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Hunger and technology
Home-prepared food supplements, mothercraft centres, and nutrition in Haiti
Gretchen G. Berggren
Harvard School of Public Health, Department of Population Sciences, Boston, Massachusetts, USA
At least two-thirds of Haitian children suffer from protein-energy malnutrition. Nutrition workers in Haiti have attempted to solve this problem through development of an appropriate cereal-legume blend-using locally available products-that mothers can prepare and feed to their children. The message about this "weaning food" has been successfully transmitted through nutrition rehabilitation centres that function on the village level.
Haiti is reputed to be the poorest country in the western hemisphere. Located in the Caribbean Sea and occupying the western third of the island of Hispaniola, Haiti is populated by descendants of slaves brought over by French colonialists in the seventeenth century. Haiti became France's wealthiest colony, exporting mahogany, rice, tobacco, coffee, sugar, and cotton. When the slaves overthrew their French masters in 1804 and gained independence, they inherited already deforested hillsides in a country considered only 20 per cent arable. Although irrigation schemes have helped somewhat with development, today Haiti still suffers agricultural problems, made worse by soil erosion, periodic hurricanes, and rapid population growth.
Following the example of their colonial masters, Haitian peasant farmers continued to grow cash crops after independence. But the French would buy no more sugar or rum, and coffee and cocoa plantations demanded care and expertise in marketing. Food crops, on the other hand, were grown with the most primitive methods of agriculture, with irrigation being rarely available in the few river valleys. Rice, corn, millet, and cassava became the staples, supplemented by beans of several varieties. Dairy herds found little chance for survival because of parasitic infestations. Goats and pigs were kept by peasants as a kind of hedge against future emergencies: these can easily be sold when cash is needed. But a regular supply of animal protein for the family diet has been, and remains, a luxury.
The population has not only survived but has actually expanded, from about 500,000 in 1789 to more than 5 million persons. Today, one-fifth of the country's total of 2,775,000 hectares of land is arable flat land and one-seventh is arable mountainous terrain. There has been little progress since 1959, when only 200,000 hectares of the potential 500,000 were available for agriculture (1). Irrigated rice is produced in the valleys, but Haiti has had to become a rice-importer to meet the needs of its burgeoning population. In the 1960s, Haiti produced corn, millet, cassava, sugar cane, sweet potatoes, plantains, rice, beans, coffee, yams, peanuts, and cocoa. In the 1980s, tobacco was added to the list. Haiti, however, continues to have one of the most malnourished populations in the western hemisphere.
Malnutrition in Haiti may have existed since slave days. The Creole word for kwashiorkor, ti-moun enflee, is a familiar part of the vocabulary of the very elderly Haitians. Protein-energy deficiency with manifest oedema was described as the "mysterious swelling disease of Haitians" in the 1920s (2). As a corollary, childhood mortality has remained elevated. Estimates for infant mortality were as high as 200 during the 1950s; Vilgrain estimated 171.4 deaths per 1,000 live births (3).
Sebrell (1) conducted a nutrition survey in which he documented that 47 per cent of all deaths in Haiti occurred in pre-school children. Nation-wide surveys revealed that Haitian children suffered from iron deficiency anaemia as well as protein-energy deficits (4). These and similar findings led to the establishement of Haiti's Bureau of Nutrition in 1959.
MALNUTRITION IN HAITI
Concern about childhood malnutrition and high childhood mortality rates led to the training of several Haitians as public health physicians in the 1950s. One of these physicians, Dr. Carlos Boulos, conducted surveys confirming the paucity of protein and calorie intake and the value of an industrial supplementary feeding programme. In 1954, he sponsored the first nutrition survey, which led to the publication of material on oedema resulting from protein-energy malnutrition in Haiti (5; 6).
