|flies and diarrhoea||Michael Golden||06.01.99|
|Detection of anaemia||Renuka Jayatissa||06.01.99|
|info request for databases on local foods||Dominique Bounie||19.02.99|
|Vitamin A status in Africa||Micheline Ntiru||02.04.99|
|Human Rights in the Tyson Case||George Kent||25.04.99|
|Re: Fwd: des nouvelles de Belgrade||Etienne Grosjean||07.05.99|
|Participatory appraisal for nutrition and housheold food security||Florence Egal||17.05.99|
|Re: Participatory appraisal for nutrition and housheold food security||Bart Burkhalter||08.06.99|
|PFEDA's databases||Dominique Bounie||17.05.99|
|Adolescent and Adult Malnutrition in Famine Situations||Michael Golden||10.05.99|
|Thiamine deficiency and magnesium||Michael Golden||24.05.99|
|National Baseline Survey on prevalence and aetiology of anaemia in Zambia||Annoek van den Wijngaart||28.05.99|
|Re: National Baseline Survey on prevalence and aetiology ofanaemia in Zambia||Ian Darnton-Hill||28.05.99|
|Re: National survey on vitamin A deficiency in Zambia||Ian Darnton-Hill||06.07.99|
|Food Insecurity in Northern Kenya||Tom Davis||28.06.99|
|anaemia attributable to iron deficiency||George H Beaton||06.08.99|
|Injury related survey questions||Ibrahim Parvanta||08.08.99|
|donate a bit of food||Ted Greiner||12.10.99|
|Fortification of Pre-cooked Split Peas||Eric Rennies||19.10.99|
|collaboration for development of a nutritional software||Dominique Bounie||25.10.99|
|Guidelines on how to conduct a Feasibility study||Cristina Lopriore||25.11.99|
|health screening||Rubina Hakeem||26.11.99|
|Estrogen overload||Valerie James||14.12.99|
|contributions to PFEDA||Dominique Bounie||17.12.99|
|UNICEF statement on the duration of exclusive breastfeeding||Ted Greiner||21.12.99|
Date: Wed, 06 Jan 1999 11:24:36 +0000
From: Michael Golden <refugeesatabdn.ac.uk>
Subject: flies and diarrhoea
WHO reviewers have relegated fly control to the group of measures which are "ineffective or ... limited feasibility, unlikely to have a role in diarrhoeal disease control". Now Chavasse et al have formally addressed this issue (Lancet 2nd Jan 1999; 353: 22-25 "Impact of fly control on childhood diarrhoea in Pakistan: community-randoised trial").
There were 3 intervention and 3 control villages with cross-over control in a second year. Ultra-low volume space spraying, twice per week from March to Nov, with 0.5-1.0 g/hectare of Aqua K-Othrine (deltamethrin) was used. Fly control was substantial (baited fly traps were ineffective in a third year). There was a 23% (CI 11-33%) reduction in diarrhoeal diseases, in <5yr old, for the sprayed villages.
This reduction is very impressive and compares favorably with other measures in impact. However, the feasibility of long term control by spraying is problematic. However, in situations with high fly densities, high vulnerability to diarrhoeal disease and geographical limitation - such as epidemic diarrhoea in refugee camps - spraying for fly control should be seriously considered - would the sanitation nognuts care to comment please.
Prof. Michael H.N.Golden
Date: Wed, 06 Jan 1999 11:55:43 +0000
Subject: Detection of anaemia
I have conducted a field project in Sri Lanka to detect haemoglobin by filter paper method in pregnant women. I used Wattman No. 1 and No. 32 filter papers with finger pricked drop of blood. It was a good pricked and was done by medical laboratory technicians and the free flow of blood was allowed to dropped on to the paper. Dry the papers and was brought to the laboratory. Discs were cut by using the special scissors. The maximum number of discs were cut from the blood drop was 4. Then washed in Drabkin solution by putting varied number of discs (2-4 discs). Comparison was done with Haemocue method.
But the readings were lower than haemocue readings with any number of discs. The sample size was 75 with each filter paper.
How do I improve this? What are the shortcomings? Could you please help me with your experience.
Dr. Renuka Jayatissa MBBS, MSc, MD.
