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Management of Severe Malnutrition:
A manual for physicians and other senior health workers

Review by EP Saitoria, Paediatric Specialist and Consultant
Arusha, Tanzania

Many thanks to World Health Organization (WHO) for its efforts to continue publishing series of health manuals which are of tremendous help to all the nations in the world. These series of manuals include the most recent and relevant advancements made in the field such as this book under review.

The Management of severe malnutrition: a manual for physicians and senior health workers, is succinctly presented in 40 pages with several practical appendices. The objective of the manual is to promote the use of the best available therapy in order to reduce the number of deaths from severe malnutrition, to shorten the duration of hospital stay, and to provide the basis for nutritional rehabilitation. The emphasis is on treatment of severe protein-energy-malnutrition in children using the most advanced methods. They include ORS, micronutrients, physical and psychological stimulants, as well as care and affection during the rehabilitation. As pointed out in the preface, it is a book on malnutrition in children, adolescents and adults, however, the treatment of malnourished adults is only briefly discussed in one section.


I have worked In Tanzania for over 30 years with severely malnourished children, and we have never had such a concise manual for teaching students and the staff in our facilities. Each person responsible for treating this population usually gains their knowledge from various donated texts and reference books. The manual's introduction includes a useful time frame (Table 1) for the management of a child with severe malnutrition. This table, coupled with the information given in the introduction, will be of great practical importance to health workers. The projected time frame is one week for initial treatment, and almost two months for rehabilitation; follow-up treatment takes approximately six months or more. For a paediatrician in Tanzania, this time frame seems quite long and expensive. Many deaths from severe malnutrition do occur in Tanzania, despite attempts at treatment according to a schedule such as this one.

The short chapter on treatment facilities is very well illustrated by Table 2 which compares residential and non-residential facilities for treating severely malnourished children. Tanzania has several residential and non-residential facilities scattered sparingly all over the country and run by NGOs and/or the Government. These facilities are attached to the hospitals or child health clinics, some of which are very far away from the patients' dwellings. These facilities, however, are poorly administered and do not fulfil the criteria shown in Table 2. This manual now provides Tanzania with a set of standards with which to upgrade our services in this area.

The descriptions for the evaluation of the malnourished child are concise and clear. The checklist for taking a child's medical history and conducting the physical examination will be very useful to health professionals all over the world. Although these are standard descriptions for diagnosing the severely malnourished child, they are expertly prepared and graphically displayed.

All health workers to whom this book is dedicated should be able to treat patients more efficiently and, hopefully, prevent the risk of death and shorten the length of time spent in hospitals. Tables 5 to 10 included in chapter one on initial treatment are practical and easy to understand. The descriptions on the treatment of the complications seen in malnourished children and the recording methods used to document these complications are particularly well-written.

The section on rehabilitation is invaluable to the health care worker. In most developing countries, rehabilitation of patients is not routinely carried out fully in the treatment and management of severe malnutrition. In Tanzania there are no accurate feeding guides for children under 24 months or over 24 months. Folic acid and iron are not usually given to malnourished children. Emotional and physical stimulation are relatively new concepts in countries such as ours, and it has never been part of the treatment plan in our few existing centres. It is, quite possibly, this failure to institute rehabilitation measures properly that leads to inadequate response to treatment. The criteria for transfer to a nutritional rehabilitation centre and for appropriate discharge are explicitly written. The authors and contributors of this manual have offered us new hope and direction with the concept of thorough rehabilitation treatment.

The chapter dealing with follow-up and detecting reasons for failure to respond to treatment should become the established protocol to which all developing countries with severely malnourished populations should adhere. Children who are discharged are advised to report to the paediatric outpatient clinics or to the children clinics which are nearest to their homes. Not surprisingly, however, those staff to whom they are referred are usually not well-versed with proper follow-up care, mostly due to the lack of an effective training and communications system. Follow-up action is emphasized because these children are at risk of increased recurrence of malnutrition or of developing other serious illnesses. Routine suggestions for follow-up are clearly illustrated and it will be useful for countries to begin to apply these recommendations. The universal reasons of failure to respond to treatment are well described and applicable to Tanzania's situation. For example, staff may not be properly trained to treat severe malnutrition; children are not usually kept in a proper nutrition unit; and several of the problems individual children face (e.g., not enough food being given, lack of micronutrients in the diet, rumination, infection), all occur in Tanzania.

