experience of 10 countries. The meeting agreed a statement on “Control of Vitamin A Deficiency”, given in full in the box (p48-49). The meeting conclusions in detail and background material are to be published later this year.- promotion of breastfeeding if this is low or declining;
- fortification when feasible would be of high priority, however this as yet appears to apply primarily to middle-income countries with processed foods widely distributed;
- dietary modification would usually be a major long-run approach depending on factors such as availability of vitamin A in the food supply, literacy, access to mass media, etc. - approaches include behavioural change, horticulture, economic/food policies, technical interventions including food preservation, plant breeding, etc.
Reference: Sommer, A. et al. (1986). Impact of Vitamin A Supplementation on Childhood Mortality: A Randomized Controlled Community Trial. The Lancet, May 24, 1169-1173.(Source: ACC/SCN, September 1993)
Contributed by the Nutrition Cluster, Programme Division, UNICEF, New York
The UNICEF Executive Board adopted a resolution at its May 1993 meeting that strengthens and updates its 1991 resolution to support and promote breastfeeding through the Baby-Friendly Hospital Initiative (BFHI).
The new resolution acknowledged the progress of BFHI over the past two years towards the achievement of the targets of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. It expressed appreciation for action taken by governments of developing countries to end the distribution of free and low-cost supplies of breastmilk substitutes. It called upon manufacturers and distributors to comply fully in countries that have acted to prohibit the distribution of free and low-cost supplies, setting a deadline of 1994 for industrialized countries to take such action.
BFHI, a joint WHO and UNICEF undertaking, began in 1991 with 12 “starter” countries, and was launched worldwide in 1992 to foster national action to meet the goals of the Innocenti Declaration by empowering women to breastfeed and by ending the supply of free and low-cost infant formula.
The basis of BFHI is the “Ten Steps to Successful Breastfeeding”, a set of guidelines for hospitals that, when followed, ensure that all mothers have accurate information about the benefits and techniques of breastfeeding, and are given the guidance and encouragement they need to breastfeed exclusively from the baby's birth.
At the end of 1992, its first full year, BFHI achieved many gains:
· Seventy developing countries took action to eliminate free and low-cost supplies of breastmilk substitutes.As a result of BFHI, countries around the world transformed hospitals by convincing them to practise the “Ten Steps”, took action to control the free distribution of infant formula and promoted breastfeeding in homes, workplaces and the community.· More than 700 hospitals around the world were close to or had been designated “Baby-Friendly” on the basis of their practice of the “Ten Steps to Successful Breastfeeding.”
· BFHI was the theme of the first ever “World Breastfeeding Week”, 1-7 August 1992, a week of activities, programmes and celebrations to promote breastfeeding, sponsored by the World Alliance of Breastfeeding Action.
Highlights include:
· In India, where more than 25 million babies are born every year. Parliament passed the Infant Milk Foods, Feeding Bottles and Infant Food Bill, in the works for more than 10 years. The law regulates the promotion and distribution practices of the country's $280 billion baby-food industry (see also “New Bill Restricts Marketing of Infant Foods in India, p.??).(Source: UNICEF, June 1993)· Asian countries have led the world in transforming hospitals to baby-friendliness, with recent counts including the Philippines at 102, Indonesia 97, Thailand 45 and China 21.
· Kenya, Cote D'Ivoire and Gabon, three of the “starter” countries, have taken strong action to eliminate free supplies of breastmilk substitutes; Kenya, has adopted a model law to protect breastfeeding and to control marketing practices.
· As a result of enacting decrees to end free supplies by Ministers of Health in Latin America, countries including the Dominican Republic, El Salvador, Ecuador and Panama are working on legislation that encompasses the entire International Code of Marketing of Breastmilk Substitutes; Brazil adopted such a law in 1992.
· Many industrialized countries are actively engaged in BFHI, and in partnership with non-governmental organizations, are working to realize the 1994 goal of ending free and low-cost distribution of infant formula.
|
THE CONTROL OF VITAMIN A DEFICIENCY The following statement has been agreed upon by participants of the ACC/SCN Consultative Group Meeting on Strategies for the Control of Vitamin A Deficiency, supported by CIDA and the Micronutrient Initiative and held at the Micronutrient Initiative, Ottawa, 28-30 July 1993. The elimination of vitamin A deficiency as a public health problem has been identified as a high priority in international nutrition and health by the International Conference on Nutrition, the World Summit for Children and the World Health Assembly. Control of vitamin A deficiency in many areas of the world will lead to substantial and lasting improvement in childhood survival as well as preventing the scandal of irreversible blindness due to malnutrition. The cause of vitamin A deficiency is a lack of pre-formed vitamin A, carotene and sometimes fat and oil in the diet. The year-round availability and adequate consumption of vitamin A/carotene-rich foods and dietary fat will be required to eradicate the deficiency. Because prevention of vitamin A deficiency is an integral part of the overall strategy to improve nutritional well-being and child health, and to conserve limited resources, vitamin A programmes should be integrated with other programmes concerned with health and development. Efforts to identify, advocate, plan, implement, evaluate, and monitor the control of vitamin A deficiency should as far as possible be combined with the control of other co-existing nutritional deficiencies. The following specific points concerning vitamin A deficiency control were agreed: 1. A combination of interventions is usually needed to prevent vitamin A deficiency; these include dietary modification (including the production, processing, marketing and consumption of vitamin A/carotene-rich foods), breastfeeding promotion, food fortification, and supplementation. The appropriate combination of interventions may change over time, depending on trends in the level of deficiency, programme outreach to vulnerable population groups, availability of technical inputs, and administrative and political priorities. 14 September 1993 |
Contributed by Professor Manuel Amador, Deputy Director, Institute of Nutrition and Food Hygiene, La Habana, Cuba.
In 1990, a National Survey on breastfeeding practices was carried out in Cuba by the Institute of Nutrition and Food Hygiene, the Mother and Child Department of the Ministry of Public Health, and the Higher Institute of Medical Sciences of Havana.
6688 mothers (4887 from urban areas and 1801 from rural areas) of infants (0 to 354 days of age) took part in the survey. The results showed that intital overall breastfeeding (OBF) prevalence (which comprises exclusive and mixed breastfeeding), was 84.2%, but that of exclusive breastfeeding (EBF) was only 62.7%. These show little differences with a nationwide cohort study of 4228 infants carried out in 1973, in which initial OBF prevalence (at 7 days) was 89.8%.
Prevalence of OBF remained high until 1 month of age, and then began a progressive decrease. Comparisons with 1973 can be made only for OBF, and they show higher prevalences in 1990 at all ages, except at six months (180 days).
For EBF, a rapid drop in prevalence started at 15 days of age and was especially pronounced after two months.
The data are summarized in table 1.
Differences among the provinces were found: prevalence and duration of EBF decreased from East to West. Eastern provinces, which are also the less developed and with a greater proportion of rural population, showed a pattern of high initial prevalence with a gradual descending slope and long duration: relative drops at three months exhibited a range between 43.8 and 61.2. Central provinces show a pattern of lower initial prevalence and rapid drop after three months with short duration - relative drops are similar to those of the Eastern ones. Western provinces, which include the city of Havana, showed diverse prevalences at birth, with a rapid drop at three months and short duration and great range in relative drops.
