Towards the Overdue Elimination of Deficiency Disease Epidemics
By André Briend
Andre Briend is a medical doctor, working for the Institut de Recherche pour le Développement (IRD), a French public research institution with a mandate to carry out research for developing countries. Until recently, he was a consultant for Nutriset, a commercial company producing food products for emergency relief.
Nutritional deficiency epidemics are all highly predictable. Softwares are now available to flag nutrients missing in a ration, making epidemic prediction easy. Indeed, there is no excuse for being taken by surprise by a deficiency disease epidemic.
Angular stomatitis seen in Myanmar refugee living in camp in Coxs Bazar
The daily menus for refugees and displaced people are remarkably similar throughout the world. They receive a cereal staple food, very often maize, beans and oil, which are the cheapest source of energy, protein and lipids available on the world market.
A diet based on maize, beans and oil has no vitamins A, C, B12, and a very low content of vitamin B2, folic acid, niacin, absorbable zinc and iron. It is not physiologically possible for refugees to live for long periods of time on such a diet and compares unfavourably with the nutrient content of most pet foods (see table 1). Consequently, one of the first things refugees do, if they can, is sell part of their ration to buy foods containing the missing nutrients1. If this is not possible, within a few weeks they fall ill with one of the many deficiency diseases reported every year, including pellagra, scurvy and beriberi2.
Blended flours as a safety net, or not?
Following repeated, and often large scale, epidemics of deficiency diseases among refugees, the decision was taken in the early 1990s to add blended flours to the list of foods systematically distributed to refugees. Fortified with vitamins, the introduction of blended flours, such as Corn Soy Blend (CSB) and Unimix, has undoubtedly played a role in the prevention of massive deficiency epidemics. Yet, their choice was based mainly on low cost and availability in food aid circuits - they were never designed to prevent nutritional deficiency epidemics. Hence, they are poorly adapted for this purpose and provide only a weak safety net.
Blended flours typically contain (after cooking) 30 mg of vitamin C and 8 mg of niacin per 100g of flour3. When logistical conditions are difficult or air transport is needed, their low nutrient density makes them an extremely poor option to prevent deficiency disease epidemics. For example, transport of one metric tonne of CSB provides only 300 g of vitamin C and 80 g of niacin, when a smaller quantity of a more nutrient dense product could be used instead. Not surprisingly, deficiency epidemics persist in areas difficult to access for logistical reasons.
The low quantity of vitamins in blended flours also has cost implications. For example, the cost of providing vitamin C using CSB, at about 0.5 _ per kg, is 160 times higher than the cost of the vitamin C in a chemical form4. Cost differences are similar or even higher for other vitamins. These ratios are quite unfavourable for food aid programmes run on a tight budget, as is usually the case.
The practical implications are staggering. In the spring of 2002, the Lancet reported a scurvy outbreak in Northern Afghanistan5. Although predicted by many, including high level UN nutritionists, a scurvy outbreak still occurred and people died. Why? Because the international aid community failed to send the equivalent of 0.0001 _ of vitamin C per person per day to the population at risk, despite several months of advance notice. Even if the logistical and technological constraints increase the real cost by a factor of 10 or a 100, this cost remains incredibly low. The lack of timely, adequate response remains difficult to explain. Considering the price of all nutrients involved in recent nutritional deficiency epidemics is incredibly low when purchased in chemical form6, persistence of these deficiencies epidemics IS unforgivable.
The absurdity of the present situation leads to a key questions. Why do NGOs, who so often pride themselves on their advocacy campaigns, remain silent about the situation? Even NGOs who lobby for control of forgotten diseases in poor countries seem to have forgotten nutritional deficiency diseases.