The management of malnutrition in disaster situations and refugee camps, as well as malnutrition in adolescents and adults are new, but all too brief, chapters in this book. Tables 13 and 14 in chapter nine respectively classifies malnutrition in adults by body mass index and provides dietary requirements which is extremely useful for physicians and other health workers. Thanks to the authors who have incorporated these long overdue chapters and we look forward to their expansion.

As noted in this review, this manual is the most practical, easy-to-understand text on treating severe malnutrition available. We look forward to updating our training programs and upgrading our services in Tanzania according to the information provided in this book. The manual should be a requirement in all health facilities dealing with problems of malnutrition, and should be sent to the developing world as a priority. *

*NOTE: Single copies of this manual are available free of charge to prospective users from low-income countries. Contact: Dr Beat SchExecutive Secretary of IDECG, PO Box 581,1001 Lausanne Switzerland; tel: +41 21 320 33 51; fax: +41 21 320 3392; email: [email protected]. This publication's price is US$15; for developing countries US$10.45 and is available from: WHO, 1211 Geneva 27, Switzerland; fax: +41 22 791-4870; email: [email protected] This manual, in its entirety, will soon be published on the web.

Dr EP Saitoria is a Consultant Paediatrician at the Arusha International Conference Centre Hospital and the former Acting Director of Kilimanjaro Christian Medical Centre. In addition, he presently operates a private paediatric clinic. He has been a practicing paediatrician for more than 30 years in Tanzania, the Sudan and other East African countries. His primary experience is in treating severely malnourished children. Dr Saitoria may be contacted at: PO Box 1162, Arusha Tanzania; fax: 255 57 4327.

The Progress of Nations - 1999


Each year, The Progress of Nations ranks countries, not by the traditional yardstick of economic growth, but by the well-being of their children. One might expect the wealthiest nations to be at the top of the class when it comes to providing for children. But the report confirms that monetary progress does not guarantee social development. The Progress of Nations plays an essential role in monitoring the global advances towards goals set in 1990 as well as in recording the setbacks. This year's edition documents the devastating impact of HIV/AIDS on children, while celebrating enormous strides that have brought the world so close to the eradication of polio. In 1999 the world will welcome the 6 billionth member of our human family. The Progress of Nations 1999 uses the occasion of this landmark birth as a lens through which to examine widely divergent prospects that await this child - and indeed all children on the eve of the millennium. The report's final commentary spotlights the need to lift the catastrophic burden that debt imposes on children and families in some of the poorest countries on earth. The Progress of Nations 1999 not only provides new and valuable data on vital issues affecting children, but it also helps governments, international organizations and NGOs focus their priorities more effectively towards attaining World Summit goals and upholding all children's rights.

The contents of this year's edition includes a "child risk measure" (CRM) which is based on a combination of five indicators: the under-five mortality rate; percent of children moderately or severely underweight; percent of primary school aged children attending school; conflict within the country as represented by its security rating; and the prevalence rate of HIV/AIDS for 15-49 year olds. A chapter called "A Priceless Legacy" by HE Sheikh Hasina, Prime Minister of Bangladesh, examines advances made in eliminating polio and vitamin A deficiencies. In 1998, almost half of all children in the world who were ar risk of vitamin A deficiency received at least one high dose of vitamin A. The challenge will be to ensure that children in marginalized situations are adequately covered.

"The AIDS emergency", a chapter by Janat Mukwaya, demonstrates that the advance of antiretroviral drugs in industrialized countries has left some with the illusion that the worst of the AIDS epidemic has passed. Nothing could be further from reality in the developing world where the silent, voracious epidemic is wiping out the historic gains of the public health and economic development efforts of the last 20 years. The League table shows the number of orphans who have lost their mother or both parents to AIDS - and the toll is mounting.

For nearly two decades, the debt crisis has had a crippling impact on some of the world's poorest countries, hobbling economic growth and draining scarce resources from health, education and other vital services. Shirdath Ramphal in his chapter called, "Debt has a child's face" questions whether the campaign for debt relief can be translated into effective action, ensuring that children of the new millennium are freed from the chains of debt and poverty. The League table ranks the total external debt as a percentage of each country's gross national product; the developing world average stands at 35%.

The final chapter reports global statistical profiles which show great disparities between countries. Among these 192 nations, per capita GNP is as low as US$90 and as high as US$45,330 a year. The under-five mortality rate varies from 4 to 316 deaths per 100,000 live births. The percent of underweight children ranges from 1 % to 60%. The primary school enrolment rate varies from 24% to 100% of children. The Progress of Nations 1999 seeks to put an end to these intolerable inequalities by exposing them to the conscience of the world community.