Prevalence and duration of EBF were higher in rural areas. Adolescent mothers (of less than 20 years), showed the highest initial prevalence of EBF.
No differences in prevalence and duration of EBF were found according to mother's parity.
Mothers with Elementary School level education (up to 6 years), breastfed more and for a longer time. They also showed higher initial prevalences.
Employed mothers showed slightly higher initial prevalences of EBF, but the slope immediately after discharge from Maternity Services was more pronounced: the drop after 3 months was significant, and there were no EBF infants after 240 days of age in this group. In non-employed mothers, the slope is softer and prevalence is significantly higher at three months, and there is a small number of infants who were breastfed beyond 240 days. Cumulative indices at 4 months were 31.7% for employees and 37.9% for non-employees.
Table 1. Prevalence of Overall Breastfeeding (OBF) in 1973 and 1990 and of Exclusive Breastfeeding (EBF) in 1990. Cuba.
|
Age (days)
|
Prevalence of OBF |
Prevalence of EBF |
|
|
1973 |
1990 |
1990 |
|
|
Initial |
89.8 |
84.2 |
62.7 |
|
15 |
- |
81.4 |
56.1 |
|
30 |
57.0 |
78.2 |
49.3 |
|
60 |
45.2 |
67.5 |
39.0 |
|
90 |
39.9 |
62.5 |
24.5 |
|
120 |
35.7 |
52.4 |
15.7 |
|
180 |
32.3 |
33.4 |
5.9 |
|
364 |
- |
4.2 |
0.2 |
In August 1992, a Workshop on “Baby Friendly Hospital Initiative” sponsored by UNICEF and the Ministry of Public Health, was held in Havana. The objectives of this workshop were: to analyze the WHO/UNICEF proposal of me initiative, to evaluate the possibility of establishment of the Program in Cuba, and to produce a working plan for its application. As a result of this meeting, it was decided to start a gradual incorporation of all the Maternity Services into the process of designation as a “Baby Friendly Hospital” starting in 1992 with six large hospitals from different regions, which account for 17% of all deliveries in the country. In 1993 the Program will be extended to another 10 Maternity Services. By the end of 1994, the Second National Survey on Breastfeeding will be carried out in order to make an initial evaluation of the impact of the interventions derived from the National Plan of Action.
(Source: Communication from the Institute of Nutrition and Food Hygiene, La Habana, Cuba, 1 December 1992)
Committee on Agriculture, 12th Session, 28 April 1993, Rome.
“Paragraph 19 of the World Declaration on Nutrition states:
“We pledge to make all efforts to eliminate before the end of this decade, famine and famine-related deaths”.
“Famine has been defined as “a condition of populations in which a substantial increase in deaths is associated with inadequate food consumption”. Famine does not necessarily arise solely from problems of food production. Natural disasters may act as triggers, but lack of sufficient food for consumption may be due to economic collapse and loss of purchasing power in some sections of the population.”
“This goal is clearly a priority objective for the international community. The World Food Programme is an appropriate UN Agency to be at the forefront in meeting the challenge of dealing with famine and famine-related deaths. If WFP is to make a contribution to such a goal, we need to know, first of all, is this possible? And second, what would it take?
“From our perspective, we believe that it is possible to improve the current situation. WFP is already making a considerable contribution to dealing with famine-related deaths through its numerous emergency operations and the many development projects that enable destitute people to improve their household food security. With regard to the second question, what it would take, the simple answer is that it will take a great deal of resources.
“In addition to seeking further pledges, WFP will also do better with the resources it now commands, in particular, improve its poverty targeting mechanisms to decrease the numbers of those at risk of danger of starvation. Simultaneously, WFP will also increase its capacity to react quickly to new emergency situations by ensuring that adequate stocks are continuously available to facilitate response.
“This will be done by:
· seeking ways to improve the speed with which WFP gets food to those in need;“WFP looks forward to working with others in dealing with hunger and hunger-related deaths.”· ensuring that WFP development project stocks are well supplied, especially at times of impending problems, so that borrowing can be arranged as needed; and
· being more involved in detailed risk mapping exercises that would permit both early response and advance planning of development projects in vulnerable areas for populations at risk.
(Source: WFP 1993, presented at the Sixth Annual Hunger Research Briefing and Exchange, Brown University, 14-15 April, 1993)Practical Household Food Security: An Approach from the Pacific
Contributed by Paul Sommers, previously UNICEF Project Officer responsible for the Pacific Regional Food and Nutrition Project
The once self reliant Pacific Island countries are undergoing major changes. Modernisation over the past few decades has brought about changes in where people live, how they use their land, and how they use their time. One of the most significant changes is in what Pacific islanders now eat.
Traditional food systems provided a generally abundant and varied diet of marine and land-based foods. These systems also provided food security for most households year-round. However, a dramatic transition is taking place, from a diet based on local food containing complex carbohydrates, low in fat, salt and sugar, to a diet of commercially processed, imported foods high in fat, salt, sugar, and refined carbohydrates.
This change in diet is affecting the health of both children and adults. Children in Melanesia and parts of Micronesia tend to be moderately undernourished, while adults in Polynesia, Micronesia, and the urban centres of Melanesia are increasingly overweight.
The immediate causes of underweight in children are inadequate dietary intake and infection. The main underlying causes are an unhealthy physical environment, inadequate maternal and child care and inadequate household food security.
Pacific island leaders were concerned about the erosion of their local self-sufficient food systems. They were disturbed by the economic implications of such a shift, especially in terms of food import bills and health care costs for preventable diet related illnesses. At a United Nations Pacific regional meeting in 1983, local leaders agreed to endorse a project that would promote home-based food production as a partial solution to their food security problems. The project, Family Food Production and Nutrition (FFPN), was originally financed by the Australian International Development Assistance Bureau and subcontracted by UNDP to UNICEF. The FFPN became the main activity of UNICEF's Pacific Regional Food and Nutrition Programme.
The project was designed to address household food security and nutrition by increasing food availability and improving food consumption especially amongst infants and mothers. The issue of infection was coordinated with other on-going health promotion activities in each country.
The FFPN project used a two-phased approach. The first phase entailed direct support to at-risk households. This strategy was based on the belief that household food security could be strengthened through more effective use of existing household knowledge, skills and resources.
Once an effective model was developed at community level, the second phase of the project focused on promoting institutional capacity building among field workers and policy makers at national and regional level. The strategy aimed to show what was possible and to help these key decision makers work out how best to incorporate household food security issues into their existing work programmes. Country specific strategies were developed within a broad regional framework. UNICEF provided technical and programming assistance to local project staff on a regular basis through its Regional Project Officer for Food and Nutrition. The field workers in turn implemented their own country programme work plan.
How effective was this strategy? A seven nation evaluation of the project was conducted by the New Zealand Department of Scientific and Industrial Research. The evaluation noted that the FFPN Project was effective in raising awareness of the current situation and its causes. In many cases the project also provided key assistance for increased food availability through home-based food production.
