From: Glenn Geelhoed
To: Internet:nutrtn1@upstate.edu
Date: 6/28/01 10:05AM
Subject: NUTRTION AND DEVELOPMENT:
Dear Michael:
I promised!
I am just now packing up for several Himalayan medical missions‑‑complete with one pallet of medicines and one pallet of surgical equipment and nutritionals (and a carry‑on bag of personal effects, not the least of which are my GPS, laptop, cameras and film to report back!)‑‑but, first, I wanted to be sure you received the editorial I had promised.
In addition to sending this down the line in Word electronically, I am sending hard copy with supporting materials, including the New York Times clipping on African obesity that I cannot believe I had saved and had on my desk fortuitously when your request for a covering editorial came in.
It was a pleasure to accommodate your request, both in the original review and in the writing of this editorial.
Enjoy Summer in Syracuse!
GWG
NUTRITION AND DEVELOPMENT IN AFRICA:
RISK FACTORS ON EITHER SIDE OF THE ECONOMIC FULCRUM
The hallmark evidence of malnutrition in the developing world is starvation-- the tragic inadequacy of macro- and micronutrients for the energy requirements of a majority of some populations. As an indicator of the short, brief leap in perceived economic transition, an emerging plague is now recognized in obesity, the characteristic malnutrition disease of the developed world. The meta-analysis of trends in Sub-Saharan Africa published in this issue of Nutrition by Walker, Walker and Adam examines the rather abrupt nature of this transition in energy imbalance in the process measured as development by most economic indicators. As many diseases as follow in train behind the underlying debility of malnutrition, it is well to look ahead to the spotty nutritional over correction occurring in developing world populations to project what further illnesses are becoming more prevalent following the noveau-obesity epidemic. The burden of illness that follows this new wave of malnutrition is much more costly in terms of health manpower and technology investments in single individual's care, as the model of any first world hospital filled with consequences of metabolic, cardiovascular, CNS and renal degenerative disorders would predict.
It is important to emphasize that “third world” is a descriptor of populations living both within and outside any political border and reflects much more coercive social, economic and cultural motives and their stigmata than is reflected by a passport. Economic transitions occur much too rapidly to have their consequences attributed to genetic change—indeed, many of the changes noted are intragenerational, and distinct from the aging process. This genetically “given” status is actually encouraging, since it suggests that the acquired abnormality may be based in learned, and unlearnable, behaviors, an epiphany which is actually empowering to medical and public health practices of prevention.
One model of coerced transition may be the tragedy of African enslavement over the centuries preceding this millennial pause for historic reflection. If Africans were taken from their home environments and cultural practices and transshipped to the new world for their labor, the few generations that have passed since this practice was stopped cannot account for the remarkable difference in the incidence of non-communicable diseases prevalent in the new world setting and nearly unknown at their origin only an evolutionary eyeblink before. In on-going Diaspora project studies, some African-American investigators have postulated (1) hypotheses to explain why, for example, black citizens of Washington DC should have a rate of hypertension, diabetes, renal failure, stroke and certain cancers that is several times higher than that of their neighbors of non-African origins, while such conditions were rare to non-existent only four to six generations ago in an African setting. The harshness of the Middle Passage in the slaves/molasses/run triangle may account for this as an “evolutionary knothole” through which this unnatural selection occurred, if the tragic losses of this harsh traffic differentially favored a “stingy gene.” Such a hypothetical gene or some combination that conferred metabolic characteristics that gave survival advantage though the conservation of calories, salt and water might be accountable for the new rash of metabolic disease in changed circumstances of mineral, energy, and foodstuff abundance.
Walker, Walker and Adams’ evidence in their review in this issue of Nutrition surveying recent changes in urban African morbidity might be used to postulate that the whole of the Sub-Saharan population of Africa may have been strained through a similar nutritional knothole, through the less geographically discrete and historically more protracted process of high infant mortality and differential death rates from diseases when starvation is co-morbid. Rather than blaming a bad deal of the genetic deck, it seems there might even be an innate protective effect, since obesity, hypertension, diabetes and stroke rates have soared, but another “big ticket” first-world plague has lagged behind: coronary heart disease, thankfully, has not kept pace, even as the other diseases bypassed the rates in Europeans in similar environments. Their warning, however, is as dire as the predicament is inevitable: although currently overshadowed and retarded by the infectious plague of HIV/AIDS, that, uncontrolled, is holding back development in much of the third world, and is pulling some emerging economies back toward the more primitive nutritional patterns, the impending rise of the coming plague of first world-pattern cardiovascular disease will be an even more crushing burden
It is refreshing to read an honest appraisal of conventional wisdom—which assumes that we have, or are soon gathering, enough information to make major efforts at prevention eradicate the big killer first-world diseases as effectively as we have controlled, say, smallpox. As nebulous a risk factor as is called “life style” seems to be correlated with a number of diseases, and is well worth working on to attempt to reduce some risks. But prescription for behavioral change must also be evidence-based and not over-reaching, even when it may seem intuitively obvious. The authors state a politically unpleasant, if correct, fact: we understand very little of the majority causes of coronary heart disease and breast cancer and even such an apparently obviously preventable condition as dental caries. All around our world, the environment is changing much faster than any genetic drift could occur. Just at the time we have made an enormous investment in the human genome project, we might come to the realization that, at least with respect to nutritional balance, a lot more of our disease burden is Lamarckian than Mendelian. We need to look up from our micro-analytic preoccupations and take the long view (2), and such meta-analytic reviews are helpful.
