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NUTRITIONAL SURVEILLANCE IN THE OGADEN
911
for mentally handicapped patients the relevant committees. The central allocation of funds for mental handicap has to be closely audited—otherwise the money gets deflected by region and area and district and sector, under pressure from consultants in other specialties. The deficiencies in proper local provision for children are only partly concealed by provision, through education funds, of places in boarding schools and, through charities, of other refuges. Even with these, too often the distance between home and school dishonours the whole notion of community caring. If there is to be public money spent on compensation then the Government could compensate by providing, even in the name of the "victims of vaccine damage", specific services and facilities which could endure in the community to the benefit of all mentally handicapped people. Such a policy would not only be better husbandry than hand-outs to a vociferous minority; it would also be less divisive.
representation on
NUTRITIONAL SURVEILLANCE IN THE OGADEN THE concept that famines are unavoidable natural disasters is difficult to eradicate. Often warnings have been uttered; but planners have failed to heed them.’1 Bangladesh, the Sahel, and Ethiopia had hundreds of thousands dead and starving before the extent of their problems was generally accepted. The famine in Ethiopia is the subject of a monograph2 which highlights both the difficulties of accurate nutritional surveillance in the field and the obstacles to translating research findings into action. It contains three reports-from the Ethiopian Nutrition Institute, the Livestock and Meat Board, and the Relief and Rehabilitation Commission in Addis Ababa-and they follow the early studies of shelter populations in the Wollo region (where in 1973 the excess loss of lives due to famine was between 50 000 and 100 000), through the development of a model for an "early-warning" system, to the testing of the model with real data collected later in the Ogaden region. The Wollo survey was carried out in May-June, 1974, when the thirteen shelters visited had been in action for nine months or so. Two main techniques were used-interviews with heads of households and standard anthropometric measurements. However, information was collected only in the two months before the main rains, and 84% of the heads of households interviewed came from four shelters. Children under 5 years old and adults aged 45 or more were greatly underrepresented in the shelter populations. Not surprisingly, the weight-for-height measurements revealed severe malnourishment in many of the children; one in five of the under-5s were below 60% of a W.H.O. standard.3 The interviews also emphasised the complete breakdown in the basic agricultural economy through crop failure, 1. Baker, R. Disasters, 1977, 2.Belete, S., Gebre-Medhin,
1, 13. M., Hailemariam, B., Maffi, M., Vahlquist, B., Wolde-Gebriel, Z., Hay, R., Licke, Y. Envir. Chld Hlth 1977, monogr.
48.
3
Jelliffe, D. B.
lack of grain relief, and lack of seed or oxen. Many peasants had been forced to mortgage or sell their lands for very low prices. How can this sort of information be used to show whether nutrition conditions are getting better or worse for the general population? The surveyors themselves point out that shelter populations were hardly representative, and even at the peak of their activities only 30 000 people used them out of over 2 million in the whole province. Clearly a single cross-sectional study can give no indication of trends over time, but confidence in any population-based data must also depend on the robustness of the sampling frame and, unfortunately, very few details are given. Was, for example, any attempt made in Wollo to compare data obtained from shelter populations with results from randomly selected communities? Were the shelters with the largest populations in the regions of most severe food shortage, or did their size depend on their placement close to good roads? This kind of fieldwork is the most taxing aspect of nutrition surveillance. Not only are there formidable obstacles to testing representative samples and obtaining accurate measurements under conditions of famine; no less formidable are the obstacles to putting conclusions drawn into practice. In Ethiopia, some of the latter difficulties seem to have been solved by the setting up of an interministerial committee with representatives from no less than seven major ministries, eleven other institutes, and services including the Relief and Rehabilitation Commission. The first move of this group was to produce a system for monitoring changes in the availability of food and in the nutritional status of populations in high-risk regions, to give advance warning of potentially serious deterioration in the famine. The suggested data base includes meteorological information, on climate and rainfall, agricultural information on land preparation and crop yield, livestock figures, and market prices for major staples and animals, nutritional status assessment, and health statistics. At present such information is hardly ever available in countries where food shortage is a continuing threat. In Ethiopia morbidity and mortality rates have not been recorded for long enough to give useful information on trends. The third report in the monograph tells how the system was tested by serial surveys between May-June, 1974, and June-August, 1975, in the at-risk region of the Ogaden. Most of the people are nomads who live off their cattle and exchange livestock for grain in markets. Their movements reflect their search for water and grazing. Rainfall data were obtained from monthly recordings in two towns, livestock holdings estimated from interviews with heads of households, prices paid for grains and animals obtained from local markets, nutritional status of children assessed by weight-for-height ratios, and age-specific mortality-rates estimated by interviews. These various indices showed a striking deterioration in the position from June, 1974, to February-March, 1975. Consequently, large-scale relief measures and a network of shelters were instituted. In the peak period about 80 000 nomads passed through the shelters; the Murrays4 have described the shelters’ disruptive effects on social and family structure. 4.