Some lessons can be drawn from the experience at both regional and national level. These lessons can be summarised as follows:
A Long Term Commitment is Required
Increasing food availability can be achieved using a combined strategy of meaningful nutrition information and increased production of home grown foods. In most cases, improvements can be realised by building on the existing knowledge, skills and resources of the household. An approach emphasising local problem assessment and analysis followed by identification of appropriate action (Triple A approach) is the most effective method for addressing household food security issues. This approach requires the commitment of all parties to ensure that the AAA cycle moves ahead toward improved assessment, analysis and more appropriate actions over time.
Do the “Do-able”
Start with those aspects of household food security that can be achieved by households themselves. Pacific households usually obtain their food in three ways: they buy it, grow it, or a combination of the two. Food exchanges do occur, but are generally in decline. The Triple A Approach will reveal opportunities to enhance food availability through improved food purchases, as well as possibilities for intensification and diversification of the household's food production. Households can identify and respond to these changes.
Start Small
The Pacific approach to household food security was designed to be implemented in two phases. The first phase was the development of a community level methodology which emphasised improved use of existing household resources. Once this methodology was worked out, a second phase of institutional capacity building was initiated. While there was demand for services both by communities and institutions, country staff resisted the temptation for rapid expansion until they were confident their methodology worked.
Women's Participation is a Key to Success
Household food security in the Pacific is mainly the responsibility of women. They are often judged by their society on their ability to provide their family with sufficient food on a regular basis. The FFPN project worked closely with women. The approach aimed to strengthen their existing food resource base by building on their skills and knowledge.
NGOs have been the Most Efficient and Effective Service Delivery Channel
Household food security involves a complex set of factors that are often specific to a particular community. NGOs are known for their involvement with community level activities. A number of Pacific governments agreed that for effective delivery of household food security services they would need to support NGOs for technical assistance. In turn, the NGOs adapted this assistance to specific community requirements.
Programming Practical Household Food Security is both an Art and a Science
A key success element of the project has been the personnel involved. Both regional and local personnel had experience in practical food production and nutrition promotion training. They also had field experience as well as the ability to adapt the household food security approach to various socio-economic, political, and climatic environments. The approach also required strong commitment to the fact that households have the ability to improve their situations through mobilisation of resources.
Household Food Security as an Entry Point
The approach used in the Pacific emphasised self-help to improve household food security. Once households could see genuine improvements stemming from their own resources, they wanted to learn more. There was great interest in what they could do to improve the survival, growth, and development of their children.
There was, for example, increased interest in child growth monitoring, and the activity took on a whole new meaning once women understood what the growth trends meant. Growth monitoring was transformed from a passive activity of recording information, the significance of which was usually not explained, to an action-oriented activity which demanded community attention. The promotion and use of immunisation, oral dehydration therapy, and clean water and sanitation, also took on a new meaning.
The World Summit for Children in September 1990 endorsed The World Declaration on the Survival, Protection, and Development of Children. A Plan of Action for the 1990s was also approved in which reducing severe and moderate malnutrition by one-half is a key goal. Achieving this goal will require addressing the underlying causes of malnutrition, one of which is inadequate household food security. The Summit Plan of Action underlines that attainment of household food security for all will require the “dissemination of knowledge and supporting services to increase food production to enhance household food security.” The people of the Pacific have already moved towards this goal. They are meeting the challenge by focusing on practical household food security activities.
(Source: UNICEF, New York, 6 February 1992.)
Contributed by Paul van Belkom, Director, Nutrition Sector, Department of Health, Housing and Community Services, Commonwealth of Australia.
Background
In August 1991, the Australian Government approved a process to develop a proposal for food and nutrition in Australia, and directed a committee comprising government, industry and consumer representatives to oversee its development. The National Food and Nutrition Policy was subsequently announced by the former Minister for Aged, Family and Health Services the Hon. Peter Staples, in September 1992.
The Policy identifies priority objectives and strategies in the areas of education/information; targeted programs for vulnerable groups; changes in the food supply consistent with the Australian Dietary Guidelines; and monitoring and surveillance. Under this program joint activities with stale and local governments, primary producers, food processors and retailers and consumer groups, are being undertaken to reduce the preventable burden of diet related disease in Australia.
Priority implementation strategies are being implemented under the food and nutrition component of the National Health Advancement Program (NHAP). Building on the successes of the National better Health Program, the NHAP focuses on four priority areas of national health goals and targets; injury; environmental health; and food and nutrition.
Achievements
The National Food and Nutrition Policy has achieved wide ranging and positive intersectoral involvement in its development, including traditionally “non-health” areas: primary industries; food manufacturers, retailers and distributors; consumers and community groups; and the Commonwealth and State/Territory government bodies.
A number of projects, consistent with priority objectives and strategies, are now underway. Projects have been funded in a diverse range of localities around Australia and with a variety of groups. Food and nutrition objectives have been incorporated into a variety of policy areas and sectors. Policy implementation will be measured against the national food and nutrition goals and targets.
Projects underway include the development of national nutrition curriculum material for schools; the release of a resource kit for consumers to learn about the Australian Dietary guidelines; the development of a point of sale program to assist consumers make healthy food choices in the retail environment; collaborative projects with two local governments to identify barriers to access of healthy foods within the locality; and a national project to develop a resource to assist Aboriginal and Torres Strait Islander communities address food and nutrition concerns.
A small policy implementation advisory group has been formed with representation from the National Food Authority, the food industry, consumers and the National Health and Medical Research Council (NHMRC). The consultative group is currently developing strategies to ensure intersectoral contributions to policy implementation, and future directions.
All Principal Committees of the NHMRC have been formally presented with the Policy, and requested to consider food and nutrition issues as pan of their decision making and policy processes. The Medical Research and Public Health Research and Development committees have been specifically requested to consider nutrition as an identified area of need for research in the next triennium.
Tools and references to measure nutritional status and advice on appropriate approaches to special groups in the community, which are developed by the Food and Health Committee, provide the scientific basis for Policy implementation.
(Source: Commonwealth of Australia Communication, 26 May 1993)
Recent research has brought to attention a difference between the patterns of growth of breastfed and formula fed babies which may have important implications for the use of the World Health Organisation weight-for-age chart - a standard based on American growth rates and calculated in the 1970s when almost all infants in the USA were formula fed.
Whilst experience worldwide has shown that these standards are useful in the 1-5 year age group, the pattern in the 0-1 year age group is often not parallel to the standards, and this has been misinterpreted. Children in developing countries show a rapid weight gain during the first six months which then slows down considerably. The explanation for this difference has been that weight gain during weaning slows down due to inappropriate diet, malnutrition and/or disease, but research in Switzerland - where breastfeeding has become increasingly popular - has shown up a similarity between the growth patterns of Swiss breastfed babies and African breastfed babies.
The weight gain of 200 Swiss breastfed babies was assessed retrospectively. All babies had been exclusively breastfed for at least five months, and then breast milk had been supplemented with mixed feeds in increasing quantity.