Date: Fri, 19 Feb 1999 18:18:46 +0100 (MET)
From: Dominique.Bounieatuniv-lille1.fr (Dominique Bounie)
Subject: Ngonut: info request for databases on local foods
I have now implemented on PFEDA the on-line display of the USDA table of food composition. More than 2300 products, from 9 of the 22 USDA food categories, are thus available : Milk and Dairy products (161 items), Herbs ans Spices (57 items), Fats and Oils (146 items), Fruits and Fruit Juices (284 items), Vegetables and Vegetable Products (748 items), Nut and Seed Products (139 items), Legumes and Legume Products (199 items), Baked Products (433 items), Cereal Grains and Pasta (156 items). The other food categories are of less interest and will be implemented latter.
The problem with such a database is that it was primarily devoted to US-type consummers, with westernized food habits. Most of the products are common on US or european markets, but are not very familiar in relief situations ! In emergencies, field practitioners have to use either products given as food aid by donor countries or products which are locally available. It would be interesting to record the precise characteristics of all these products in a centralized database which could be easily and freely accessed by everyone and which could be used, in a second step, as a reference table for optimization of food rations in the field and quality control (traceability of foods along the delivery chain).
- For food items which are channelled from donor countries, I have developed the FOOD database which is currently available on PFEDA ; I remind you that your contribution is required to update this database ;
- For local foods, we also need to identify them and list their specifications. My request is on references of electronic databases that could be freely implemented on PFEDA, in the same way I did with the USDA database. Did anybody develop electronic databases on local foods which could be used on PFEDA or do you have addresses (Internet URL, email, postal address) where to get a free version of such databases ?
Date: Thu, 11 Mar 1999 16:03:38 +0000
From: David Morley <Davidatmorleydc.demon.co.uk>
Colleagues, If there is anyone who sees hypothermia in malnourished children frequently do contact me. A friend John Zeal has developed a 12mm black disc which can be stuck in the axilla. As long as the dhild's temperature is over 35.5 centigrade the black disc turns into a gree smiling face. We hope the mother can be taught to put the child into close ? skin contact if it is not a "smiling face".
David Morley,Emeritus Professor of Tropical Child Health, University of London.
Tel: & Fax. 44 (0) 1582 712199.
Preferred Address; 51 Eastmoor Park, Harpenden, AL5 1BN. UK.
Date: Fri, 02 Apr 1999 09:13:32 -0500
From: "Micheline Ntiru" <mntiruatsmtp.aed.org>
Subject: Ngonut: Vitamin A status in Africa
I am looking for information on any papers (published or unpublished) that have critically analyzed options and issues for implementation of interventions aiming at improving vitamin A status in Africa, with specific attention to issues of supplies/logistics, sustainability, and integration with health and food security programs.
From: "George Kent" <kentathawaii.edu>
Subject: Human Rights in the Tyson Case
Date: Sun, 25 Apr 1999 15:50:36 -1000
Some of you may have heard about the Tyson trial, in Eugene, Oregon, in which an HIV+ woman is being prevented from breastfeeding her infant by the state. You may be interested in my comments on the human rights aspects of the issue, at http://www2.hawaii.edu/~kent
From there, go to menu item 3, "Select Unpublished Papers" Then go to the end of the list for the paper on "The Tysons' Missing Testimony".
I would welcome comments.
Aloha, George Kent
From: phil.lepageatvillage.uunet.be (lepage) (via Jehan Desjeux <desjeuxatcnam.fr>)
Subject: Re: Fwd: des nouvelles de Belgrade
Je vous transmets ci-après le texte d'un message que je reçois de mon amie Milena Sesic, professeur à l'université de Belgrade, donnant des formations dans le domaine de la coopération culturelle européenne et collaborant avec nous au sein de la Fondation marcel Hicter depuis de nombreuses années.
Elle transmets "aux amis" un message émanant d'un certain nombre d'organisations et associaitions volontaires de Yougoslavie et elle y ajoute quelques commentaires et informations personnelles.
Milena est quelqu'un qui au coeur de la Serbie se bat pour la démocratie.
Faites suivre, faites connaître...
LETTER TO ALBANIAN FRIENDS FROM NONGOVERNMENT ORGANIZATIONS
We are writing to you in these difficult moments of our shared suffering. Convoys of Albanians and other citizens of Kosovo, among whom many of you, were forced to leave their homes. The killings and expulsions, homes destroyed and burnt, bridges, roads and industrial buildings demolished - paint a somber and painful picture of Kosovo, Serbia and Montenegro, as in indicating that life together is no longer possible. We, however, believe that it is necessary and possible.