For further information contact: UNICEF, Div of Communication, 3 UN Plaza, NY NY 10017 USA; email: [email protected]

Human Development Report 1999


Global markets, global technology, global ideas and global solidarity can enrich the lives of people everywhere. The challenge is to ensure that the benefits are shared equitably and that this increasing interdependence works for people - not just for profits. This year's Report argues that globalization is not new, but that the present era of globalization, driven by competitive global markets, is outpacing the governance of markets and the repercussions on people.

Characterized by "shrinking space, shrinking time and disappearing borders", globalization has swung open the door to opportunities. Breakthroughs in communications technologies and biotechnology, if directed for the needs of people, can bring advances for all of humankind. But markets can go too far and squeeze the non-market activities so vital for human development. Fiscal squeezes are constraining the provision of social services. A time squeeze is reducing the supply and quality of caring labor. And an incentive squeeze is harming the environment. Globalization is also increasing human insecurity as the spread of global crime, disease and financial volatility outpaces actions to tackle them.

The Report recommends an agenda for action: reforms of global governance to ensure greater equity, new regional approaches to collective action and negotiation and national and local policies to capture opportunities in the global marketplace and translate them more equitably into human advance.

In addition to the ranking of 174 countries on the human development index (HDI), this year's Report presents a new table on trends in human development from 1975 to 1997 for 79 countries. This new table reveals that, overall, countries have made substantial progress in human development, but that the speed and extent of progress have been uneven.

This Report also includes special contributions. Nobel laureate Amartya Sen describes the success of the HDI in bringing a human face to the assessment of development processes. Professor Paul Streeten gives a ten-year perspective on the Human Development Reports. And media magnate Ted Turner appeals for partnerships with the UN to face the new global challenges of our times. This Report was prepared by a team of eminent economists and distinguished development professionals under the guidance of Richard Jolly, Special Adviser to the Administrator of UNDP, and Sakiko Fukuda-Parr, Director of the Human Development Report Office.

The Report is available through: UN Publications, Room DC2-853, Dept DO99, NY NY 10017 USA; tel: 800 253-9646; Internet: ; email: [email protected]

The World Health Report 1999 - Making a Difference


The World Health Report 1999 - Making a Difference challenges the international community to examine the difference health can make in humanity's continuing progress. Issued by WHO Director-General Dr Gro Harlem Brundtland as WHO itself undergoes comprehensive reform, the report shows how the pursuit of lasting improvements in health, when supported by vision and leadership, can also secure considerable social and economic gains. It gathers the arguments and evidence that give health messages their persuasive power in the formulation of national policies and the direction of international aid.

The report explains how lessons learned from past successes and failures can guide a more targeted and pragmatic approach to current and emerging health challenges. It warns of the unprecedented complexity of these challenges, and offers strategic directions for tackling them in the next decade. Clear conclusions emerge. Despite recent spectacular progress in disease control and extended life expectancy, more than one billion people today have not shared in these gains. Meanwhile, the threat posed by infectious diseases is being accompanied by the growing prominence of non-communicable diseases, many of which are far more complex and costly to manage.

Consequently, health systems can no longer afford to allocate resources to interventions of low quality or low efficacy related to cost. Spontaneous growth in any country's health system cannot reliably ensure that the greatest health needs are met. In defining priorities and selecting interventions, decision-makers must focus their efforts on areas where the return in health gains is demonstrably greatest. In contrast to a classical "universalism" that advocated government finance and provision of all services for everyone, the report -and WHO - argue for a "new universalism". This would maintain government responsibility for financing and leadership, while recognizing government's own limits. Public finance for all entails that not all things can be publicly financed. Private sector provision of publicly financed services is compatible with government responsibility for health for all, but requires a clear regulatory role of governments.

WHO must also focus on priorities. While actively engaged across the full range of health problems, WHO targets two particular areas in order to reform work methods and co-operation with other partners: Roll Back Malaria and the Tobacco Free Initiative. The report describes the problems of malaria and tobacco - major representative elements of the double burden of disease - and indicates how timely action can make a difference. Both projects advocate using cost-effective technologies and innovative partnerships. They also serve as pathfinders, showing how, when priority problems are identified and addressed with vision, moral courage, and sound technologies, WHO leadership can make a difference -even when resources are limited.