Wld. Hlth.
Org. Monogr. Ser. 1966, no.
53.
Murray,
M.
1, 1283.
J., Murray, A. B., Murray, M. B., Murray, C. J. Lancet, 1976,
912 The difficulties of surveying nomadic populations are notorious, yet the Ethiopian report claims that "the early warning system which is in the making has proven its value in the field". If so, we must smartly learn
lessons from their methodology. Unfortunately the report says very little about sampling techniques. In times of stress poorer families of nomads are more likely to be found in the most accessible places, such as near roads or concentrations of population; nutritional surveys of children, done in the middle of the day, will give different results from surveys at dawn or dusk (when more healthy children who have been out herding will be represented) and livestock prices, such as those of camels, vary widely at different times of day even in the same market. Future work, as well as judgments on immediate action, will be the better for taking such critical variables in account. The value of surveillance clearly increases with the quality of the data, and the challenge is then to translate reliable data into effective action.
MORNING DIPPERS DEATHS due
asthma are particularly sad when, as unexpected, the victim is young, and prompt treatment might have saved the life. Early sur-
often, they
to
are
veys revealed
useful risk factors save that deaths in chronic asthmatics and in those recently discharged from hospital. But a review of 19 adult asthmatics who died in Greater London in 1971 revealed that two-thirds had succumbed between midnight and 8 A.M.2 At the Brompton HospitaP there were ten respiratory arrests amongst 1169 consecutive patients admitted with asthma, and 9 of these occurred between midnight and 6 A.M. By conventional assessment4 the patients had not been severely ill and the arrests were usually unexpected. The one common factor in these patients was a wide variation in the peak flow-rate in the days before the respiratory arrest. However, a greater than 50% variation in peak flow within a day was also found in about a third of all patients admitted with asthma irrespective of severity. This variation occurs particularly when a severe attack of asthma is remitting.s Striking diurnal variation in peak flow seems to be the best marker of sudden death; why does this variation occur and how can it be prevented? In healthy people the peak flow is about 10% higher at midday than in the early hours of the morning.6 Asthmatics have this variation in exaggerated form. In physiological terms, nocturnal and early-morning asthma is identical to ordinary daytime asthma.7 Usually the airways obstruction is readily reversed by bronchodilators; in a few patients there is no response to bronchodilators in the early morning but by 2 P.M. the airways obstruction has gone, suggesting that mucous plugging was an important factor. The dip in peak flow usually occurs tended
no
to occur
1. MacDonald, J. B., Seaton, A., Williams, D. A. Br. Med. J. 1976, i, 1493. Cochrane, G. M., Clark, T. J. H. Thorax, 1975, 30, 300 3. Hetzel, M. R., Clark, T. J. H., Branthwaite, M. A. Br. med. J. 1977, i, 808. 4. Stark, J. E. Br. J. Hosp. Med. 1972, 8, 241. 5. Turner-Warwick, M. Br. J. Dis. Chest, 1977, 71, 73 6. Remberg, A., Gervais, P. Bull Physio-Path. Resp. 1972, 8, 663. 7. Hetzel, M. R., Clark, T. J. H., Houston, K. Thorax, 1977, 32, 418. 2.
during the early hours of the morning but may start the previous evening. It coincides with the lowest levels of corticosteroid8 and catecholamineexcretion, but administration of corticosteroids does not prevent the nocturnal dip in peak flow, and small doses infused to keep the plasma-cortisol above 10 p.g/dl are seldom beneficial. Plasma-catecholamine concentrations can be augmented with slow-release salbutamol, which abolishes the nocturnal dip in some but not all patients. Posture seems irrelevant: neither sleeping in a chair nor prolonged recumbency alters the diurnal variation.9 Sometimes the nocturnal dip is related to the lack of treatment during the night-particularly in patients who have a low and constant peak flow without treatment, readily reversed by bronchodilators. But in most cases regular treatment through the night does not abolish the dip. Nocturnal asthma has been attributed to house-dustmite allergy, but mites live in soft furnishings and carpets as well as in the bed, so that patients are usually exposed day and night. Much more likely is that an allergen can precipitate an attack of asthma, which may be followed by recurrent nocturnal attacks due to endogenous mechanisms. Recurrent nocturnal asthma has been reported after single exposures to allergen.1Q-12 Shift workers reverse their diurnal variation in peak flow by the end of the first natural sleep after a night up9-a much speedier change than that with other physiological variables-suggesting that sleep itself may be the most important cause of a dip in peak flow. Patients who are kept awake until the normal time of their nocturnal dip simply postpone the dip until they go to sleep later on. Staying awake all night has occasionally stopped the nocturnal dip.3 Electroencephalography reveals that asthmatic children are least likely to be woken by asthma during deep (stage-iv) sleep." Stage iv sleep occurs mostly in the first third of the night, and hardly at all in asthmatic adults.14 Slow-release salbutamol, perhaps supplemented by slow-release theophyllines, is the best of a not very satisfactory therapeutic approach. Agents which increase stage-iv sleep (which include exercise and alcohol) should perhaps be next for trial.