The better future of citizens of Kosovo, Serbia and Montenegro, of Serbs and Albanians, as citizens of one state or closest neighbors, will not arrive by itself, or over night. But it is something we can and must work on together, as we have many times in the past, not so long ago. We know that it will now be very difficult, and sometimes very painful. The example of the German-French postwar reconciliation and cooperation could serve as a model and stimulus.
In the sake of future life together, the pain of crime has to be revealed so that it is, with forgiveness, remembered. This tragedy, yours and ours, personal and collective, is a result of a long series of erroneous policies of the most radical forces among us and in the international community. The continuation of these policies will take both Serbs and Albanians into abyss. Also, the road of collective guilt is a road of frustration, continuation of hatred and endless vengeance.
That is why this road has to be abandoned. Our first step of distancing from hatred, ethnic conflict and bloody retaliations is a public expression of our deepest compassion and sincere condemnation of everything that you and your fellow citizens are experiencing.
As citizens of Serbia, we today suffer destruction and casualties as a result of NATO bombing, armed conflict in Kosovo and long lasting economic and social tumbles under the burden of the dictatorship's deadly policies.
Ethnic cleansing, NATO bombing and armed conflict should stop because they are not contributing to the solution of the Kosovo crisis but are only making it deepen. There should be no more casualties. All refugees should be allowed to return safely to their homes and live in the manner appropriate for free and proud people.
We are convinced that together, we will find strength and courage to step on the road of peace, democracy, respect of human rights, mutual reconciliation and respect. Dialogue, political negotiations and peace process have no alternative. For all of us, it is the only way out of the war conflict. It is the safest way to secure the return of refugees to their homes, to renew normal life and activities and find a solution to the status of Kosovo.
In order to make this happen, we have to join our efforts to end the war conflict, revitalize the peace process and reconstruct, economically and democratically, the development of Kosovo, Serbia and the entire Balkan region. We are convinced that by joining forces we can contribute to the reaching of a just and rational political solution to the status of Kosovo and build confidence and cooperation between Serbs and Albanians.
Association of Citizens for Democracy, Social Justice and Support to Trade Unions
United Branch Trade Unions NEZAVISNOST
European Movement in Serbia
Forum for Ethnic Relations
Center for Transition to Democracy-ToD
Center for Democracy and Free Elections
Distrikt 0230 (Kikinda)
Helsinki Committee for Human Rights in Serbia
Women in Black
Belgrade Center for Human Rights
Students Union of Serbia
VIN-Weekly Video News
Yu Lawyers Committee for Human Rights
Foundation for Peace and Crisis Management
Urban Inn (Novi Pazar)
Union for Truth about Antifascist Resistance
Sombor's Peace Group (Sombor)
Society for Peace and Tolerance (Backa Palanka)
Alternative Academic Educational Network
In Belgrade, April 30, 1999
Commentaire de Milena Sesic
What I can add as a personal message - I even do not know how this message will reach those the message is really aiming... It is nearly 10 years that I am looking with great pain the colons of refugees - My heart definitely was broken with colons of muslims from Trebinje in 1992, arriving in Rozaje and then expelled throughout the world. After that, all masacres, exodus came as part of our everyday life - and make all of us cruel - cruel, because we have not reacted, protested, fighted against. We even have not reacted on police control forbidding Serbian refuggees from Krajina to enter Belgrade in 1995, like today Macedonian police is keeping Macedonian teritorry of "uncontrolled" entry...
Yes, of course, we have discussed, we made statements, but fear, sentiment of "impuissance" or just complete depression made all of us apathical... There is no excuse, no excuse for anyone looking people leaving their homes to completely uncertain future - not to speak about terror anterrieur to exodus... Recently in Budapest I saw a lot of serbian refugees who are also living in fear, stress, leaving their homes, part of the families, having brothers mobilized on Kosovo... but their decision to leave was their decision - out of fear or protest (some of them thought that even their presence in the country is making them complices). Albanians who left - left in awful circumstances. But majority of Serbian people could not seen that, or even heard about it. And even if they heard, they do not want to believe - it is easier to survive that way - to be blind sometimes... to persuade yourself that they are leaving because they want to leave, they feel insecure, and so on... I saw today, 1st of May on McDonalds in New Belgrade the words: Stay here (Ostajte ovdje!) famous title of poem written by Aleksa Santic for Bosnian muslims after Balkan wars - but now, I do not dare to say these words, because I can not invite you to stay in democratic Serbia with police forces which is fighting also against civil Belgrade since 9 March 1991 with tanks and armaments. The number of victims we can not compare - but none of the murderers ever was imprisoned and judged... even one who was captured with TV image shooting 24 December 1996 on Knez Mihajlova street...