Subsequent surveys found 3 to 7 per cent of Haitian preschool children with kwashiorkor (1; 7). Beghin (4) described between one-quarter and one-half of pre-school children as having second- and third-degree malnutrition according to the Gomez standard. Most Haitian infants are breast-fed and grow normally until about the fourth month of age, after which their growth becomes retarded according to international standards (8).
Lysine fortification of wheat flour was tried experimentally in 1960 in the form of bread, a favourite "luxury food" in Haiti. A study of 600 school children revealed that adding bread to the diets greatly enhanced growth, with or without the addition of Iysine (9). This remarkable result, as well as increasing concern about kwashiorkor in rural Haiti, led Dr. William Fougère, head of the Bureau of Nutrition, and others to document the problem more accurately and search for a solution to Haiti's nutrition problem.
Hospital and clinical records revealed that deficits in food nutrients resulted commonly in clinical diagnosis of kwashiorkor, marasmus, keratomalacia, ariboflavinosis, and anaemia during the 1960s (4). Food patterns from dietary surveys in rural Haiti revealed that deficits in foods rich in vitamin A were related to extreme seasonal fluctuations in availability (10). Calcium composition tended to fall in a range of 200 to 400 mg per day. Survey results showing calorie deficits as low as 1,000 cal per day were further analysed by King, as summarized in table 1.
Future plans call for utilization of primary health care workers to carry out nutrition monitoring and to transmit the message about timing of food supplementation, appropriate culinary techniques, and the importance of more frequent and generous meals.
TABLE 1. Percentage Contributions of Protein, Fats, and Carbohydrate to the Total Caloric Supply of Rural Haitians
|Area||Period||Per cent of total calories|
|Fond Parisien||Aug. 1964||8||27||65|
|Fond Parisien||Dec. 1964||9||20||71|
Source: ref. 10.
Foods available in the local market, on the other hand, were shown by King, Fougère, and others to be subject to seasonal fluctuation, but plentiful enough and adequate in quantity for pre-school children (1). Furthermore, Haitian children in the upper socio-economic groups received enough nutrients to grow at normal rates, while children in lower socio-economic groups dropped to a "norm" equal to the third percentile of Boston children after six months of age (11). The staff of Haiti's Bureau of Nutrition determined that Haitian pre-school children did not consume enough foods such as millet, corn, red beans, pigeon peas, leafy vegetables, and mangos, although these were inexpensive and readily available.
From the beginning, the staff of Haiti's Bureau of Nutrition sought not only to develop appropriate weaning foods, but to focus on the best method of transmitting information about such foods to mothers. They adopted a concept introduced by Bengoa in 1964, that of educating by demonstrations on nutrition through village-level Mother-craft Centres (12). While plans were evolving for these centres, eight target criteria for an appropriate weaning food multi-mixture were adopted (12). Nutritionists decided to search for a cereal legume blend which
- had ingredients restricted to those common on rural markets,
- had a maximum of two components to simplify teaching of mothers,
- was amenable to current cooking practices,
- was free from toxicity,
- had sustained acceptance as a major food,
- had 12 to 15 per cent crude protein with a PER of 1.7 to 2.0,
- was able to support growth,
- had minimum cost.
Developing a Weaning Food from Locally Available Produces
From 1961 to 1963, King and co-workers tested samples of 87 different mixtures of cereals and legumes from rural Haiti. Each ingredient was identified taxonomically and nutritionally and analysed for calorie, crude protein, true protein, and amino-acid composition (13). Mineral composition was also analysed (14), and variations in samples from products grown in different geographic areas of Haiti were taken into consideration. Sirinit showed, through proximate analysis, that these locally available foods, combined in various multi-mixes, not only met desired nutrient content criteria but supported normal growth in rats (15).
Three blends made by mixing rice, corn, or sorghum (70 per cent) with red, white, or black beans (30 per cent) were found to be most promising in terms of raw material availability, biological value of protein, and cost (16).
