Reviews of “Protein Energy Malnutrition” and “The State of the World’s Children 1994”

“Protein Energy Malnutrition”

(1992) by John C. Waterlow (with contributions by A.M. Tomkins and S.M. Grantham-McGregor). Edward Arnold, London. 407 pages.

This book is classical John Waterlow at it’s best. In his long career, John Waterlow has made tremendous contributions to the understanding of protein metabolism, to the understanding of the clinical features of Protein Energy Malnutrition (PEM), and to the clinical treatment of Kwashiorkor and Marasmus. As a clinician-scientist interested in the clinically presented disease, Waterlow also developed a major interest in the aetiology of PEM, in the development and use of markers for the identification and assessment of the problem, and like many others, in approaches that might be effective in the amelioration of PEM in populations. In this book, Waterlow attempts to provide an integrated overview, a distillation of his understandings and interpretations of issues ranging from sub-cellular to world population levels. It is very difficult, if not impossible, to prepare a comprehensive review of such a broad field without being accused of being naive or superficial in some areas and overly detailed in others (the judgements varying with the reader). In writing the Foreword, the author recognized this limitation and indicated that “I decided to have a go and to try to produce a book that might be interesting and useful to physicians and public health workers, especially in Third World countries, even if it did no more than act as a source of references.....I have not hesitated to express my own views on subjects that are controversial. The important part is not that the reader should agree with those views but rather that he or she should realize that differences in opinion exist and perhaps be stimulated to undertake studies that might resolve those differences.”

To an amazing, but perhaps not surprising, degree, John Waterlow succeeded in accomplishing his goals. This book presents that blend of historical perspective, factual knowledge and personal interpretation that is of great value to the student be he or she in an industrialized or pre-industrialized setting. If it suffers a fault, it might be that for the not very astute student, the personal opinions (the ‘my views on controversial matters’) are not always clearly identified and the casual reader might take those views as accepted consensus. This is a very small price to pay for what John Waterlow has given us in return. The book is a narrative attempt by a highly regarded scientist to present his view of the world’ and most important, how he links the layers of discovery and understanding. That is the real educational value of this book. One may disagree with some of the practical inferences and conclusions that Waterlow derives but you will have learned much by attempting to understand the rationale presented.

As one might expect from the author’s own background, the strongest parts of this book are those addressing protein metabolism, clinical manifestations of PEM, and the treatment of this disorder. Constituting almost half the book (Chapters 1 through 12), this should be compulsory reading for all clinical staff still faced with cases of severe malnutrition. Also as expected, the remainder of the book (addressing growth, assessment, requirements, feeding practices and possible approaches to amelioration of problems in the community) rests on a shakier foundations and reflects much more the opinions and judgements of the author. These chapters (13 through 20) should certainly be read by the student of public health but they cannot be taken as carrying the same authority for public health workers as did the chapters on the clinical manifestations and treatment for primary health care workers.

Perhaps a limitation of the book’s approach is the difficulty experienced by the author in moving back and forth between arguments and approaches relating to individuals (as in treatment) and to populations (as in population assessment or control programmes). This difficulty becomes apparent in chapters dealing with assessment of nutritional status in the community (Chapter 14) and the associated discussion of growth (Chapter 13). It also arises in the discussion of protein requirements. This should not be taken as a major criticism of the book. Rather, it might be seen as a warning. The interfacing of concepts relating to individuals and to groups is not easy; John Waterlow has presented his interface and drawn his conclusions; the reader must be sensitized to recognize that others draw different conclusions and inferences. Generally, but not always, the distinctions have little practical importance. Occasionally, the views and interpretations expressed are in substantive discord with the current direction of thinking and ultimately it is left to the reader to discern what is a description of consensus and what is a personal judgement on the part of the author.

This book will undoubtedly become one of the classic reviews of a major nutritional problem. It is worthy of that stature. John Waterlow has done the sort of job that only John Waterlow can do and we should all be deeply indebted to him for doing it. This reviewer would certainly recommend the book to all students of clinical nutrition and of public health nutrition; it is perhaps not a book for the uninitiated or uncritical.

George H. Beaton

“The State of the World’s Children 1994”

by James P Grant, Executive Director of UNICEF. Published for UNICEF by Oxford University Press. 87 pages.

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The 1994 State of the World’s Children report should be read by anyone concerned about the future. It’s about children, of course; but it’s also about development in the broadest sense: the kind of world we live in, where it seems to be heading, and how its progress might be re-directed for the benefit of all. Everyone - not just children, not just those in developing countries - since problems of poverty, population growth and environmental stress in this increasingly inter-dependent world threaten to engulf us all. The writing, as always, is vivid and visionary; but the proposals are practical and pragmatic, and deserve to be understood and discussed by as many people as possible. Indeed, this is an essential part of the argument, which calls for a change in the prevailing climate of ideas: “...political vision often appears to be circumscribed by opinion polls, and to extend only as far as the next election, whereas the widely acknowledged problems which threaten our own and our children’s futures require vision and action on a different scale in both place and time.”

The report is presented in four sections. The first discusses the substantial progress made in recent years in improving the health, nutrition and education of children. This has occurred despite the relatively small proportion of government expenditures and of foreign aid currently spent on primary health care, basic education, safe water supply, and family planning. But greater priority will have to be given to these issues to ensure that the social goals agreed at the World Summit for Children in 1990 are attained in all countries by the end of the decade.

The second section discusses how past progress and future potential in these areas are threatened by the mutually reinforcing effects of poverty, population growth and environmental deterioration, referred to as the “PPE spiral”. This is presented in the larger context of managing a world-wide transition to a sustainable human future. Failure to achieve this, the report argues, will result in increasing economic disruption, political unrest, set-backs for democracy, and instability within and between nations. It is thus “a matter of fundamental self-interest, as well as of altruistic concern...” “For poor countries to remain within the PPE spiral... is to invite disaster. But for four fifths of the world’s people to follow the path of development blazed by the one fifth who live in today’s industrialised nations is to invite a disaster of a different kind.” One criterion of a new definition of acceptable progress would be: “can the developing countries, if they so choose, aspire to similar life-styles without exceeding the planet’s capacity?”

The third section examines how achieving the basic human goals could make a fundamental contribution to resolving the PPE problems that threaten the future of society. The report considers the proposition that withholding certain low-cost health-promoting techniques will reduce child survival and thereby (it is alleged) limit population growth, and shows that the argument is incorrect, as well as unethical. On the contrary, the synergistic consequences of improving child survival, health, education and family planning services, with special attention to the status of women, might halve the size of the global population that will ultimately stabilize, which could be the determining factor for ensuring success in managing the transition to a sustainable future. The report quotes the Vice-President of the United States, who wrote that “the Marshall plan took the broadest possible view of Europe’s problems and developed strategies to serve human needs and promote sustained economic progress; we must now do the same on a global scale.”

Finally, nine revised statistical tables provide economic and social information for 145 countries with populations of 1 million or more, and less complete information for 41 less populous countries. Regional summaries are also provided.

“The State of the World’s Children 1994” can be obtained from the Oxford University Press, Walton Street, Oxford, OX2 6DP, Oxfordshire, UK. Oxford University Press also has outlets in New York Toronto, Delhi, Bombay, Calcutta, Madras, Karachi Peealing Jaya, Singapore, Hong Kong, Tokyo Nairobi, Dar-es-Salaam, Cape Town, Melbourne Auckland, and associated companies in Beirut Berlin, Ibadan, and Nicosia. The book is priced at £4.50 (UK) and $8.00 (USA).

J.P. Greaves.