Other microenvironments have been examined as suggested laboratories of the often-unanticipated downside of development. (3) One example that shows the economic dislocation of sudden passive wealth has lead to the world’s highest adult onset diabetes, hypertension and renal failure rates within a generation of the phosphate mining exploitation of the Pacific Island of Nauru, the UN’s smallest member state, for now among its wealthiest per capita, and with a population being eroded as much as the mining of the island’s base is by this recently acquired morbidity. (4)
In a comparative study of populations within Mozambique over time, Maputo province had relatively good records a century ago showing essentially no evidence of hypertension and its consequences in this relatively urban province, in which now the leading non-infectious causes of death in adults are these same hypertensive consequences. (5) This might be a lesson to some of us attempting to replete certain micronutrients, through vertical programs in rural areas such as Nyasa Province in the same country where most of these hypertension consequences are still rare. Promotion of, for example, iodized salt, is clearly intended as a means of combating iodine deficiency, but it may not be seen (perhaps because it is too obvious) that it is first of all a social marketing--of salt. In a population that has been chronically short of both, we should monitor not only the laudable reduction in goiter and cretinism as the benefits we seek, but also the changes in rates of blood pressure abnormalities and perhaps the start of other evidence of urbanization patterns of morbidity, reflected from the century earlier warning from Maputo Province and the onset of possibly preventable epidemics associated with development. Untoward consequences of medical relief and rehabilitation programs should be looked for and honestly reported, even while the laudatory objectives are so easily and rapidly reported. (6)
No one should be advocating a retro-dedevelopment, much less celebrating the health advantages of destitution from the privations attending famine, war, overpopulation pressures or economic oppression. “Development”, however is usually assumed quite comprehensively (unfortunately, by many economic advisors,) summed as the iteration of the measurable data of production and consumption. Consumption of increasing numbers of resources in health care might be viewed as a positive marker of development (particularly by those who receive the benefit of these services—and lest it be forgotten, these nearly always include the professional providers), but the need for such services should fit on the debit scale in such a meta-analysis of nutritional development, for which focus the authors are to be congratulated.
Is it the role of healthcare personnel and health educators to point out such tradeoffs that should be mitigated in any development program? Some clearly think not (7, 8, 9) and that such “collateral damage” should be relegated, at best, to other specialists. But, it seems, at least in Southern Africa, that the very health care personnel who should be the foot soldiers of this preventive program, who are the most embedded in the culture, (10) are those most severely afflicted by these “diseases of development.” A campaign in the Republic of South Africa to send public health nurses through the schools to warn against the problems of obesity and in case finding for diabetes and hypertension had to be called off, when every single one of the experienced public health nurses (thus, employed professionals) who pitched up to be sent out on the campaign was morbidly obese! (11) Many of the surprised health personnel did not understand why the preventive program would be contradicted by its very emissaries. It was explained that obesity, far from a stigma, was part of the desiderata of development, like a big house or a motorcar, a mark of achievement, a presumptively apparent negative serology in the context of the dreaded “Slim,” and evidence particularly for a woman, implying a man who cared for her, or at least a disposable income, invested in her overconsumption and underexertion.
Such cultural blind spots may have been prevalent in prior decades of first world overachievers, who were really only certifiable as members of the excelling type-A executive class after their coronary bypasses. First world hospitals boasted about the superior high-technology care invested in such individual cases of preventable disease. These examples may be first and emerging third world res ipsa loquitor cases of health professionals in transition, dazzled by the immediate economic and technologic numbers, turning blind eyes over the downside of development and the untoward consequences of “advances” in nutritional development and health care. The warning in the suffix of this meta-analysis title “What of the Future?” predicts a larger population of greater dependence on palliative treatments if economic development is not mitigated in view of this detrimental health consequence.
Glenn W. Geelhoed, MD, DTMH, MPH, FACS
Professor of Surgery
Professor of International Medical Education
Professor of Microbiology and Tropical Medicine
George Washington University Medical Center
Washington DC
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