It was found that both Swiss and African breastfed babies show a rapid weight gain up to 6 months of age, with considerable slowing down between 6 and 12 months. This result did not correspond to the weight gain of Swiss and American bottlefed babies, and Swiss breastfed babies gained less weight than bottlefed babies in the weaning period, despite low incidence of malnutrition or severe infections.
The logical conclusion reached by the author is that “growth patterns of American formula fed babies (WHO chart) should not be used to monitor the weight gain of breastfed babies, whether in America or in developing countries.”
(Source: Achard, T. (1992). Is the WHO Weight-for-Age Chart Appropriate for Infants of the Developing World? Tropical Doctor, October, 170-172)
Researchers have discovered a previously unrecognised role of breastfeeding in the relationship between energy intake and diarrhoea as they affect child growth, which may have important implications in the design of public health policies aimed at improving child growth, health and development.
As reported in an earlier issue of SCN News, results of supplementation studies on children aged 0-36 months (Colombia) and 3-36 months (Guatemala) have already provided evidence to support a biological model which predicts that “the effect on attained length of a given level of nutritional supplementation will depend on both the prevalence of diarrhoea and the energy content of the home diet. The relationship between inadequate energy intake and diarrhoea is synergistic, and affects growth in a manner far greater than the simple additive effects of diarrhoea or inadequate energy intake would predict.”
It is only recently, however, that researchers have found that the source of energy in the home diet appears to have an effect on the extent to which diarrhoea affects child growth. In a study in Peru, it was found that weight gain was not associated with prevalence of diarrhoea in babies aged 1-6 months of age where a high proportion of energy came from breastmilk. In older infants, however, who received less of their total energy from breastmilk in their home diets, there was a significant negative relationship. Why?
Nutritional status is compromised during diarrhoeal episodes partly because less energy is ingested. However, according to the authors of the Peruvian results, “numerous studies have confirmed the fact that breastmilk consumption is unchanged (or may be increased) during diarrhoea” whereas in contrast “estimates of the reduction in energy intake from other food sources range from 15% to 20%”. Moreover, they state that is thought that faecal losses may depend in part of the type of diet consumed. Breastfeeding may thus reduce energy deficit resulting from diarrhoea in two ways - by avoiding the reduction of energy intake that often occurs during diarrhoeal episodes, and by reducing faecal losses.
Thus, the authors conclude, “efforts to promote increased energy intake among infants and young children should be coupled with efforts to promote exclusive breastfeeding through at least the first four months of infancy and partial breastfeeding through 24 months when children are most at risk for diarrhoea.”
(Sources: (i) ACC/SCN, (1990). Supplementary Feeding Counteracts Effects of Diarrhoea on Growth. SCN News No. 5, 35-36. (ii) Lutter, C.K., Habicht, J.P., Rivera, J. & Martorell, R. (1992). The Relationship between Energy Intake and Diarrhoeal Disease in their Effects on Child Growth: Biological Model, Evidence and Implications for Public Health Policy. Food and Nutrition Bulletin, 14 (1), 36-42.)
The Indian Parliament has passed an “Infant Milk Substitutes, Feeding Bottles & Infant Foods (Regulation of Production, Supply & Distribution) bill”, a move which, if implemented successfully, will severely restrict the advertising and promotion of these baby products.
The bill essentially incorporates the recommendations laid out in the International Baby Food Code adopted by the World Health Assembly in 1981, but additionally it covers infant foods, defined as “foods provided as a complement to mother's milk to meet the growing nutritional needs of the infant after the age of four months”.
When the bill comes into force, advertising of these products will be banned, as will promotional activities such as the distribution of free samples. Donations of infant-milk substitutes and bottles will only be allowed to orphanages.
The law also extends to the labelling of products. Words such as “humanised” or “maternalised” and pictures of mothers, infants or both will no longer be allowed - and all information material provided with the products will be required to promote breastfeeding and warn of the financial and social implications of using infant formulas and baby bottles.
The penalties for breaking this law may be imprisonment for up to 3 years or fines of up to Rs 5000 ($100).
Some doubt has been expressed, however, as to whether the government will be able to implement the bill successfully. It is feared that the food inspectors responsible for identifying offences - already overworked and sometimes corrupt - will not carry out the task adequately. In addition, while the bill bans use of the health system or its employees for promotion of advertising of baby products, no agency has been set up to monitor the functioning of the health system, and there is an expanding private health sector which is largely unregulated.
There are also fears about the effect of the legislation on poor working women. According to Padma Prakash, writing in The Lancet, “Restricting promotion of baby food must be accompanied by creation of conditions that enable the vast majority of poor women to breastfeed. Such a task in a country where most women are forced to work in the unorganised sector would be colossal.”
(Source: Prakash, P. (1992). India: Advertising of Infant Foods to be Restricted. Lancet, 340, 962-963)
A case-control study carried out in Italy appears to have found evidence of a protective effect of breastmilk against Urinary Tract Infection (UTI) in infants in their first six months of life.
Working at the Medical School of Naples Department of Paediatrics, researchers compared the feeding methods used for the 128 patients (aged 6 months or less) admitted to the hospital with UTI between the years 1976-1989, with 128 control patients - sampled from amongst those infants who had been admitted to hospital with acute illness between during the same time period but who did not have UTI. The control patients were matched to the case patients by gender, age (within 15 days), and year and month of admission.
The infants were categorised as either “never breastfed” or “ever breastfed” based on information derived from hospital records. Infants were additionally classifed according to the type of feeding the infant was receiving at the time of hospitalisation - but this method was treated with caution because it might have led to bias due to reverse causality - the illness itself affecting choice of feeding method. 64 of the case patients (50%) were found to have ever been breastfed compared to 93 of the control patients (73%), a significant difference (p<0.001).
The possibility that other factors could have been responsible for the differences in incidence of UTI between the case and control groups was also addressed by the researchers - the two groups are described as having been similar with regard to age, gender, birthweight, social class, birth order and maternal smoking.
The mechanism by which protection against UTI is afforded is not discussed in detail by the authors of the study, however they do report that some authors have found an oligosaccharide in the urine of breastfed infants that causes inhibition of Escherichia coli adhesion to uroepilhelial cells, and other researchers have shown an increased concentration of immunologic factors in the urine of breastfed infants.
(Source: Pisacane, A., Graziano, L., Mazzarella, G., Scarpellino, B. & Zona, G. (1992). Breastfeeding and Urinary Tract Infection. Journal of Pediatrics, 120(1), 87-89)
In 1988, the World Health Organization and its 182 Member States declared their commitment to the global eradication of poliomyelitis by the year 2000 - a goal endorsed in 1990 by UNICEF and more than 130 world leaders at the World Summit for Children. Five years on, how much have we progressed towards being free of poliomyelitis?
The following summary figures are taken from a recent report by Dr Nakajima, Director-General of the World Health Organization:
· In 1991, 14,245 cases of poliomyelitis were reported to WHO - a 33% decrease compared to 1990 and a 60% decline since 1988.In addition, it has been reported by WHO that 81% of the world's infants are being vaccinated against polio each year.· The number of countries reporting zero cases has risen steadily, and the number of cases has diminished.
· In the Region of the Americas, nine cases of poliomyelitis were reported from only two countries in 1991.
