84
I VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY
Tropical Doctor, April I976
FOOD
Village-level production of supplementary food (Indo-Dutch Project for Child Welfare, Hyderabad) Youraj Chandra Mathur, MD, DCH Professor of Social Paediatrics and Paediatrician, Institute of Child Health, Niloufer Hospital, Hyderabad
Miss V. Madhavi Dietitian, Niloufer Hospital, Hyderabad
TROPICAL DOCTOR,
1976, 6, 84-86
Malnutrition is one of the major public health problems confronting the developing world. Affecting about lIs of the pre-school population, it is related to poverty and ignorance. Malnutrition in utero and during the first years of life has repercussions in later life and may result in impairment of physical and mental growth. Various schemes have been, and are still being formulated to combat protein calorie malnutrition and one such project is in progress in Hyderabad. The Indo-Dutch Project for Child Welfare started in IQ69 at the Chevella Development Block in Hyderabad District in South India. This area is 40 km from the city of" Hyderabad and has a population of 1I4,000, the proportion of the child population being 41%. The aim of the project is to provide comprehensive child care within the community including preventive, curative, social, and environmental care for the children of the area and also antenatal services for expectant mothers. There are one primary health centre and eight sub-centres in addition to one hospital in the centre and one in the southern part of the relevant area. During the first year, background and base line data were collected. The mobile social-paediatric team from the Institute of Child Health, Hyderabad, has been responsible for the health and the nutrition part of the project, which was started in stages. First at the Primary Health Centre at Shankerpally with the eight villages nearby, each about S km distant from the Centre; then it was spread to sub-centres. Every clinic cares for a population of about 10,000 people. The emphasis is mainly on maternal health, child health, nutrition, family planning, and health education. As far as possible the local resources are utilized, one of the aims of the project being selfsupport so that it can continue even when there is a shortage of money and personnel. The project, now in its fifth year, covers about
Fig.
I.
Contents of each packet of 70 g weight.
Fig. 2. Preparation of basic ingredients. Cleaning, roasting, and grinding is carried out by local members of Mahila Mandals who earn a small profit of 3-4 paise per packet. 50,000 of the population and nearly half of the entire block. The local medical officers of the primary health centre have been re-trained and at the subcentre level the local auxiliaries were given a ten-weeks' in-service training orientated with an emphasis on preventive, social, and nutritional aspects. The
Tropical Doctor, April IfJ76
VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY FOOD
Fig. ]. Distribution of mixed contents into individual packets.
infant mortality rates are quite high, i.e. 110 per thousand in the entire block. Morbidity and mortality studies are undertaken in the same season of the year. It was found that protein calorie malnutrition was heading the list of diseases in children in the area, with diarrhoea, respiratory infections, skin infections (scabies) being the next priorities. A socio-economic survey revealed that the average income per family (extended family) was Rs.60j(7 dollars) per month. This survey was based on the agricultural produce. A dietary survey carried out simultaneously showed that a pre-school child received a diet which was 300 calories less than the recommended minimum. The survey also brought to light the attitudes, beliefs, and taboos of the community. An attempt was made to bridge the calorie gap of the pre-school child by providing supplements made from locally grown foods. These supplements were based on a cereal-pulse combination in a precooked form. The cereals and pulses were roasted and powdered and mixed with sugar; 70 g of this powder (being one day's supplement for a child) was packed and sealed in a polythene bag. The composition of this "Hyderabad Mix" or "Protein Packet" is as follows: Components: Wheat or jowar Bengal gram dhal (split chick peas) 17·S g Ground nuts (peanuts) 6.og Sugar II·S g Content:
Fig. 4. The "Hyderabad Mix" can be mixed with milk to make porridge or it can be compressed into balls (laddoos). It can also be eaten as dry powder.