DISOPYRAMIDE FOR CARDIAC ARRHYTHMIAS DISOPYRAMIDE is
anti-arrhythmic agent with pharmacological properties likely to influence a wide variety of electrophysiological disorders. Routine prophylactic treatment in acute myocardial infarction is said to reduce both the incidence of dangerous arrhythmias and the mortality. On p. 887 Dr Zainal and his colleagues report a double-blind study of disopyramide in the general wards of three London hospitals: ventricular fibrillation occurred once in 30 patients in the disopyraan
8. Soutar, C. A., Costello, J., Ijaduola, O., Turner-Warwick, M. ibid. 1975, 30, 436. 9. Clark, T. J. H., Hetzel, M. R. Br. J. Dis. Chest, 1977, 71, 87. 10. Gandevia, B., Milne, J. Br. J. ind. Med. 1970, 27, 235. 11. Hendrick, D. J., Lane, D. J. ibid. 1975, 34, 11. 12. Davies, R. J., Green, M., Schofield, N. McC. Am. Rev. resp. Dis. 1976, 114, 1011. 13. Kales, A., Kales, J. D., Sly, R. M., Scharf, M. B., Tjiauw-Ling, T., Terry, A., Preston, B. A. J. Allergy, 1970, 46, 30. 14. Kales, A., Beall, G. N., Bajor, G. F., Jacobson, A., Kales, J. D. ibid. 1968.
41, 164.
for mentally handicapped patients the relevant committees. The central allocation of funds for mental handicap has to be closely audited—otherwise the money gets deflected by region and area and district and sector, under pressure from consultants in other specialties. The deficiencies in proper local provision for children are only partly concealed by provision, through education funds, of places in boarding schools and, through charities, of other refuges. Even with these, too often the distance between home and school dishonours the whole notion of community caring. If there is to be public money spent on compensation then the Government could compensate by providing, even in the name of the "victims of vaccine damage", specific services and facilities which could endure in the community to the benefit of all mentally handicapped people. Such a policy would not only be better husbandry than hand-outs to a vociferous minority; it would also be less divisive.
representation on
NUTRITIONAL SURVEILLANCE IN THE OGADEN THE concept that famines are unavoidable natural disasters is difficult to eradicate. Often warnings have been uttered; but planners have failed to heed them.’1 Bangladesh, the Sahel, and Ethiopia had hundreds of thousands dead and starving before the extent of their problems was generally accepted. The famine in Ethiopia is the subject of a monograph2 which highlights both the difficulties of accurate nutritional surveillance in the field and the obstacles to translating research findings into action. It contains three reports-from the Ethiopian Nutrition Institute, the Livestock and Meat Board, and the Relief and Rehabilitation Commission in Addis Ababa-and they follow the early studies of shelter populations in the Wollo region (where in 1973 the excess loss of lives due to famine was between 50 000 and 100 000), through the development of a model for an "early-warning" system, to the testing of the model with real data collected later in the Ogaden region. The Wollo survey was carried out in May-June, 1974, when the thirteen shelters visited had been in action for nine months or so. Two main techniques were used-interviews with heads of households and standard anthropometric measurements. However, information was collected only in the two months before the main rains, and 84% of the heads of households interviewed came from four shelters. Children under 5 years old and adults aged 45 or more were greatly underrepresented in the shelter populations. Not surprisingly, the weight-for-height measurements revealed severe malnourishment in many of the children; one in five of the under-5s were below 60% of a W.H.O. standard.3 The interviews also emphasised the complete breakdown in the basic agricultural economy through crop failure, 1. Baker, R. Disasters, 1977, 2.Belete, S., Gebre-Medhin,
1, 13. M., Hailemariam, B., Maffi, M., Vahlquist, B., Wolde-Gebriel, Z., Hay, R., Licke, Y. Envir. Chld Hlth 1977, monogr.