· Despite intensive surveillance, no wild poliovirus has been detected in the western hemisphere since September 1991.
· Small numbers of cases are being reported from Europe, North Africa, Southern Africa, the Middle East and several countries of the Western Pacific.
· Bangladesh, China, India and Pakistan reported over 80% of the poliomyelitis cases in the world in 1992.
· Surveillance in much of Africa is extremely limited and the situation with regard to poliomyelitis in most of Africa remains unclear.
According to Dr Nakajima, “immunizing 80% of the world's children has been a tremendous achievement. Reaching the remaining 20%, many of whom live in hard-to-reach areas of the world will be no less of a challenge - a challenge that has to be faced and overcome each year as more children are born, each needing a full course of immunization. In addition, it is usually necessary to supplement routine immunisation with additional mass immunisation campaigns, if the virus itself is to be eradicated”
The basic WHO strategy is to improve disease surveillance, strengthen laboratory services and increase immunization coverage all over the world - including supplemental immunization activities designed to interrupt circulation of wild poliovirus - and the success of the poliomyelitis eradication initiative in the Region of the Americas demonstrates that the main technical issues have been solved. In many countries in Africa, however, the infrastructure is poor, there are surveillance and diagnostics problems, and social unrest and military conflicts make the situation more difficult. And according to the Director-General's report there are other constraints. Several countries, such as China, are committed to eradication, but are unable to conduct an effective programme because of insufficient funds to purchase vaccine. External Resource support is also lacking in some areas. Additional external support is required at global, regional and country levels for laboratories, logistics, personnel and research.
The report lists as an additional worry the lack of political commitment to poliomyelitis eradication by some donor agencies, industrialised countries, and polio-endemic countries. “Although significant progress has been made, the goal cannot be reached without additional political commitment at all levels.”
Rotary International was, however, commended for its advocacy efforts and in 1993 was the first nongovernmental organisation to receive WHO'S prestigious Health-for-All Gold Medal, in recognition of its outstanding contribution to the global fight against poliomyelitis.
Despite the constraints, Dr Ralph Henderson, Assistant Director-General of WHO has stated that, “WHO, UNICEF and Rotary International believe we have a recipe for success, provided there is a commitment and a will on the part of the international community to get rid of the disease once and for all.”
(Source: WHO Features, May 1993 & Expanded Programme on Immunization: Eradication of Poliomyelitis. Report by the Director-General. Provisional Agenda item no.19, 46th World Health Assembly, 23 March 1993.)
Further to the article in SCN News No. 8 “The Dangers Faced by Children in the Americas” (an interview with Luis Rivera, Deputy Regional Director of UNICEF for Latin America and the Caribbean) which reported that at least 15 million children aged 10-14 are working on the streets of cities in Latin America - many exposed to criminal violence and accidents of all kinds - a recent WHO report “A One Way Street?” has revealed serious problems of substance abuse amongst the estimated 100 million children living on the streets of cities worldwide.
The report discusses the results of the first phase of a project undertaken by the WHO Programme on Substance Abuse investigating the use of alcohol and other drugs by street children in 10 cities around the world; Rio de Janeiro, Alexandria, Cairo, Tegucigalpa, Montreal, Toronto, Manila, Bombay, Mexico City and Lusaka.
Amongst the 550 children who participated in the study, the most widely used substances were those which were cheap and easily available, including alcohol, tobacco, cannabis, glue, solvents and pharmaceuticals - but the use of cocaine, heroin, amphetamines, combinations of drugs and drug injecting were also reported. Children were often found to be involved in the production and marketing of cocaine, and the trafficking of cannabis and heroin.
The use of drugs was often quoted as a means of coping with stress, pain and suffering - every day children face hunger, and many fear for their lives. Of those interviewed in Rio de Janeiro, 55% claimed to have attempted suicide.
The WHO reports that promising strategies have been identified by the project based on assisting and strengthening organisations which work with street children. It is hoped that community development, empowerment, education and activities offering children a healthier, safer and more constructive lifestyle will protect them from drugs and alcohol.
It is proposed that in the next phase the project will be developed in association with the United Nations and other organisations including the Commonwealth Secretariat and Street Kids International.
Director of the WHO Programme on Substance Abuse, Dr Hans Emblad, has expressed his fears for the wellbeing of these children. “This is a global problem and it should be addressed globally. The future of millions of children is at stake. Unless we have a strong and influential network of individuals and agencies to work with street children firmly in place, the current tragic situation will continue, and drugs will go on damaging more and more young lives.”
(Source: WHO Press Release, 26 March 1993)
The results of two population-based surveys, published in The Lancet, have revealed extremely high mortality rates in urban populations in central Somalia during the 1992 famine, especially amongst displaced persons and children.
In Baidoa, 250km west of the Somali capital, Mogadishu, a sample of the population in camps for displaced persons were asked about living household members and deaths that had occurred in the household (i.e. parents, spouses, or children) between April 3 (Ramadan) and November 21 (date of interview), 1992. Of the 338 displaced persons reported to have been alive on April 3, 132 (39%) were reported to have died - an average daily crude mortality rate (CMR) of 16.8 deaths per 10,000 population. 62 of these 338 displaced persons were children under 5 years of age. 46 had died during the 232 days preceding the interview - a CMR of 32.0 deaths daily per 10,000 population aged <5 years. For all age groups, the most common reported causes of death were diarrhoea (56%) and measles (25%).
In Afgoi, a town lying 40km west of Mogadishu, mortality data were collected from 152 households for 1019 persons who were alive on April 3. Of the 763 long-term residents of Afgoi and 255 persons displaced from other areas who were included in the sample, 115(11%) died between April 3 and December 6, 1992 - a CMR of 4.7 deaths daily per 10,000 population. Most commonly reported causes of death were measles (34%) and Diarrhoea (19%). Displaced persons were more than 1.5 times as likely to die as residents during this period.
To set these figures in context, the authors report that “in most countries of Sub-Saharan Africa, reported national mortality rates are between 20 and 24 deaths per 1000 population per year, equivalent to 0.55 - 0.65 deaths per 10,000 per day. Although displaced persons commonly have higher mortality rates than non-displaced persons, the mortality rates found in our survey are among the highest recorded for civilian populations over a long period. Among displaced households surveyed in camps in Baidoa, mortality rates were about thirty times higher than expected in peacetime.” “Community-based public health interventions to prevent and control common infectious diseases are needed to reduce these exceptionally high mortality rates in Somalia.”
Source: Moore, P.S., Marfin, A.A., Quenemoen, L.E., Gessner, B.D., Ayub, Y.S, Miller, D.S., Sullivan, K.M. and Toole, M.J. (1993). Mortality Rates in Displaced and Resident Populations of Central Somalia during 1992 Famine. The Lancet, 341, 935.938.
A new piece of research has found that the effects on intelligence of lead accumulation in childrens' blood may be partially reversible when blood lead content is reduced. 154 children from 1 -7 years of age took part in the study undertaken by a research team at Albert Einstein College in New York. All were diagnosed with moderate lead poisoning - defined as lead levels between 25 and 55 micrograms of lead per decilitre of blood.