All three blends were fed at high levels of intake for seven to eight weeks to pre-school children with second- and third-degree malnutrition. A good nutritional rehabilitation was achieved. Oedema disappeared in three weeks, and anthropometric measurements and serum protein levels increased significantly. Neither toxicity nor intolerance was observed. Acceptability was excellent throughout the study. It was concluded that the blend could contribute to the eradication of protein-calorie malnutrition in Haiti in three ways: (i) by home-manufacturing and utilization by low-income mothers; (ii) by commercial distribution in cities and institutions; and (iii) by allowing a more rational use of some of the food surpluses from highly developed countries (16).
Transmitting the Message
Haiti was one of several countries that launched nutrition education and rehabilitation centres, or "Mothercraft Centres," as a means of transmitting the message about appropriate weaning foods (17). A two-year evaluation of the effectiveness of such a centre, published in 1968, showed that mothers of malnourished children learned to prepare and use appropriate cereal-legume blends effectively. After dismissal from the centre children held their own even in the face of a worsening economic situation when compared to a control group (18).
Further evaluation was carried out by W.L. Berggren, not only of the rehabilitation of children treated for three months in the Mothercraft Centres but also of growth of younger siblings after their mothers had been educated (19). He observed that two to five years after discharge of an original crass, 75 per cent of younger siblings had a higher percentage of standard weight than the original enrollees. Furthermore, data from a hospital in the district showed that from 1968 to 1975 admissions for severe protein-energy malnutrition fell to less than half their initial level in the 100,000-person district served by Mothercraft Centres. At the same time, admissions from nearby districts that were not served by the centres remained constant or tended to rise. The difference was found to be statistically significant (p < 0.0235). In agreement with this, deaths attributable to uncomplicated protein-energy malnutrition in children aged zero to four years fell from 12 per 10,000 persons to 2 per 10,000 during the same period (20).
Does the message about the use of appropriate weaning foods last in a community after a Mothercraft Centre has closed and the educator has moved on to other communities? In Fond Parisien, two years after closure of a Government-sponsored centre, only 3 per cent of the children felI into third-degree malnutrition, compared to 13 per cent before nutrition education through the Mothercraft Centre had begun. Better use of locally available foods was also observed.
Marketing a Weaning Food in Haiti
In 1966 the Haitian Bureau of Nutrition collaborated with the Quaker Oats Company to produce a centrally processed weaning food comparable to the cereal-legume blend used successfully in the Mothercraft Centres. In the centres, mothers learned to combine pureed beans with a cereal product such as boiled corn meal mush. The producers hoped that a milled product, attractively packaged, would not only be more convenient, but could cut down use of costly fuel. The product was named "Ak-a-Mil" ("Ak-a-1,000") since it was alleged to be "ten times better" than the usual starchy gruel fed to weanling children, called akasan ("ak-a-100") in Creole.
Nutritionists from Quaker Oats and the Haitian Bureau of Nutrition decided to fortify the product with vitamins and iron and to test marketability in the pert-urban areas. A local company produced and tested the product, fortifying it with the same formula of vitamins used to enrich US flour at the time. It was packaged in one-half-pound to one-pound plastic bags and tested on local markets. After two years of testing, it was decided that the cost of purchasing the cereals and beans and cleaning, storing, grinding, enriching, packaging, and marketing them was too great to permit marketing the product at a price poor families could afford. It was therefore concluded that "no market potential existed" for the product (K.W. King, personal communication, 1981).
Recently, the Bureau of Nutrition has observed increasing use of laundry starch and other inappropriate products as weaning foods in the deprived pert-urban areas. Renewed interest in the necessity of marketing a low-cost, centrally processed weaning food from locally available products in Haiti will be encouraged for the benefit of the burgeoning population of factory workers now streaming into the capital city.