That is the country we are living in, and we are leaving... both, albanians in huge colons, serbs individually or psychologically - but our future I would like to consider to be the future for all of us, together, although every day makes normal, peacful solution more difficult. Hoping that exodus will have to come to an end, and that you, like my grandfathers in World War I, will cross once again Albania and come back home..
Philippe Lepage, Chef de Service de Pediatrie
Centre Inter-Universitaire Ambroise Pare
7000 Mons, BELGIUM
Tel (work) : 32-65392111, Tel (home) : 32-65364355, Fax : 32-65364238
Date: Mon, 17 May 1999 21:55:21 +0200 (MEST)
From: Dominique.Bounieatuniv-lille1.fr (Dominique Bounie)
Subject: : PFEDA's databases
We are in the process of designing a self-executable version of the Microsoft Access databases that we have already implemented on the PFEDA website (PARTNERS and FOOD databases, respectively directories of resource persons and relief foods, with detailed technical specifications ; the objective with PARTNERS and FOOD is to provide an interactive system for on-line/off-line consultation by users of centralized databases concerning emergencies and eased updating of data, both in the centralized and personal databases ; see : http://www.univ-lille1.fr/pfeda). Once completed, this self-executable version will be available free of charge on PFEDA website.
Presently, these databases are available for on-line consultation on the website and for downloading (as Access files) + further use out of Internet. The self-executable versions will enable to use them without having Access, which could enlarge their diffusion. At this occasion, we intend to improve these databases by adding new headings and new functionalities (for ex. nutritional calculations, design of optimal food rations).
We need advices from nutritionists to design such functionalities. We are therefore requesting your help to improve these databases and to taylor them according your needs ; we would apreciate if you could send us comments and proposals concerning the different provisional versions that we are developping. In order to work efficiently and interactively, we have installed all the necessary files + project description + procedure explanation at the following URL address:
http://www.univ-lille1.fr/pfeda/softs/softs_e.htm (this page is not presently available from PFEDA main menu).
We have only a short time available for this work (until mid-june) and we wish that such an interactivity with possible futur users could speed up the process.
Thank you in adavance for your help,
(PS : this program is designed to work with PC computers + Windows 95, or higher versions)
Date: Mon, 17 May 1999 17:47:59 +0200
From: "Egal, Florence (ESNP)" <Florence.Egalatfao.org>
Subject: Participatory appraisal for nutrition and housheold food security
FAO is planning to prepare guidelines for participatory appraisal in nutrition and household food security (as a complement to the Guidelines for Participatory Nutrition Projects that some of you may know). We are well aware that many colleagues/institutions have experience in this field. We are also concerned to avoid duplication of efforts or material.
We would therefore be pleased to learn what has been exactly produced in this regard and would also like to explore possible partnerships with interested nutrition/household food security experts.
Florence Egal, Nutrition Programmes Service
Date: Tue, 08 Jun 1999 14:30:29 +0100
From: "Bart Burkhalter" <bburkhalataed.org>
Subject: Re: Participatory appraisal for nutrition andhousheold food security
Participatory appraisal for nutrition and housheold food security Florence,
You should take a look at two documents produced by the BASICS Child Survival Project (infoctratbasics.org). One document describes an effort carried out by Judi Aubel with NGOs in Senegal and Burkina Faso. The work is described in "NGO Promising Practices: Building collaborative NGO networks to share lessons learned about commuity health," Nov 1998, authored by Judi Aubel and Bart Burkhalter. The second document is "Summary Report: High Impact PVO Child Survival Programs, Vol 1," Proceedings of an expert consultation at Gallaudet University, Washington DC, June 21-24, 1998, edited by BR Burkhalter and CP Green, and published by BASICS and the CORE Group. This gathering of NGOs presented and analyzed highly successful community projects from throughout the world, many of which were based on participatory approaches, some quite innovative.
Date: Mon, 10 May 1999 16:11:35 +0100
From: Michael Golden <m.goldenatabdn.ac.uk>
Subject: Adolescent and Adult Malnutrition in Famine Situations
Date: 15 Apr 1999
An Ongoing Omission: Adolescent and Adult Malnutrition
in Famine Situations
Peter Salama and Steve Collins consider the quality of the humanitarian intervention during the 1998 emergency in southern Sudan with specific reference to the choice of target groups for selective feeding interventions.