48.
3
Jelliffe, D. B.
lack of grain relief, and lack of seed or oxen. Many peasants had been forced to mortgage or sell their lands for very low prices. How can this sort of information be used to show whether nutrition conditions are getting better or worse for the general population? The surveyors themselves point out that shelter populations were hardly representative, and even at the peak of their activities only 30 000 people used them out of over 2 million in the whole province. Clearly a single cross-sectional study can give no indication of trends over time, but confidence in any population-based data must also depend on the robustness of the sampling frame and, unfortunately, very few details are given. Was, for example, any attempt made in Wollo to compare data obtained from shelter populations with results from randomly selected communities? Were the shelters with the largest populations in the regions of most severe food shortage, or did their size depend on their placement close to good roads? This kind of fieldwork is the most taxing aspect of nutrition surveillance. Not only are there formidable obstacles to testing representative samples and obtaining accurate measurements under conditions of famine; no less formidable are the obstacles to putting conclusions drawn into practice. In Ethiopia, some of the latter difficulties seem to have been solved by the setting up of an interministerial committee with representatives from no less than seven major ministries, eleven other institutes, and services including the Relief and Rehabilitation Commission. The first move of this group was to produce a system for monitoring changes in the availability of food and in the nutritional status of populations in high-risk regions, to give advance warning of potentially serious deterioration in the famine. The suggested data base includes meteorological information, on climate and rainfall, agricultural information on land preparation and crop yield, livestock figures, and market prices for major staples and animals, nutritional status assessment, and health statistics. At present such information is hardly ever available in countries where food shortage is a continuing threat. In Ethiopia morbidity and mortality rates have not been recorded for long enough to give useful information on trends. The third report in the monograph tells how the system was tested by serial surveys between May-June, 1974, and June-August, 1975, in the at-risk region of the Ogaden. Most of the people are nomads who live off their cattle and exchange livestock for grain in markets. Their movements reflect their search for water and grazing. Rainfall data were obtained from monthly recordings in two towns, livestock holdings estimated from interviews with heads of households, prices paid for grains and animals obtained from local markets, nutritional status of children assessed by weight-for-height ratios, and age-specific mortality-rates estimated by interviews. These various indices showed a striking deterioration in the position from June, 1974, to February-March, 1975. Consequently, large-scale relief measures and a network of shelters were instituted. In the peak period about 80 000 nomads passed through the shelters; the Murrays4 have described the shelters’ disruptive effects on social and family structure. 4.
Wld. Hlth.
Org. Monogr. Ser. 1966, no.
53.
Murray,
M.
1, 1283.
J., Murray, A. B., Murray, M. B., Murray, C. J. Lancet, 1976,
912 The difficulties of surveying nomadic populations are notorious, yet the Ethiopian report claims that "the early warning system which is in the making has proven its value in the field". If so, we must smartly learn
lessons from their methodology. Unfortunately the report says very little about sampling techniques. In times of stress poorer families of nomads are more likely to be found in the most accessible places, such as near roads or concentrations of population; nutritional surveys of children, done in the middle of the day, will give different results from surveys at dawn or dusk (when more healthy children who have been out herding will be represented) and livestock prices, such as those of camels, vary widely at different times of day even in the same market. Future work, as well as judgments on immediate action, will be the better for taking such critical variables in account. The value of surveillance clearly increases with the quality of the data, and the challenge is then to translate reliable data into effective action.