Necessary involvement of industrial partners
Pellagra seen in patient attending MSF-B clinic in Kuito, Bie Province
Some micronutrients, such as niacin, needed to prevent pellagra, have a very unpleasant taste, while others are toxic at high doses. For these reasons, it is necessary to incorporate nutrients in a chemical form into a food with a pleasant taste but also a volume (or a taste) which prevents over consumption. This approach is much more successful than providing multi-vitamin tablets, which are difficult to distribute and always poorly accepted. These constraints imply that the food industry must be involved in deficiency disease prevention because only they have the expertise needed to develop appropriate food carriers with the optimal nutrient weight /cost ratios. Technically, there are no apparent major obstacles preventing the development by the industry of highly fortified foods, with nutrient/weight ratios 50 or even 100 times higher than in CSB, and a favourable nutrient/cost ratio.
|Table 1 Comparison of nutritional composition of a typical refugee ration (without addition of blended flour) with that of pet food|
|Food||Vitamin B2||Vitamin B1||Niacin||Folic acid||Vitamin C||Vitamin A||Cases|
Adapted from Tomkins and Henry, 19927. Note: Vitamin C is not an essential nutrient for most animals, with the exception of guinea pigs and primates.
Consequences of the NGO's medical culture
The need to involve the food industry in the prevention of nutritional deficiency diseases may be a major stumbling block in improving the current refugee situation. Headquarters of NGOs working in relief are usually staffed by health professionals with a medical bias, who are not used to consulting the food industry. Arguably, nutritionists working in NGO or UN agencies could have played a role to promote food based prevention of deficiency diseases, but being suspicious of the food industry has long been part of their professional culture. This may stem from previous dishonest attempts to promote breast milk substitutes by some wellknown companies.
Changing attitudes to prevent epidemics
A relationship between NGOs and the food industry must evolve and a dialogue must start if we want to eliminate the remaining deficiency disease outbreaks. Minerals and vitamins can be incorporated into a vast range of foods and there are many choices available, ranging from vitamin C in candies to the addition of iron to salt.Tasks should be clearly defined for each partner, relating to product development on the industry side and evaluation for the NGOs.
In conclusion, the current situation of continuing deficiency epidemics will change only if NGOs recognise that their attitude must change. A preventive approach should be adopted and the alarm bell rung as soon as it is noted that the level of any key nutrient is low in the ration used to feed refugees. Blended flours have proved unsuccessful in preventing deficiency disease. A dialogue must begin with the food industry to develop and field test alternative solutions.
For further information, contact André Briend, email: firstname.lastname@example.org
1Reed BA, Habicht JP. Sales of food aid as sign of distress, not excess. Lancet. 1998; 351: 128-30
2Toole JM. Micronutrient deficiencies in refugees. Lancet 1992; 339: 1214-5
3Report of a workshop on the improvement of the nutrition of refugees and displaced people in Africa. Machakos, Kenya, 5-7 December 1994. University of Nairobi.
4Vitamin C bought in bulk costs about 10 euro per kg. If one estimates daily requirements at 100 mg, or 10-4 kg, these requirements represent a cost of 10-3 euro. The prevention of scurvy requires much less vitamin C, about 10 mg per day, at a cost of 0.0001 euro.
5Ahmad K. Scurvy outbreak in Afghanistan prompts food aid concerns. Lancet. 2002; 359: 1044.
6Similar calcuations to vitamin C, see footnote 4
7Tomkins A, Henry CJK. Comparison of nutrient composition of refugee ration and pet foods. Lancet 1992; 340: 367
More like this
FEX: Appropriate Vitamin C Fortification Levels for CSB?
Report summary : The Institute of Medicine In 1995 the Senate Appropriations Committee Report directed USAID to initiate a pilot programme to increase the vitamin C content of...
FEX: Outbreak of micronutrient deficiency disease: did we respond appropriately?
By Dianne Stevens, Patricia Araru and Buwa Dragudi, Save the Children (UK) Dianne Stevens is a nutritionist with a Masters in Public Health and Tropical Medicine. She has been...
FEX: Persistent Micronutrient Problems among Refugees in Nepal
by Janack Upadhyay This article describes nutritional aspect of emergency food aid in Bhutanese refugee camps in Nepal; the author was regional Food & Nutrition...