I 85
so% 2S% 8·S% 16·S%
Calories 260 Proteins log
Initially these packets were prepared at the Institute of Child Health, Hyderabad, but soon became very popular and now the preparation has been transferred to the village itself. The local "Mahila MandaI" (women's club) has been instructed in the preparation ofthese packets and the community response has been encouraging. These mixtures are now being prepared locally in most of the villages, and various combinations and permutations are being tried, e.g. jowar (sorghum) instead of wheat, green gram instead of wheat, green gram instead ofchick peas, and "jaggary" (brown sugar) instead of refined sugar, etc. Sometimes, all or part of the ingredients are donated by farmers. The cost of the packet varies according to the market value but ranges from IS to 18 paise (2-3 US cents). These foods have not only helped in reducing the prevalent protein calorie malnutrition but were often used as weaning foods. In the villages weaning is usually delayed up to the age of 2 years, in the belief
86
I VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY FOOD
that a child will not be able to digest any solid food, until the age at which he is voluntarily able to partake of adult food. This happens to be around 1 t to 2 years of age. The "Hyderabad Mix" being in powder form and pre-cooked, the mother is willing to try it on her child. Thus these packets have proved to be of value in nutrition education. Many mothers who avoided locally available bengal gram and ground nuts in their daily diets, in the belief that they produce nausea, vomiting, and diarrhoea, have started using them after the good response of their children to this vegetable protein mixture. Preparation of these packets by the local "Mahila
Tropical Doctor, April I976
Mandal" has taken the project right into the heart of the villages and that itself was a motivation for these women to use weaning foods and supplements in their diets. Thanks to this community nutrition programme the morbidity pattern has changed. Protein-energy malnutrition has descended from first to fourth position in order of importance. This technique places in the hands of village women food which is locally available, cheap, culturally acceptable for weaning, and that can be used as a supplement during the rapid growth phases and during recuperation from protein-energy malnutrition.
Notes and News ONCHOCERCIASIS AND ITS CONTROL
Onchocerciasis has been known to have its endemic foci in most of the countries of tropical Africa, in Yemen and in Central and South America, but in recent years the true magnitude of the problem has been recognized with new foci being detected as a result of better case-finding and improved diagnostic techniques. Recent evidence shows that the figure of 20 million people affected, given by the health authorities earlier, was an understatement. The use of more sensitive diagnostic tests has led to a doubling of the number of cases estimated earlier. The massive WHO programme to control the disease in the savannah area of the Volta River basin in West Africa, one of the worst endemic onchocerciasis zones in the world, has been launched in 1975. The project area is about 700,000 square kilometres and comprises parts of seven West African countries. Of the 10 million people living in the area, at least 70,000 are blind and many more have serious visual impairment. The disease is being fought by systematically destroying the breeding sites of the vector. Many of these are inaccessible by land and are sprayed with insecticide released from fixed-wing aircraft or helicopters. The insecticide used is temephos, a biodegradable compound selected for the programme after years of research. It is highly effective against the blackfly and does not harm other animal or plant life.
As a result of the completed first operational phase, for almost a year no adult flies have been found in the area covered. However, relatively large numbers of flies, many of them infected, have been found in the peripheral parts of this area. It is assumed that the flies come from breeding sites outside the treated zone and that most of them will be eliminated as the programme enters its second and third phases. As onchocerciasis is brought under control, fertile river valleys in the project area, now largely deserted by the people for fear of the disease, will be open for resettlement and development. There is need for adequate measures to prevent the outbreak of other diseases, such as sleeping sickness and schistosomiasis, in the newly developing areas. There is also need for new and suitable drugs to treat onchocerciasis. The drugs now available, even though effective, cause serious side-effects, making them unsuitable for use on a mass scale. Therapeutic trials were suggested to determine the signs and symptoms that precede serious damage to the eye and to develop methods of preventive therapy. Further information is needed on the distribution and identification of the various kinds of blackflies that belong to the Simulium damnosium complex. It was pointed out that identification of these insects cannot easily be done by conventional means but only through the complicated technique of examining the larvae reared from eggs of females caught in natural conditions.
I VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY
Tropical Doctor, April I976
FOOD
Village-level production of supplementary food (Indo-Dutch Project for Child Welfare, Hyderabad) Youraj Chandra Mathur, MD, DCH Professor of Social Paediatrics and Paediatrician, Institute of Child Health, Niloufer Hospital, Hyderabad
Miss V. Madhavi Dietitian, Niloufer Hospital, Hyderabad
TROPICAL DOCTOR,
1976, 6, 84-86
Malnutrition is one of the major public health problems confronting the developing world. Affecting about lIs of the pre-school population, it is related to poverty and ignorance. Malnutrition in utero and during the first years of life has repercussions in later life and may result in impairment of physical and mental growth. Various schemes have been, and are still being formulated to combat protein calorie malnutrition and one such project is in progress in Hyderabad. The Indo-Dutch Project for Child Welfare started in IQ69 at the Chevella Development Block in Hyderabad District in South India. This area is 40 km from the city of" Hyderabad and has a population of 1I4,000, the proportion of the child population being 41%. The aim of the project is to provide comprehensive child care within the community including preventive, curative, social, and environmental care for the children of the area and also antenatal services for expectant mothers. There are one primary health centre and eight sub-centres in addition to one hospital in the centre and one in the southern part of the relevant area. During the first year, background and base line data were collected. The mobile social-paediatric team from the Institute of Child Health, Hyderabad, has been responsible for the health and the nutrition part of the project, which was started in stages. First at the Primary Health Centre at Shankerpally with the eight villages nearby, each about S km distant from the Centre; then it was spread to sub-centres. Every clinic cares for a population of about 10,000 people. The emphasis is mainly on maternal health, child health, nutrition, family planning, and health education. As far as possible the local resources are utilized, one of the aims of the project being selfsupport so that it can continue even when there is a shortage of money and personnel. The project, now in its fifth year, covers about
Fig.
I.
Contents of each packet of 70 g weight.
Fig. 2. Preparation of basic ingredients. Cleaning, roasting, and grinding is carried out by local members of Mahila Mandals who earn a small profit of 3-4 paise per packet. 50,000 of the population and nearly half of the entire block. The local medical officers of the primary health centre have been re-trained and at the subcentre level the local auxiliaries were given a ten-weeks' in-service training orientated with an emphasis on preventive, social, and nutritional aspects. The
Tropical Doctor, April IfJ76
VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY FOOD
Fig. ]. Distribution of mixed contents into individual packets.
infant mortality rates are quite high, i.e. 110 per thousand in the entire block. Morbidity and mortality studies are undertaken in the same season of the year. It was found that protein calorie malnutrition was heading the list of diseases in children in the area, with diarrhoea, respiratory infections, skin infections (scabies) being the next priorities. A socio-economic survey revealed that the average income per family (extended family) was Rs.60j(7 dollars) per month. This survey was based on the agricultural produce. A dietary survey carried out simultaneously showed that a pre-school child received a diet which was 300 calories less than the recommended minimum. The survey also brought to light the attitudes, beliefs, and taboos of the community. An attempt was made to bridge the calorie gap of the pre-school child by providing supplements made from locally grown foods. These supplements were based on a cereal-pulse combination in a precooked form. The cereals and pulses were roasted and powdered and mixed with sugar; 70 g of this powder (being one day's supplement for a child) was packed and sealed in a polythene bag. The composition of this "Hyderabad Mix" or "Protein Packet" is as follows: Components: Wheat or jowar Bengal gram dhal (split chick peas) 17·S g Ground nuts (peanuts) 6.og Sugar II·S g Content:
Fig. 4. The "Hyderabad Mix" can be mixed with milk to make porridge or it can be compressed into balls (laddoos). It can also be eaten as dry powder.