Six months after having been treated to reduce the levels of lead in their blood, and their homes cleaned to reduce exposure to lead, the children showed significant improvement on standardised tests for cognitive development. The improvement was in direct proportion to the drop in blood lead levels.
There is now evidence to suggest that levels of blood lead much lower than were present in these children can damage the developing brain and affect intelligence. The Centers for Disease Control in Atlanta now considers a level of 10 micrograms per decilitre of blood to be a matter of concern. According to US Federal Data, in 1990, eight million American children had lead levels of more than 10 micrograms.
Although the results of the research point to there being a need to increase efforts to reduce children's exposure to lead and to identify and treat children with dangerous lead levels in their blood, Dr Holly Ruff, leader of the research team is cautious. “Our study is only suggestive, not definitive, and should be followed with more work to determine specifically which kinds of interventions would be most helpful.”
(Source: International Herald Tribune, 8 April 1993)
According to the World Health Organisation's Tropical Disease Research Programme (WHO/TDR), deaths from five major tropical diseases - Malaria, Leishmaniasis, African Sleeping Sickness, Lymphatic Filariasis, and Schistosomiasis - could double from two million a year to four million a year by 2010 unless immediate action is taken.
In response, TDR has set new research targets - some scheduled for completion as early as next year - aimed at identifying and making available means of attacking these diseases. Areas of research include new drugs, diagnostics and vaccines, and TDR is also examining the role of women in controlling these diseases.
Malaria is by far the most serious problem. 270 million people in the world are infected with the malaria parasite which is carried and passed on by infected female mosquitos. 90% of those infected are in sub-Saharan Africa, where malaria kills at least a million people annually (some estimates approach two million). The main victims are children under five years of age, and non-immune children entering endemic areas.
The World Declaration on Control of Malaria, adopted by over 100 Governments in Amsterdam in October 1992 identified four key objectives: (a) early diagnosis and treatment; (b) selective and sustainable mosquito control; (c) early detection and containment or prevention of epidemics; and (d) regular reassessment of each country's malaria situation.
TDR's research targets will support these goals. If adequate resources are available, as well as developing new more effective drugs for prevention and treatment of malaria including one which could be used in the 50% of all cases in which malaria is indistinguishable from acute respiratory infection - TDR hopes to know by 1996 whether insecticide-soaked bednets and curtains can save children's lives throughout much of Africa. Large-scale studies are now underway in parts of Burkina Faso, Ghana and Kenya in response to the discovery in a small study in the Gambia that home-soaked nets could reduce child deaths by more than half.
They also envisage that by 2002 human trials should be complete on most of the 15-20 current leading malaria vaccine antigen candidates and combinations. It should then be clear whether, in exactly what form, and at what cost, a malaria vaccine will work.
Genetic manipulation systems are also being developed for both the most dangerous form of the malaria parasite - Plasmodium falciparum - and for the mosquito. Genetic transformation of the parasite, which has already been achieved, should increase the speed at which drugs can be developed, and drug resistance understood and controlled. In the mosquito, the aim is to develop mobile, self-propagating genetic elements that will disable the insect from carrying the parasite at all.
Recognising that already four out of five malaria cases are treated in the home, TDR is investigating “how mothers diagnose and treat the disease, and how they may be aided to distinguish malaria from other, less serious illnesses, to save their children's lives.
The costs of reaching the targets laid out for malaria research and the other tropical diseases will be large, but as Dr Tore Godal, Director of TDR, points out “apart from the millions of lives lost and ruined, malaria alone causes over 200 million weeks of lost work a year. Even at developing country incomes - say US$5 a week - that comes to a loss of US$ 1 billion a year, and for just one of the diseases.”
“To spend a tiny fraction of that to save lives and hope is the only possible moral course of action, but it clearly makes good business sense too.”
(Source: WHO Office of Information Background Document on Tropical Diseases, 29 March 1993)
Dr Hiroshi Nakajima, Director-General of the World Health Organization, has announced the appointment of Dr Fernando Antezana Aranibar as Assistant Director-General with effect from 1 June 1993.
Dr Antezana will be responsible for the Division of Food and Nutrition, the Action Programme on Essential Drugs, and the Division of Drug Management and Politics.
Dr Antezana, born in Cochabamba, Bolivia, joined WHO in 1976. Since then he has held a number of positions, including Scientific Adviser in the Unit of Drug Policies and Management, and Senior Scientist in the Division of Prophylactics, Diagnostic and Therapeutic Substances. He served as WHO Representative in Guatemala from 1986 to 1989, and since 1992 has been Director of the WHO Action Programme on Essential Drugs.
(Source: WHO Press Release, 2 June 1993.)
Bread for the World - an organisation which describes itself as “a Christian citizens' movement to end hunger” - is launching this year the Many Neighbours, One Earth campaign - an effort to make reducing hunger and poverty in environmentally sound ways the main focus of US foreign aid.
Findings by the Bread for the World Institute - which works closely with Bread for the World - have indicated that “of the $15 billion 1991 foreign aid budget, only about 20%, or $3 million was allocated to programs focussed on reducing poverty and hunger in environmentally sound ways” and that “At present about half of the foreign aid budget is set aside for military and security purposes” - an allocation which Bread for the World argue is inappropriate now that the Cold War is over.
The campaign seeks to provide grassroots support for a new foreign aid approach that supports people-centred development; the main principles of which are described by Bread for the World as the following:
· Development must support people's efforts to meet their basic needs. These include food, clean water, basic health care, shelter, and education. Meeting these needs allows people to enjoy a decent quality of life that is every person's right and ensures that people are healthier, more productive members of society.Bread for the World state that their goal is to “direct aid to countries that demonstrate commitment to these objectives, with priority given to the poorest countries. In all selected countries, aid should target the poorest people”, and believe that “by reordering foreign assistance to reflect new priorities, the United States can help set the global standard for post-Cold War development assistance, give a major boost to poor people worldwide, and improve US prospects for security and lasting wellbeing. Appropriate foreign aid can help break the cycle of hunger and poverty one step at a time.'· Development must create opportunities for poor people to increase their incomes. These opportunities include the creation of better paying jobs, strong markets for farm and other products, and access to resources that enhance earning capacity. The most important resource is land, but other productive resources include financial credit, technology, and training. Economic growth in poor countries can help raise incomes among poor people, but growth in GNP should not be seen as an end in itself. The benefits of growth must be fairly distributed to reach poor and hungry people.
· Development must reinforce patterns of living that protect the environment. Promoting poor people's access to land is also critical to environmental protection. Otherwise, they may be forced to overgraze, cultivate marginal lands, or cut forests in order to meet daily needs for food, water, fuelwood, timber and income. Agricultural and industrial production methods must also protect the soil, water, and other resources, and rely on renewable sources of energy.
· Development must promote the full participation of men and women in social and economic decision-making at the local and national level. Democratic participation is an end in itself, and also tends to protect poor people and the environment. Strengthening the capacity of grassroots organizations, respecting human rights, with special attention to the rights of women and minorities are key elements of equitable, sustainable development.