FEX: Micronutrients - The Basics
Taken from draft guideline material prepared by Fiona Watson, Institute of Child health, London. Micronutrients are essential for life and are distinct from macronutrients...
FEX: Potential of Using QBmix to Prevent Micronutrient Deficiencies in Emergencies
By Evelyn Depoortere, Epicentre Evelyn Depoortere is currently a medical epidemiologist for Epicentre. Previously she worked on several MSF missions, including Southern Sudan...
FEX: Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018
View this article as a pdf Read the postscript to this article here. Summary of research1 Location: Kenya What we know: Refugee populations dependent on food assistance are...
FEX: A pellagra epidemic in Kuito, Angola
By Sophie Baquet and Michelle van Herp Sophie Baquet is the headquarter nutritionist in MSF Belgium and Michel van Herp, Headquarters epidemiologist in MSF Belgium. This...
en-net: Type 1 and Type 2 Nutrients
I have been reading several articles on classification of nutrients as type 1 and type 2 based on how the body responds to their deficiencies. I am confused that all vitamins...
FEX: Recurrent pellagra in Angola
Summary of report* Since March 1999, successive waves of people have arrived in the town of Kuito, Angola, displaced by fighting in their native Bie province. As a result,...
FEX: Acceptability and use of cereal-based foods in refugee camps: case studies from Nepal, Ethiopoa and Tanzania
By Catherine Mears with Helen Young Outbreaks of scurvy, pellagra and beri beri among refugees in the 1980s caused a public outcry, as many of these more unusual deficiency...
en-net: Upto what extend iron flour fortification can increase the Hb level of anemic adolescent women if iron fortified wheat flour is feed to these anemic adolescent women for 3 months?
i am doing my Mphil research on iron wheat flour fortification for anemic adolescent women. can any one have any information or relevant site or paper that how much it will...
FEX: The use and acceptability of micronutrient enriched foods
A study by Oxfam, UNHCR and Micronutrient Initiative. Emergency general rations supplied by the international aid community have frequently failed to supply adequate amounts...
FEX: Scurvy outbreak and erosion of livelihoods masked by low wasting levels in drought affected Northern Afghanistan
By Fitsum Assefa Signs of scurvy: blackness of the legs indicative of haemorrhage Fitsum Assefa is a nutritionist who recently joined Save the Children, United States (SC/US)...
en-net: Sphere Project 2010: Consultation on the Revision of Micronutrient Indicators
As part of the ongoing work on revising the 2004 Sphere project hand book, I have been asked to initiate an informal consultation and discussion. This has the aim of...
FEX: Micronutrient research in progress
Examination for scurvy in Tanzania An article in the last issue of Field Exchange presented a review of the approaches that agencies and others use for identifying...
FEX: Developing food supplements for moderately malnourished children: lessons learned from RUTF
Summary of research1 Location: Global What we know: RUTF is as effective as F100 in treating SAM, where weight gain is the recovery outcome. Food supplements for moderate...
FEX: Further perspectives on scurvy outbreak
View this article as a pdf This is a poscript for the field article 'Scurvy outbreak among South Sudanese adolescents and young men - Kakuma refugee camp, Kenya,...
FEX: Derivation of nutrient requirements for disaster-affected populations - Sphere Project 2011
Summary of research1 Location: Global What we know: The Sphere Handbook defines minimum standards and indicators for assessing humanitarian responses, including food and...
FEX: Angular stomatitis and riboflavin status
Summary of published paper1 Severe angular stomatitis Between 1990 and 1993, fear of persecution led 83,000 ethnic Nepalese to flee from Bhutan to refugee camps in Nepal....
FEX: Issue 10 Editorial
Dear Readers, Over the past ten years large-scale outbreaks of pellagra have only occurred amongst populations dependent on emergency food aid. The most recent outbreak in...
Reference this page
André Briend (). Towards the Overdue Elimination of Deficiency Disease Epidemics. Field Exchange 21, March 2004. p13. www.ennonline.net/fex/21/towards