I 85
so% 2S% 8·S% 16·S%
Calories 260 Proteins log
Initially these packets were prepared at the Institute of Child Health, Hyderabad, but soon became very popular and now the preparation has been transferred to the village itself. The local "Mahila MandaI" (women's club) has been instructed in the preparation ofthese packets and the community response has been encouraging. These mixtures are now being prepared locally in most of the villages, and various combinations and permutations are being tried, e.g. jowar (sorghum) instead of wheat, green gram instead of wheat, green gram instead ofchick peas, and "jaggary" (brown sugar) instead of refined sugar, etc. Sometimes, all or part of the ingredients are donated by farmers. The cost of the packet varies according to the market value but ranges from IS to 18 paise (2-3 US cents). These foods have not only helped in reducing the prevalent protein calorie malnutrition but were often used as weaning foods. In the villages weaning is usually delayed up to the age of 2 years, in the belief
86
I VILLAGE-LEVEL PRODUCTION OF SUPPLEMENTARY FOOD
that a child will not be able to digest any solid food, until the age at which he is voluntarily able to partake of adult food. This happens to be around 1 t to 2 years of age. The "Hyderabad Mix" being in powder form and pre-cooked, the mother is willing to try it on her child. Thus these packets have proved to be of value in nutrition education. Many mothers who avoided locally available bengal gram and ground nuts in their daily diets, in the belief that they produce nausea, vomiting, and diarrhoea, have started using them after the good response of their children to this vegetable protein mixture. Preparation of these packets by the local "Mahila
Tropical Doctor, April I976
Mandal" has taken the project right into the heart of the villages and that itself was a motivation for these women to use weaning foods and supplements in their diets. Thanks to this community nutrition programme the morbidity pattern has changed. Protein-energy malnutrition has descended from first to fourth position in order of importance. This technique places in the hands of village women food which is locally available, cheap, culturally acceptable for weaning, and that can be used as a supplement during the rapid growth phases and during recuperation from protein-energy malnutrition.
Notes and News ONCHOCERCIASIS AND ITS CONTROL
Onchocerciasis has been known to have its endemic foci in most of the countries of tropical Africa, in Yemen and in Central and South America, but in recent years the true magnitude of the problem has been recognized with new foci being detected as a result of better case-finding and improved diagnostic techniques. Recent evidence shows that the figure of 20 million people affected, given by the health authorities earlier, was an understatement. The use of more sensitive diagnostic tests has led to a doubling of the number of cases estimated earlier. The massive WHO programme to control the disease in the savannah area of the Volta River basin in West Africa, one of the worst endemic onchocerciasis zones in the world, has been launched in 1975. The project area is about 700,000 square kilometres and comprises parts of seven West African countries. Of the 10 million people living in the area, at least 70,000 are blind and many more have serious visual impairment. The disease is being fought by systematically destroying the breeding sites of the vector. Many of these are inaccessible by land and are sprayed with insecticide released from fixed-wing aircraft or helicopters. The insecticide used is temephos, a biodegradable compound selected for the programme after years of research. It is highly effective against the blackfly and does not harm other animal or plant life.
As a result of the completed first operational phase, for almost a year no adult flies have been found in the area covered. However, relatively large numbers of flies, many of them infected, have been found in the peripheral parts of this area. It is assumed that the flies come from breeding sites outside the treated zone and that most of them will be eliminated as the programme enters its second and third phases. As onchocerciasis is brought under control, fertile river valleys in the project area, now largely deserted by the people for fear of the disease, will be open for resettlement and development. There is need for adequate measures to prevent the outbreak of other diseases, such as sleeping sickness and schistosomiasis, in the newly developing areas. There is also need for new and suitable drugs to treat onchocerciasis. The drugs now available, even though effective, cause serious side-effects, making them unsuitable for use on a mass scale. Therapeutic trials were suggested to determine the signs and symptoms that precede serious damage to the eye and to develop methods of preventive therapy. Further information is needed on the distribution and identification of the various kinds of blackflies that belong to the Simulium damnosium complex. It was pointed out that identification of these insects cannot easily be done by conventional means but only through the complicated technique of examining the larvae reared from eggs of females caught in natural conditions.