The year of the 1998 famine will go down as another disastrous period in the history of southern Sudan. Once again aid agencies rushed in to deliver services as Operation Lifeline Sudan (OLS) and non-OLS agencies alike, either initiated or expanded operations in response to the humanitarian crisis. The international donors poured millions into OLS, which expanded into one of the largest emergency operations in history. As the rains end and the cease-fire, that has allowed the response in Bahr el Ghazal to continue, draws to a close it will be important to evaluate the quality of the humanitarian intervention in southern Sudan. In particular the prioritisation of resources is a key area that should be closely examined. This article focuses on one aspect of this; the choice of target groups for selective feeding interventions.
The focus on child malnutrition
By August 1998, according to UNICEF figures, there were 18 NGOs operating 50 SFCs and 21 TFCs in Bahr el Ghazal with anticipated numbers of beneficiaries of 40,753 and 6,430 respectively (1). To our knowledge, not one of these centres provided services tailored towards older children and adults. Although some centres did include small numbers of adults, particularly if they were categorised as 'vulnerable' (disabled, elderly, pregnant and lactating women), the inclusion of adolescents and adults was generally on an ad hoc basis. This focus on child malnutrition did not always correspond with the mortality patterns in a given location. In a number of areas these were typical of a late stage in a severe famine, with adult and adolescent deaths out-numbering those of children under the age of five(2). The inappropriately low amount of resources targeted towards acutely malnourished adults and adolescents indicates a failure to rationally prioritise relief interventions in order to address the vital needs of this population.
Past lessons forgotten
Lessons, supposedly learnt in Somalia and Angola, about the importance of treating malnutrition in all sections of the population appeared to have been forgotten. The inattention to the plight of malnourished adults and adolescents, characteristic of most humanitarian responses to famine and war since the Second World War, returned. During 1992 in Baidoa, Somalia, although adults and adolescents accounted for two thirds of recorded deaths, there were almost no specialised nutritional services for these age groups, who were instead, expected to recover on a basic ration of rice and beans (3). The success of the single adult therapeutic centre in the town prompted a rethink as to the importance of adult and adolescent malnutrition in famine. By the following year some lessons had been learnt. In the town of Melange, Angola, where the mortality picture was again similar, with 75% of the bodies buried during the first few months of the aid operation aged more than 10 years, (4,5) adult therapeutic services figured strongly in the response. This increased attention towards adult feeding continued, and in more recent relief operations, for example in the Great Lakes region since 1994, or in Liberia during 1996/7, specialised adult feeding centres have played important roles in the humanitarian response.
Why were malnourished adults and adolescents neglected?
In view of these recent experiences and successes with feeding programmes targeted towards adults, why was this target group neglected in southern Sudan? The reasons are complex. Many factors, such as the inadequacy of the literature on the problems of starving adults, the focus of nutritional epidemiology on the under five age group, inexperience, the short history of contemporary adult selective feeding programmes, media expectations and funding pressures, are all important. These are explored in the following paragraphs.
Diagnosis and treatment of malnourished adolescents and adults still in its 'infancy'
There is little good scientific literature available on the diagnosis and treatment of malnourished adolescents and adults and the tools for assessing these age groups in the field remain primitive. As recently as 1996, Mason et al were unable to find any studies on the relative risk of mortality from under-nutrition in adults (6). There is still little uniformity in the international standards and accepted protocols for adult nutrition programmes. BMI, in vogue for the assessment of chronic malnutrition in adults is problematic. Large individual variations in body shape, particularly the relative lengths of the legs and back can alter individual BMIs by as much as 4 kg/m2 irrespective of nutritional status. Whilst these differences can be corrected on a population level , by adjusting BMI values using the "Cormic Index" (sitting height/standing height), such adjustments are not practical on an individual basis for screening admissions to feeding centres. The height and weight measurements required can also be difficult to obtain in severely malnourished adults. Although admission indicators based upon a combination of MUAC and clinical criteria are being developed, measurement error can be significant and the problem of appropriate discharge criteria remains. For adolescents, especially post-pubertal adolescents (and particularly in the 'nilotic' people of southern Sudan) the level of knowledge is even more basic.
Extended weight for height charts are poor predictors of mortality and extended BMI for height charts have as yet been little used, remain invalidated and are likely to suffer from similar problems as BMI in adults. The use of MUAC for adolescents, although promising, has not yet been adequately explored and no cut-off values exist.
Much research on screening and assessment tools is still needed.