This publication can be obtained for US$9.75; for developing countries US$6.82 from: WHO, 1211 Geneva 27, Switzerland; fax: +41 22 791-4870; email: [email protected]

1999 World Development Indicators


The World Development Indicators, now in its third year, is the World Bank's most general statistical publication. Along with its companions, the World Bank Atlas and the World Development Indicators CD-ROM, it offers a broad view of the record of development and the condition of the world and its people. It also provides a continuing survey of the quality and availability of internationally comparable indicators.

The organization of the World Development Indicators reflects a comprehensive development framework that integrates the measures of social progress and the quality of life of people with those of economic development, physical infrastructure, government policy and performance, and the condition of environment. In this year's edition, new indicators have been added to the People section, providing data on wages and earnings, expanded coverage of education, and a full table on the global HIV/AIDS epidemic. The Environment section includes two new tables: one of city-level indicators and another that extends last year's measures of genuine savings to 121 economies. The other sections have been revised as needed while preserving the now-familiar order and layout of the book.

The World Development Indicators also tracks progress toward the international development goals adopted by the World Bank, the United Nations, and the Development Assistance Committee of the OECD. This year the opening World View section reports on the prospects for developing countries in the aftermath of the financial crisis that swept much of the world. It is too soon to draw conclusions - indeed, we are only beginning to measure the effects. What is dear is that the world cannot afford another lost decade like the one Latin America endured after the debt crisis of the 1980s. Such a setback would put all our goals out of reach and leave millions of people in still greater distress.

Like everyone who uses these indicators, we remain concerned with the quality, coverage, and timeliness. As in previous editions, each table is followed by a discussion of the data, short descriptions of the indicators, and the sources for each of them. Despite the enormous improvements in communications and information management in the past decade, the gathering of statistical information remains difficult, costly, and time-consuming.

We continue to depend on the support and co-operation of our many partners - who make this publication possible. We also appreciate comments and responses from users - helping us measure how we are doing in continuing to make the World Development Indicators a useful tool.

For further information contact: Development Data Center, The World Bank, 1818 H St NW Rm MC2-812, Washington DC 20433 USA; tel: 202-473-7824; fax: 202 522 1498; Internet; email: [email protected]

Seating Up, Scaling Down
Overcoming Malnutrition in
Developing Countries
Thomas J Marchione, USAID

"Commitments to accelerate action in tackling nutritional problems are at the heart of this important, positive and energizing volume...Reading this book makes clear that the task of reducing and ending malnutrition is a challenging but achievable goal..." - Richard Jolly, Chairman, UN ACC/SCN


The essays in this book champion the idea of increasing, or scaling up, grassroots operations to provide nutritional security, while scaling down the efforts of national and international institutions. Household nutritional "security" can be defined as the successful - and sustainable -achievement of nutritional status that is adequate for maintaining a healthy and active life for all individuals in the household. This security arises from an adequate supply of food in the house, sufficient care for the individuals, and the prevention and control of disease.

Scaling up involves strengthening local capacities to improve and expand upon current successful programs by building upon existing local culture and organizations. This, in turn, enables the programs to strengthen relationships with national governments, international bilateral/multilateral donors, as well as non-governmental organizations. Scaling down concerns the ways and means by which these various organizations encourage and complement local development. Therefore, as local capacities are scaled up, the national/international control over decisions and functions is, ideally, scaled down.

Selected contents: Eliminating Hunger after the Cold War: Progress and Constraints, Peter Uvin; Nutritional Status: A Master Key to Child Survival, David Pelletier; Scaling Up a Poverty Alleviation and Nutrition Program in Vietnam, Monique and Jerry Sternin and David Marsh; Equity and Sustainability of the Health System: A Community Agenda in the Central Region of Togo, Kasa Pangu, Komlan Aflagah, M Kaba, El Jadji Tairou, and S Tchedre; Increasing Micronutrient Intakes in Rural Bangladesh: A NGO's Search for Program Sustainability, Ted Greiner and MA Mannon; Rapid Food and Livelihood Security Assessments: A Comprehensive Approach for Diagnosing Nutrition Insecurity, Timothy Frankenberger and MK McCaston; Nutrition Capacity Building: Reflections on the South African Application of Nutrition Constraints Assessment, Milla McLachlan and FJ Levinson.

This 1999, 320pp book (ISBN 90-5700-547-6) is available for US$50 and may be ordered from: Gordon & Breach Publishers; North/South America tel: 1 800 326 8917; fax: 1 802 864 7626; email: [email protected]; Europe/Middle East/Africa tel: +44 123 546 5500; fax: 44 123 546 5555; email: [email protected]; Asia tel: 65 741 6922; fax: 65 741 6922; email: [email protected].