MORNING DIPPERS DEATHS due
asthma are particularly sad when, as unexpected, the victim is young, and prompt treatment might have saved the life. Early sur-
often, they
to
are
veys revealed
useful risk factors save that deaths in chronic asthmatics and in those recently discharged from hospital. But a review of 19 adult asthmatics who died in Greater London in 1971 revealed that two-thirds had succumbed between midnight and 8 A.M.2 At the Brompton HospitaP there were ten respiratory arrests amongst 1169 consecutive patients admitted with asthma, and 9 of these occurred between midnight and 6 A.M. By conventional assessment4 the patients had not been severely ill and the arrests were usually unexpected. The one common factor in these patients was a wide variation in the peak flow-rate in the days before the respiratory arrest. However, a greater than 50% variation in peak flow within a day was also found in about a third of all patients admitted with asthma irrespective of severity. This variation occurs particularly when a severe attack of asthma is remitting.s Striking diurnal variation in peak flow seems to be the best marker of sudden death; why does this variation occur and how can it be prevented? In healthy people the peak flow is about 10% higher at midday than in the early hours of the morning.6 Asthmatics have this variation in exaggerated form. In physiological terms, nocturnal and early-morning asthma is identical to ordinary daytime asthma.7 Usually the airways obstruction is readily reversed by bronchodilators; in a few patients there is no response to bronchodilators in the early morning but by 2 P.M. the airways obstruction has gone, suggesting that mucous plugging was an important factor. The dip in peak flow usually occurs tended
no
to occur
1. MacDonald, J. B., Seaton, A., Williams, D. A. Br. Med. J. 1976, i, 1493. Cochrane, G. M., Clark, T. J. H. Thorax, 1975, 30, 300 3. Hetzel, M. R., Clark, T. J. H., Branthwaite, M. A. Br. med. J. 1977, i, 808. 4. Stark, J. E. Br. J. Hosp. Med. 1972, 8, 241. 5. Turner-Warwick, M. Br. J. Dis. Chest, 1977, 71, 73 6. Remberg, A., Gervais, P. Bull Physio-Path. Resp. 1972, 8, 663. 7. Hetzel, M. R., Clark, T. J. H., Houston, K. Thorax, 1977, 32, 418. 2.
during the early hours of the morning but may start the previous evening. It coincides with the lowest levels of corticosteroid8 and catecholamineexcretion, but administration of corticosteroids does not prevent the nocturnal dip in peak flow, and small doses infused to keep the plasma-cortisol above 10 p.g/dl are seldom beneficial. Plasma-catecholamine concentrations can be augmented with slow-release salbutamol, which abolishes the nocturnal dip in some but not all patients. Posture seems irrelevant: neither sleeping in a chair nor prolonged recumbency alters the diurnal variation.9 Sometimes the nocturnal dip is related to the lack of treatment during the night-particularly in patients who have a low and constant peak flow without treatment, readily reversed by bronchodilators. But in most cases regular treatment through the night does not abolish the dip. Nocturnal asthma has been attributed to house-dustmite allergy, but mites live in soft furnishings and carpets as well as in the bed, so that patients are usually exposed day and night. Much more likely is that an allergen can precipitate an attack of asthma, which may be followed by recurrent nocturnal attacks due to endogenous mechanisms. Recurrent nocturnal asthma has been reported after single exposures to allergen.1Q-12 Shift workers reverse their diurnal variation in peak flow by the end of the first natural sleep after a night up9-a much speedier change than that with other physiological variables-suggesting that sleep itself may be the most important cause of a dip in peak flow. Patients who are kept awake until the normal time of their nocturnal dip simply postpone the dip until they go to sleep later on. Staying awake all night has occasionally stopped the nocturnal dip.3 Electroencephalography reveals that asthmatic children are least likely to be woken by asthma during deep (stage-iv) sleep." Stage iv sleep occurs mostly in the first third of the night, and hardly at all in asthmatic adults.14 Slow-release salbutamol, perhaps supplemented by slow-release theophyllines, is the best of a not very satisfactory therapeutic approach. Agents which increase stage-iv sleep (which include exercise and alcohol) should perhaps be next for trial.
DISOPYRAMIDE FOR CARDIAC ARRHYTHMIAS DISOPYRAMIDE is
anti-arrhythmic agent with pharmacological properties likely to influence a wide variety of electrophysiological disorders. Routine prophylactic treatment in acute myocardial infarction is said to reduce both the incidence of dangerous arrhythmias and the mortality. On p. 887 Dr Zainal and his colleagues report a double-blind study of disopyramide in the general wards of three London hospitals: ventricular fibrillation occurred once in 30 patients in the disopyraan
8. Soutar, C. A., Costello, J., Ijaduola, O., Turner-Warwick, M. ibid. 1975, 30, 436. 9. Clark, T. J. H., Hetzel, M. R. Br. J. Dis. Chest, 1977, 71, 87. 10. Gandevia, B., Milne, J. Br. J. ind. Med. 1970, 27, 235. 11. Hendrick, D. J., Lane, D. J. ibid. 1975, 34, 11. 12. Davies, R. J., Green, M., Schofield, N. McC. Am. Rev. resp. Dis. 1976, 114, 1011. 13. Kales, A., Kales, J. D., Sly, R. M., Scharf, M. B., Tjiauw-Ling, T., Terry, A., Preston, B. A. J. Allergy, 1970, 46, 30. 14. Kales, A., Beall, G. N., Bajor, G. F., Jacobson, A., Kales, J. D. ibid. 1968.
41, 164.