The focus of nutritional epidemiology in famine situations on the under five age group, draws attention away from adults. As a result, the extent of adult malnutrition may not be so apparent to planners. This is particularly so in areas, such as southern Sudan, where famine oedema is uncommon and severe malnutrition in older people, therefore, less easily recognised. The exclusive focus of nutritional surveys on the under five age group (in Sudan less than 115cm) also means that there is usually no baseline indicator against which adult nutritional programmes can be monitored and their impact assessed. This makes it difficult to judge effectiveness or decide when to close programmes. We feel that older age groups should be included in nutrition surveys, especially in locations where famine has been present for a longer period of time.
Inexperience, at both individual and agency levels is another important reason behind the disregard for malnourished adults. In the absence of clear epidemiological data and agency guidelines, the experience of field workers and co-ordinating agencies is all the more important. Generally however, NGO and UN field co-ordinators, managers (as well as funders), are less familiar with implementing adult feeding programmes. Not only may the problem remain unrecognised, but also expectations and the specific difficulties involved in them may be poorly understood.
Complexity of adult feeding programme design
The design of adult feeding programmes is often more complicated than that of child programmes. The potential for adult centres to become quasi-hospices, to contribute significantly to population displacement, or undermine survival strategies and contribute to adverse outcomes for children of the malnourished are factors that need to be taken into account at the design stage (7). Frequently, other illness, particularly chronic infectious diseases such as TB, and HIV will complicate a high proportion of cases. On admission it is extremely difficult to differentiate between malnutrition secondary to these illnesses and primary malnutrition, itself often complicated by other illnesses. These two forms of malnutrition , however, require different approaches to treatment. The absence of tools to quickly identify TB, and the ethical problems involved in the spot diagnosis of HIV, or the treatment of TB in unstable populations, therefore complicate programme design and implementation.
Even in cases where rehabilitation is relatively straightforward, primary malnutrition responds slower to treatment, with a mean length of stay of around 30 days and a mean increase in weight of less than 10 g/kg/day (8). Furthermore in some countries socio-economic factors, such as the pressure on beneficiaries to leave centres to plant crops, or problems of compliance with a milk-based diet and inpatient care, result in higher default rates in adult centres than in those providing care for children. Addressing food preferences through supplementation of diet with local foods in the recovery phase may improve compliance.
Appropriate care must be taken at all times to maintain adult dignity especially in the TFC setting. These differences mean that adult nutrition programmes often require more involved planning and more intensive medical interventions than under five programmes. Even with this, programme results, as defined by successful exits, may be less positive than for childhood programmes. It will be necessary to evaluate adult nutrition programmes using different reference standards, since successful recovery rates of more than 75% or mortality rates of less than 10% are probably unrealistic (9).
Media and public relations
Lastly nutrition programmes for adolescents and adults may not meet media expectations. Amongst the media and the increasingly influential 'agency public relations officers', images of starving infants are deemed to be more powerful in eliciting western sympathies than images of starving adults. The journalist who visited a Concern adult TFC in Sudan and requested 'to see the starving babies' was not an isolated simpleton, but represented a mainstream conception of what the media considers 'sexy'.
Certainties and failure of response
Amidst all this confusion, inadequate information and inexperience, there are some certainties. The first is that in a severe famine, particularly towards the end of its evolution at a time when humanitarian interventions are up and running, severe malnutrition amongst the adolescent and adult population is frequently a major public health problem. Secondly with the correct treatment; 24-hour therapeutic care, with the careful titration of calories given to the weight and stage of recovery, rehabilitation is often successful. Even the most emaciated adults can survive and thrive. Thirdly, it is vitally important to save the lives of adults and older children as these age groups are the most economically productive and, in agrarian or agricultural communities, the major food producers (10). The deaths of mothers and older children have dramatic ramifications for survival of other children and the structure of society. Furthermore the elderly and elders in many communities, particularly where traditions and culture are transmitted orally, are critically important to community and cultural integrity and coherence. We feel that in southern Sudan particularly in Bahr el Gazal, the omission of supplementary and therapeutic feeding, specifically targeting adults and adolescents was a major failing of the humanitarian response. It is time that attention to these age groups in planning and programme design was built into famine relief responses in a systematic and structured manner.
The need for targeted adult and adolescent feeding programmes should always be investigated as part of any famine relief response and when necessary specialised services should be set up. In addition, the many areas of uncertainty outlined above will only be clarified if such programmes are accompanied by operational research to assess the effectiveness of the different indicators and treatment regimens used. For this to progress efficiently, good inter-agency co-ordination is required to ensure the utilization of existing knowledge in this field, standardize protocols and develop a common research agenda.