Inventory of Current Vitamin A
and Program Activities Related
to Child Survival in Developing


USAID has completed a global summary of newly completed and ongoing research and programmes that focus on vitamin A. This research inventory highlights areas of consolidation and progress and areas where more research and programme activities are needed to increase child survival and possibly even the survival of other age groups.

Research on vitamin A directly relevant to developing countries ranges from laboratory-based investigations on vitamin A metabolism to operational research on the effectiveness of interventions to prevent vitamin A deficiency. Much of the research underway examines the relationship between vitamin A status and both natural and synthetic retinoid and carotenoid supplements, in particular their role in morbidity and mortality prevention from communicable diseases such as respiratory infections and HIV and their potential role in preventing chronic diseases such as coronary heart disease and some cancers. Interest in the latter has recently increased because of the antioxidant functions of carotenoids. Program activities to alleviate vitamin A deficiency are similarly diverse and include the distribution of high dose vitamin A supplements, food fortification, and dietary diversification.

Topics summarized in this document include: surveys and studies on the prevalence of vitamin A deficiency; studies on factors associated with vitamin A status; observational studies on the relationship between vitamin A status and infection; studies on assessment of vitamin A status; studies on food sources, bioavailability, and metabolism of vitamin A; vitamin A supplement studies; and programme-related research activities. The document begins with an overview of both the studies and the study outcomes. This is followed by details of each study included in the review. Vitamin A child survival research activities are listed alphabetically by country in an appendix. USAID plans to update this inventory annually.

This March 1999 publication is available free of charge to developing countries and for US$3.50 to developed countries from: OMNI Research, ILSI Human nutrition Institute, 1126 Sixteenth St NW, Washington DC 20036-4810 USA.

TB Advocacy - A Practical Guide 1999


This 42 page practical guide holds a wealth of information which may be readily transferable to other health and nutrition advocacy strategies. Its importance lies in the fact that "Advocacy is winning the support of key constituencies in order to influence policies and spending, and bring about social change". Successful advocates usually start by identifying the people they need to influence and planning the best ways to communicate with them. They do their homework on an issue and build a persuasive case. They organize networks and coalitions to create a groundswell of support that can influence key decision-makers. They work with the media to communicate the message. Advocacy attempts to change the behaviour of politicians rather than risk groups or patients.

This practical guide outlines four basic steps that are essential for an effective advocacy initiative - documenting the situation, packaging the message, working with the media, and mobilizing others. Information for each of these steps is clearly organized in boxes containing 10 points, each addressing a specific advocacy strategy. One of the most common mistakes made by many field specialists and first-time advocates is to attempt to communicate too much detailed information. Presentations that may be appropriate for medical or health specialist audiences are almost certain to put journalists, politicians and donors to sleep. This book "packages" the message, showing readers how to use powerful, fresh, visual language to target audiences. Other chapters cover media campaigns and mobilization strategies in detail, giving specific "tips" for every facet of advocacy.

This document is not a formal publication of WHO. Copyright 1998 by the WHO Tuberculosis Programme. Authors: B Owens, K Klaught For further information contact: WHO TB Programme, 1211 Geneva 27, Switzerland; tel: 41 22 791 2630; Internet:; email: [email protected]

How to Grow a Balanced Diet
A handbook for community


A Burgess, G Maina, P Harris and S Harris

"An excellent book, well-illustrated, user-friendly...highly recommended." - David Morley

How to Grow a Balanced Diet is a much-needed practical handbook which bridges the gap between nutritional problems and agricultural solutions. This book will help community workers and local groups identify nutritional needs and grow the required food crops organically. This 224 page book with 117 illustrations, provides information on effective nutrition education and extension; and the basic techniques of organic agriculture in non-technical language for those without agricultural training.

The book lists more than 40 common food crops and vegetables from a wide range of agro-climatic zones, with detailed instructions on how to grow and store them. Tables identify crops which combat a nutritional deficiency and which can be grown locally. This book may be used as both a training manual and as a self-study guide.

This 1999 book (ISBN 09509050 6 2) is US$12.70 per copy plus post and packing charges. For further information contact VSO Books, 317 Putney Bridge Rd, London SW 15 2PN UK; tel: 44 181 780 7200; fact 44 181 780 7300; email: [email protected]