For further information on the Many Neighbours, One Earth: Transforming Foreign Aid campaign, please contact: Bread for the World, 802 Rhode Island Avenue, N.E., Washington, D.C. 20018, USA. Tel: 202 269 0200.
(Source: Selvaggio, K. (1993). Many Neighbours, One Earth: Transforming Foreign Aid. Bread for the World Background Paper No. 128.)
According to Alan Berg, Senior Nutrition Adviser at the World Bank “Task Managers for South Asia and East Asia Nutrition projects should be alert to co-financing possibilities with the Asian Development Bank, which for the first time is expressing interest in nutrition. Its initial investment in this field could be as co-financer of the Bangladesh Nutrition Project, based on recent participation in the pre-appraisal mission.”
(Source: World Bank Office Memorandum “New and Noteworthy in Nutrition”, April 26, 1993)
Following the International Conference on Nutrition (ICN) held in Rome from 5-11 December, 1992, and in response to a request by Member States that the WHO strengthen its capacity for action in the field of Food and Nutrition, the Director-General of the WHO has established a WHO Division of Food and Nutrition with effect from 1 May 1993.
The new division comprises three units, Food Aid Programmes (FAP), Food Safety (FOS) and Nutrition (NUT). Its function will be in particular to support Member States in the implementation of recommendations contained in the World Declaration and Plan of Action for Nutrition, laid down at the ICN. It will help Member States to develop and implement their National Plans of Action for nutritional improvement, giving priority to the countries that are least developed, have low income or are affected by disasters.
Other priority activities of the new division will include: micronutrient control programmes; training in preparedness for nutritional emergencies; control of diet-related chronic diseases; maternal, infant and young child nutrition; monitoring nutritional status; and prevention of food-borne diseases.
Dr Georg Quincke has been appointed Director of the new division. Dr Quincke joined WHO in 1969 as Medical Officer at headquarters. In 1970 he was appointed Regional Adviser for Health Laboratory Services for the African Region of WHO, and he subsequently became WHO Representative, first for Botswana, Lesotho & Swaziland, then Cameroon. Since 1985 he has been Chief of the Food Aid Programmes Unit, WHO.
(Source: WHO Press Release, 27 May 1993)
The Tanzania Food and Nutrition Centre celebrates this year 20 years of Nutrition work in Tanzania.
Its major achievements have been:
· development of a food and nutrition policy for Tanzania;The anniversary celebration activities will be running from January - Early December 1993 throughout Tanzania.· development of a conceptual framework for the analysis of malnutrition problems;
· the creation of awareness on nutrition for nutrition decision makers and the public at large;
· collaboration with various international agencies and ministries in the development and implementation of community based nutrition programmes related to child survival and development; and
· development of national programmes for the control of iodine deficiency disorders (IDD), vitamin A deficiency, nutritional anaemia and breastfeeding.
For further information contact: The Chairperson, 20 Years of TFNC, PO Box 977, Dar es Salaam, Tanzania. Tel: 29621-3. Fax: (255) 51 28951 Telex 41280 LISHE, TZ
(Source: TFNC, 18 May 1993)
On 1-7 August, 1993, the second annual World Breastfeeding Week (WBW), organised by the World Alliance for Breastfeeding Action (WABA), took the theme of the Mother-Friendly Workplace Initiative (MFWI). Last year's theme, the Baby-Friendly Hospital Initiative, has to date encouraged over 70 countries take action to initiate activities and programmes in support of breastfeeding - and a growing number of hospitals are “now converting their institutions into baby-friendly facilities.”
UNICEF, the WABA's main partner in World Breastfeeding Week, has stated that “although important progress has been made in many countries through the BFHI, the goal of enabling all women to breastfeed optimally will only be achieved when there are more supportive environments both at work and in the community.”
The challenge, then, for the WABA is to “take baby-friendliness outside the hospitals into other parts of society.” The WABA hopes that “through the Mother-Friendly Workplace Initiative, the home, streets, farms, offices and other workplaces - both formal and informal - will become more mother friendly work environments.”
The goals of WBW 1993 are:
· To create public awareness of the rights of working women to breastfeed;For more information contact any one of the following: Sarah Amin, WABA Secretariat, PO Box 1200, 10850 Penang, Malaysia. Tel: 60 4 884 816 Fax: 60 4 872 655; Penny Van Esterik, Coordinator, Women & Work Task Force, Dept of Anthropology, Vari Hall, York University, North York, Ontario M3J 1P3, Canada. Tel: 1 416 7365261 Fax: 1 416 7365768; or Marta Trejos, Coordinator, Social Mobilisation Task Force, CEFEMINA, Apartado 5355, 1000 San Jose, Costa Rica. Tel: 506 244 620 Fax: 506 346875.· To facilitate and protect cultural/traditional practices which are supportive to the breastfeeding mother working at or away from home;
· To involve community leaders and other popular groups (ecological, women & development groups) to develop the social support needed for women in the informal & agrarian sectors to combine breastfeeding & work;
· To have more trade unions demand maternity rights & provide a supportive work environment for all women workers who choose to breastfeed (e.g. a creche, better transport, etc.);
· To ensure that national legislation to protect the breastfeeding rights of working women is implemented in as many countries as possible; and
· To make as many workplaces as possible become Mother-Friendly.
(Source: WABA leaflet & WABA Link Nos 5 & 6, February 1993)
The following is extracted from an announcement provided by the University of Queensland
“Established in 1979, the Nutrition Program of the University of Queensland offers postgraduate training in nutrition for professionals coming from health, agriculture, economics and other backgrounds. Over 200 students have graduated through the Nutrition Program, with more than 70 per cent being drawn from Asia, 15 per cent from Africa and the remainder primarily from Australia and the Pacific.”
“The MCN is aimed at professionals involved in the formulation and implementation of nutrition policy and programs and those who train other professionals to work in the area of nutrition.
“An interdisciplinary approach to nutrition problems is stressed in this one year course. Six months of coursework in Brisbane covers the analysis of food and nutrition systems, nutrition policy and planning, social change and development, management, statistics and epidemiology. This is followed by six months of supervised fieldwork at one of the collaborating universities, the Institute of Nutrition at Mahidol University or Khon Kaen University in Thailand, or the University Kebangsaan Malaysia in Malaysia. The course commences in June each year.
The Nutrition Program also provides research training at the masters and PhD levels for students from Australia and overseas. The masters degree is normally completed in two years of full-time study, while the doctorate is normally completed in three years.
“The scope of student research is broad, with a primary focus on public health nutrition, but increasingly with emphasis on issues of relevance to clinical nutrition and dietetics.
“Current areas of research among the Nutrition Program staff include: food and nutrition policy studies; nutritional surveillance; health promotion; evaluation of programs; agriculture and nutrition; iodine deficiency disorders; recommended dietary intakes; beta-carotene and skin cancer; nutrition and development of non-communicable diseases; and nutrition and child morbidity.”
For further information contact: The Director, Nutrition Program, University of Queensland, Royal Brisbane Hospital, Queensland 4029, Australia. Tel: 61 7 365 5400 Fax: 61 7 257 1253.