1 OLS Southern sector update 21/8/98, emergency nutrition programme Bahr el Ghazal, southern Sudan.
2 In Ajiep, the epicentre of the famine in southern Sudan surprisingly the death rates of the adult and under five population registered in August were quite similar. In fact, of the last 513 deaths registered prior to 28/8/98, 231 were less than 20 years of age and 282 were more than 20 years of age. Furthermore in some areas where cattle camps still exist, anecdotal evidence suggests that the under five population may be less vulnerable than older children (who may not have access to cow's milk and milk products).
3 Collins S. 1993 The need for adult therapeutic care in emergency feeding programmes JAMA 270 *5: 637-638.back
4 Concern 1993b, Data from Concern's adult feeding centre, Melanje, Angola.
5 Davies, AP. Targeting the Vulnerable in Emergency Situations: Who is Vulnerable? Lancet, 348 (9031): 868-71 Sept 1996.
6 Mason JB et al. (1996) Undernutrition. In: Murray CJL, Lopez AD, eds. Malnutrition and the burden of disease; the global epidemiology of protein energy malnutrition, anaemias and vitamin deficiencies. Cambridge, Harvard University Press.
7 In some situations it may be appropriate to combine adult and child TFCs or at least situate them on adjacent sites. If this is done, the integration of adults into the programme should be planned from the outset.
8 Collins, S. The limit of Human adaptation to starvation. Nat. Med. 1995; 1:810-4.
9 See Sphere minimum standards in nutritional interventions.
10 Murray CJL and Lopez AD, eds. The Global Burden of Disease, 1996, Harvard School of Public Health, Harvard University Press for the World Bank and World Health Organization.
Peter Salama is medical co-ordinator for emergencies for Concern and was the emergency co-ordinator for southern Sudan between August and December 1998. Steve Collins is an independent consultant in nutrition and health who was involved in the design of the Concern programme for adolescents and adults in Ajiep. Thanks to Annalies Borrel for comments.
Phone: 1850 410510 , email: infoatconcern.ie
Prof. Michael H.N.Golden
Date: Fri, 21 May 1999 11:21:36 +0100
From: David Morley <Davidatmorleydc.demon.co.uk>
Dear Colleagues, If you are working in a situation where hypothermia may occur in newborns or in malnourished or severely ill older children you may be interested in a new device. It is a 12mm black disc with a sticky back.It is placed in the axilla and as long as the temperature of the child is over 35.5C the black disc changes to a green smiling face. It is hoped that mothers will put any infant or child who is cold in close contact with ther body (skin to skin if possible). Anyone interested in trying out a free sample please contact TALC e-mail talcukatbtinternet.com We are interested in qualitative results and the situations in which this low cost device may save lives.
David Morley,Emeritus Professor of Tropical Child Health, University of London.
Tel: & Fax. 44 (0) 1582 712199.
Preferred Address; 51 Eastmoor Park, Harpenden, AL5 1BN. UK.
Date: Mon, 24 May 1999 15:24:31 +0100
From: Michael Golden <m.goldenatabdn.ac.uk>
Subject : Thiamine deficiency and magnesium
This week McLean J & Manchip S (1) describe a patient on oral diuretics who developed life-threatening thiamine deficiency which responded within a few hours to 250 mg thiamine IV, only to relapse within 8 days and require the same treatment. She then developed symptoms suggestive of pyridoxine deficiency whilst under care. She did not recover until it was recognised she was deficient in magnesium and magnesium administered. Thiamine deficiency refractory to treatment until magnesium is given has been reported before (2,3).
The retention of magnesium during the treatment of malnutrition is massive - the body is more avid for magnesium than for most other nutrients (4-10). Clearly, these children are usually very magnesium deficient. The extent to which this determines the symptoms and signs is not known.
Magnesium is not only lost with diuretics, it is the commonest deficiency recognised by adult gastroenterologists in chronic diarrhoea, and yet this is not generally recognised as being common in paediatric practice. Vomiting of pregnancy and a poor diet are other causes.
Of the cereals, polished white rice is particularly low in magnesium - only sago is lower - (White rice 13mg/100g, brown rice 110, bulgur 140, oatmeal 110, wheat flour 120, white wheat flour 31, Rye 92, barley 65, Maize flour 44, Sago 3) - a restricted monotonous rice diet may lead to combined magnesium/thiamine deficiency (as well as other deficiencies).