THE ROLE OF WEANING FOODS IN THE CONTEXT OF NUTRITION MONITORING BY PRIMARY HEALTH CARE WORKERS
Thoughtful papers on preventive and therapeutic benefits related to cost pointed to the continued usefulness of Mothercraft Centres as recently as 1975-1978 (21; 22). However, following the thrust of the World Health Organization's campaign "Health for All by the Year 2000," Haitian health personnel are now developing methods for primary health care workers to accomplish nutrition monitoring and education about weaning foods.
Berggren used locally trained primary health care workers to play a key role in nutrition monitoring in their own villages (23). These workers learned to weigh and measure children, as well as to distribute, interpret, and up-date growth charts.
Targeted supplementary feeding was used only for those cases where the mother could not overcome growth deficits using pureed beans and rice, corn, or millet in the manner taught by the primary health care worker. An analysis of the responsibility of these workers carried out by the Integrated Project of Health and Population in the Petit Goave area appears in table 2.
REVISING THE CONTENT OF THE NUTRITION MESSAGE
In Haiti, as in much of the third world, the most appropriate nutrition message to be taught will vary from rural to urban areas. Mothers in deprived pert-urban areas have no "kitchen gardens" and must learn how to buy the best combination of nutrients per unit of cost; mothers in rural areas need to learn how to get the best nutrient combination per unit of garden space. The challenge that faces Haiti's nutritionists is constant, careful, continued monitoring of troth the agricultural and the local market situation. In 1980, the author observed that buying an adequate supply of cow's milk would use Up nearly half the income of the average poor, working-class mother in Port-au-Prince. Cooking oil and sugar have become so costly that mothers in both urban and rural areas must depend more and more on cereals. Beans are becoming a luxury for the urban poor, and meat is out of the question.
TABLE 2. Analysis of the Responsibilities of the Primary Health Care Worker in the Nutrition of Children during the Weaning Process in Rural Haiti
|Registers all 0-5-year-old children pregnant women in the community and maintains a check||Comprehension of the definitions of marasmus, kwashiorkor, protein-energy malnutrition||Understands importance of nutrition and monitoring|
|Invites mothers and children to health rallies or well-baby clinics for monitoring||Role of carbohydrates, protein, vitamins, and iron in nutrition; sources of these nutrients in local foods||Cares about children in the community enough to ferret out those who nutrition fail to come to nutrition-monitoring sessions|
|Weighs/measures children and completes and interprets "Road- to-Health" weight/age cards for mothers||Timing of supplementation Necessity of regular nutrition monitoring to prevent malnutrition||Understands role of birth spacing in prevention of malnutrition|
|Identifies target populations and maintains distribution of food supplements to children whose growth falters||Appropriate methods of preparing locally available foods||Is willing to make nutrition message understandable to mothers|
|Determines which children are eligible for referral to nutrition centre or clinic||Importance of preventing infection in malnutrition; principles of prevention and early referral|
|Teaches oral rehydration skills||Role of regular, frequent feedings|
|Role of rehydration in diarrhoea|
|Role of "re-feeding" children recovering from infections|
The role of a central agency, such as the Bureau of Nutrition, in tailoring and revising the appropriate nutrition message for primary health care workers remains a continuing challenge. In addition, this central unit will provide expert advice on the need (if any) for and use of imported foods to supplement Haiti's diet.
1, W.H. Sebrell, Jr., S.C. Smith, E.L. Severinghaus, H. Delva, B.L. Reid, H.S. Olcott, J. Bernadotte, W. Fougère, A,P, Barron, G. Nicolas, K.W. King, G.L. Brinkman, and C.E. French, "Appraisal of Nutrition in Haiti," Am. J. Clin. Nutr., 7:1-48 (1959).
2. W.L. Mann, J.B. Helm, and C.J. Brown, "An Edema Disease in Haiti," J.A.M.A., 20 Nov. 1920.
3. J. Vilgrain, "Caractéristiques de la population haïtienne," Bull. de l'lnstitute Haïtien du Statistique, vols. 19 119551. 20 (1955),21 (1956).