(Source: University of Queensland Nutrition Program leaflet)
Professor Abdus Salam from Pakistan, President of the Third World Academy of Sciences, has communicated that Professor Dutra de Oliveira from the Medical School of Ribeirao Preto, University of Sao Paulo, Brazil, and President of the International Union of Nutritional Sciences, has been elected as a Member of the Academy. The Fellows of the Academy are elected among Scientists of the Developing Countries who have reached the highest international scientific standards in their areas of work. The Academy is the first international forum to unite distinguished men and women of science with the objective of enhancing the promotion of basic and applied sciences in the Third World. The Membership Committees of the TWAS include those for Agriculture, Biology, Engineering, Biochemistry & Biophysics, Chemistry, Geological and Earth Sciences, Mathematics, Physics & Astronomy and Medical Sciences. It is presently located at the International Centre for Theoretical Physics at Miramare, Trieste, Italy and run by the International Atomic Energy Agency and the United Nations Educational, Scientific and Cultural Organisation (UNESCO).
(Source: IUNS, 11 April 1993)
The World Conference on Natural Disaster Reduction, organised by the United Nations Department of Humanitarian Affairs (UNDHA)/International Decade for Natural Disaster Reduction (IDNDR), in cooperation with the Government of Japan, will be held in Yokohama from 23 to 27 May, 1994.
The aims of the Conference will be to:
· review IDNDR accomplishments at national, regional, and international levels;The results of the Conference will contribute to the midterm review of the IDNDR, which was launched with the objective of reducing the loss of life, property damage and economic and social disruption caused by natural disasters, especially in developing countries.· chart an action program for the future;
· exchange information on the implementation of IDNDR programs and policies; and
· increase awareness of the importance of the progress of disaster reduction policies.
Participation is anticipated to include government ministers and high-level officials, representatives of the over 100 National Commitees and Focal Points for the Decade, representatives of regional and international organisations concerned with natural disasters, both governmental and non-governmental and other interested persons.
Potential participants are invited to write to the IDNDR Secretariat in Geneva as soon as possible for further conference information at the following address:
IDNDR Secretariat, Palais des Nations, CH-1211 Geneva 10, Switzerland. Fax: (41 22 733 8695)
(Source: IDNDR Special Announcement)
“Africa Make or Break” is the name given to Oxfam's new campaign to curb the current trend of increasing poverty in Sub-Saharan Africa. The campaign will press northern industrial governments to agree to a plan of action to help underpin African recovery. According to David Bryer, Director of Oxfam, launching the campaign in the Observer newspaper:
“Such a plan would need to start by removing what UN Secretary-General Boutros Boutros-Ghali has described as 'the millstone around the neck of Africa' - an external debt of over US$ 130 billion... Africa transfers to the north $10 billion annually in debt repayments, draining the region of its limited capital resources.”
“Alongside debt relief, increased aid is vital. In real terms, development assistance to Africa has stagnated since 1989.”
“In addition to increased aid and debt relief, there is an urgent need for reform of World Bank and IMF structural adjustment programmes, which have dominated economic policy in Africa for over a decade. These programmes have conspicuously failed to create a platform for economic recovery, and they have marginalised poor people.”
“In Africa, as in other parts of the world, peace, stability and democracy do not come cheap. However, failure to act will carry a price - a price which will not only be borne by Africans, but by us in the north too.”
For a copy of the Oxfam “Africa Make or Break” report and further information on the campaign contact: OXFAM, 274 Banbury Road, Oxford OX2 7DZ, United Kingdom. Tel. 0865 312253.(Source: Observer, 21 May 1993)
The Second Asian Conference on Food Safety will take place in Bangkok, Thailand, on September 19-23, 1994. It is hoped that the conference will attract national and regional health policy planners, as well as scientists and other professionals from industry, government, academia and others concerned with food safety - over 400 scientists and policy makers representing Asia, South America, Europe, and North America were present at the First Conference, held in 1990 in Malaysia.
The specific objectives of the conference will be to:
1. Focus attention on new challenges of food safety in the Asian region.The conference is being organised by the International Life Sciences Institute South East Asia, Thailand, in association with the International Life Sciences Institute, the Food & Drug Administration, Thailand, the International Union of Food Science & Technology, the Food and Agricultural Organisation, and the World Health Organization. Topics will cover the areas of Food Safety, Microbiology, Water, Nutrition and Emerging Issues.2. Promote the harmonisation of sound food protection regulations.
3. Provide a forum for discussing current and future issues in food safety; and
4. Promote the safety of food products and increased trade within the region.
For further information please contact: In Asia: Dr Saipin Maneepun, Secretariat, 2nd Asian Conference on Food Safety, c/o ILSI Southeast Asia, Thailand Office, P.O. Box 170, Bangkok 10400, Thailand. Tel: 662 579555-1, 5790572. Fax: 662 561 1970. All others: Ms Lili C Merritt, ILSI, 1126 16th St., N.W. Washington, D.C. 20036, USA. Tel. 202 659 0074. Fax: 202 659 3859.
(Source: ILSI Leaflet, June 1993)
The East, Central and Southern Africa Food and Nutrition Cooperation (ECSA), whose membership consists of Directors and Heads of Food & Nutrition Institutes and units in the region, is organizing a two day Micronutrient Symposium scheduled for 28-29 October, 1993, in Windhoek, Namibia.
The meeting is also open to International Organizations interested in assisting ECSA in developing a feasible Micronutrient Programme.
The aims of the Symposium are to
- increase awareness of the problem of micronutrient deficiencies in ECSA;There will be presentations on country initiatives on micronutrients from which country, inter-country and regional level follow-up strategies will be drawn.- facilitate development of strategies for cooperation between countries in the region on activities to combat micronutrient malnutrition; and
- plan a series of regional training activities.
For further information please contact: Catherine Siandwazi, Coordinator, Food & Nutrition, The Commonwealth Regional Health Community Secretariat for East, Central & Southern Africa, PO Box 1009, ARUSHA, Tanzania. Tel: 255 57 8362/3 Fax: 255 57 8292.
(Source: CRHCS Communication, 25th May 1993)
Recognising that most nutrition workers need training in the basic techniques of assessing the state of nutrition in the field, the Centre for Human Nutrition of the London School of Hygiene and Tropical Medicine, in association with the Save the Children Fund (UK), has produced a set of training materials which introduce the basic concepts of human nutrition, show in detail how anthropometric data can be collected and interpreted, and give some practice in the statistical work associated with surveys.
Originally produced as tape-slide sets and workbooks, the training packages are now available at lower cost on video, still accompanied by the workbooks.
For further information contact: Centre for Human Nutrition, London School of Hygiene & Tropical Medicine, 2, Taviton Street, London WC1H OBT, United Kingdom. Tel: 071 380 0599 Fax: 071 383 5859.
(Source: LSH&TM leaflet)
It has been brought to the attention of the SCN that an error was made in the reporting of awards given to Dr Barbara Underwood (SCN News No. 8, p.28). The awards were given by the American Institute of Nutrition (AIN) and not by the International Union of Nutritional Sciences. We apologise for any confusion this may have caused.