It is entirely plausible that beri-beri is caused by a combination of moderate thiamine deficiency and moderate magnesium deficiency as often as it is due to severe thiamine deficiency alone. Such combined deficiencies may determine which of the several thiamine deficient syndromes the patient succumbs. At any rate it is important to give additional magnesium to all those at risk of thiamine deficiency as well as thiamine itself.
Despite this, nearly all rations are deficient in magnesium as well as potassium (11). Magnesium is cheap - why has it not been added to blended foods and weaning foods used for children prone to diarrhoea, in adequate amounts? Compelling data of its critical role for the malnourished has been languishing on the shelves of libraries for nearly 40 years.
Magnesium is a cofactor for about 70% of all enzymes - without it thiamine cannot be phosphorylated to its active form. This could account for many of the other effects of an inadequate magnesium intake - as with thiamine these are usually ascribed to a simple deficiency of the nutrient whose metabolism is rendered abnormal.
Thus, potassium is lost and potassium supplements not retained without magnesium - indeed, even in with gross potassium deficiency, potassium supplements are often useless without magnesium, whereas magnesium supplementation ALONE frequently restores potassium to normal (12-14), a fact ignored by most prescribing diuretics. Potassium depletion is almost universal in malnutrition - the extent that this is simply secondary to Mg deficiency is unknown.
Rickets and osteomalacia can be totally refractory to treatment with vitamin D in the face of magnesium depletion - and Mg depletion alters the responses of bone to calcium mobilising hormones. The very frequent costo-chondral bossing (rickety rosary) in malnutrition could be due to phosphorus or calcium deficiency - however, magnesium deficiency could add to the symptoms and has not been studied - this could be one reason for the high prevalence of rickets in many poor tropical countries.
Magnesium is one of the forgotten nutrients. Why I am not sure - perhaps because there are no clearly recognisable signs and symptoms of deficiency. However, the data are clear. There is no excuse for continuing to formulate weaning and relief diets that fail to give adequate amounts of magnesium when populations are prone to diarrhoea, malnutrition, rickets or beri-beri.
1) McLean J & Manchip S "Wernicke's encephalopathy induced by magnesium deficiency" Lancet 353; 1768, 1999)
2) Zieve L "Influence of magnesium deficiency on thee utilization of thiamine" Ann NY Acad Sci 162; 732-743; 1969
3) Dyckner T, Ek B, Nyhlin H, Wester PO "Aggrevation of thiamine deficiency by magnesium depletion" Acta Med Scand 218; 129-131; 1985
4) Montgomery RD. Magnesium metabolism in infantile protein malnutrition. Lancet 1960;2:74-76.
5) Montgomery RD. Magnesium deficiency and tetany in kwashiorkor. Lancet 1960;ii:264
6) Montgomery RD. Magnesium balance studies in marasmic kwashiorkor. J.Pediatr. 1961;59:119-123.
7) Caddell JL. Magnesium in the therapy of protein-calorie malnutrition of childhood. J.Pediatr. 1965;66:392-413.
8) Caddell JL. Studies in protein-calorie malnutrition. 2. A double-blind trial to assess magnesium therapy. N.Engl.J.Med. 1967;276:535-540.
9) Caddell JL, Goddard DR. Studies in protein-calorie malnutrition. 1. Chemical evidence for magnesium deficiency. N.Engl.J.Med. 1967;276:533-535.
10) Pretorius PJ, Wehmeyer AS, Theron JJ. Magnesium balance studies in South African Bantu children with kwashiorkor. Am.J.Clin.Nutr. 1963;13:331-339.
11) Michaelsen KF, Clausen T. Inadequate supplies of potassium and magnesium in relief food: implications and countermeasures. Lancet 1987;1:1421-1423.
12) Whang R, Whang DD, Ryan MP. Refractory potassium repletion. A consequence of magnesium deficiency. Arch.Intern.Med 1992;152:40-45.
13) Dorup I, Clausen T. Correlation between magnesium and potassium contents in muscle: role of Na(+)-K+ pump. Am.J.Physiol. 1993;264:C457-C463
14) Dorup I, Skajaa K, Thybo NK. Oral magnesium supplementation restores the concentrations of magnesium, potassium and sodium-potassium pumps in skeletal muscle of patients receiving diuretic treatment. Journal of Internal Medicine 1993;233:117-123.
Prof. Michael H.N.Golden