4. I.D. Beghin, W. Fougère, and K. King, L'alimentation et la nutrition en Haïti (Presses Universitaires de France, Paris, 1970), p. 153.
5 C. Boulos, "Une Enquête alimentaire en Haiti," Bull. de L 'Association Médicale Haïtienne, vol. 6 (1954).
6. C. Boulos, "Oedème de carence," Sem. Hop. de Paris, vol. 30 (1954).
7. D.B. Jelliffe and E.F.P. Jelliffe, "The Nutrient Status of Haitian Children," Acta Trop. (Baser) 28:1-45 (1961).
8. Bureau of Nutrition, Department of Public Health and Population, Republic of Haiti, Haiti Nutrition Status Survey: 1978 (Bureau of Nutrition, Port-au-Prince, 1978).
9. K.W. King, W.H. Sebrell, Jr., E.L. Severinghaus, and W.O. Storvick, "Lysine Fortification of Wheat Bread Fed to Haitian School Children," Am. J. Clin. Nutr., 12:36-48 (1963) .
10. K.W. King, G. Dominique, G. Uriodain, W. Fougère, and l.D. Beghin, "Food Patterns from Dietary Surveys in Rural Haiti," J. Am. Dietet Assoc., 53:114-118 (1968).
11. K.W. King, J. Foucauld, W. Fougère,, and E.L. Severinghaus, 'Height and Weight of Haitian Children," Am. J. Clin. Nutr., 13:106-109 (1963).
12, J.M. Bengoa, "Nutrition Rehabilitation Programmes," J. Trop. Pediat., 10: 63-64 (1964).
13. K. King, "Development of All-Plant Food Mixture Using Crops Indigenous to Haiti: Amino Acid Composition and Protein Quality," Econ. Bot., 18:311-322 (1964).
14. K.W. King and N.O. Price, "Mineral Composition of Cereals and Legumes Indigenous to Haiti," Arch. Latinoamer. Nutr., 26:213-291 (1966).
15. K. Sirinit, A.M. Soliman, A.T. Van Loo, and K.W. King, "Nutritional Value of Haitian Cereal Legume Blends," J. Nutr., 86:415-423 (1965).
16. K.W. King, W. Fougère,, and l.D. Beghin, "Un Melange de protéins vegetates (AK-1000) pour les enfants haïtiens," Ann. Soc. Belg. Med. Trop., 46:741-745 (1966).
17. A Practical Guide to Combating Malnutrition in the Preschool Child (Appleton-century Crofts, The Meredith Corporation, New York, 1970).
18. K.W. King. I.D. Beghin, W. Fougère,. G. Dominique, R. Grinker and J. Foucauld, "Two-Year Evaluation of a Nutritional Rehabilitation (Mothercraft) Center," Arch. Venez. Nutr., 18:245-261 (1968).
19. W.L. Berggren, "Evaluation of Effectiveness of Education and Rehabilitation Centers," Proc. Western Hemisphere Nutrition Congress, III: 84 87 (Futura Publishing Co., Mt. Kisco, N.Y., USA, 1971)
20. "Evaluation of the Impact of Mothercraft Centers on Therapy and Prevention of Malnutrition," Nutr. Rev., 35:275-278 ( 1978).
21. K.W. King, "Mothercraft Preventive Centers, " Am. J. Clin. Nutr., 28:435-437 (1975).
22. K.W. King, W. Fougère,, R.E. Webb, G. Berggren, W.L. Berggren, and A. Hilaire, "Preventive and Therapeutic Benefits in Relation to Cost: Performance over 10 Years of Mothercraft Centers in Haiti," Am. J. Clin. Nutr., 31:679-690 (1978).
23. W.L. Berggren, B.C. Ewbank, and G.G. Berggren, "Reduction of Mortality in Rural Haiti through a Primary Health Care Program," New Engl. J. Med., 304 :1324-1330 (1981).
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