The Sterile Nutrition Debate
Africa's Own Weapon of Mass Destruction
By Basil Kransdorff
April 2, 2007 - Toronto 2006 has come and gone. From South Africa I watched in horror as our dysfunctional HIV nutrition debate was aired on the international stage. Africa faces a crisis as infections and deaths mount, but we lack real leadership and an appropriate integrated strategy.
The nutrition issue has been marginalised by a damaging public media debate on nutrition versus medicine that has polarised proponents of nutrition on the one hand and proponents of antiretrovirals (ARVs) and other pharmaceuticals on the other. This either/or debate is specious and does not serve anyone. We need both if we are to succeed.
On the positive side of our 'circus of shame', protagonists must take credit for putting nutrition firmly on the international HIV agenda. Though for the thousands who did not need to die, it is tragically all too late.
The terms 'nutrition' or 'a balanced diet' are used in the African context with little understanding of what they mean. Valuable resources continue to be wasted promoting ineffective nutritional interventions and outdated approaches. The failed policies of the past 40 years have precipitated a nutritional crisis on a global scale. Many communities are experiencing health problems not seen by their grandparents, who often lived in similar poverty.
The causes of failure are not addressed because international agencies remain in denial, preferring to promote the illusion that their programmes are working. Critical issues are ignored on the basis that the cheapest components must be used. This approach is rationalised by experts who argue that a little is better than nothing, or that there are just too many mouths and not enough budget, even when their interventions do not address nutritional requirements. As a result, the problems grow and ongoing failure results in donor fatigue.
The reality is that there cannot be a partial solution to addressing nutritional requirements. Effective nutrition is not just a label claim, a full stomach, a handout of animal feed, or seeds for the proverbial vegetable patch. It can never be a monthly food parcel, fortified with the cheapest inorganic chemical nutrients, and used as a 'nutrition tool' just because it is donated.
Our bodies are designed to require daily quantities of nutrients, minerals and vitamins from the food we eat. Modern food processes and agricultural practices remove nutrients from the food chain. As a result, we can no longer rely on what is often referred to as a balanced diet to deliver the nutrients the body requires. In the context of the South African nutrition debate, garlic, lemon juice, beetroot, African potato and olive oil do contain food nutrients needed by our body, but to promote these foods as the basis of good nutrition, or as a substitute for treatment regimes, does a disservice to both the science of nutrition and medicine.
Those who believe that Africa's health problems are solvable solely by cheap or free handouts of drugs need a wake up call. South Africa is planning 1.2 million ARV treatments by 2010 at a cost of R12 billion [US$1.6 billion]. What about their 2010 projected queue of over 9 million people living with HIV/AIDS who are not being planned for? What about the millions of victims living in African countries that do not have the resources to implement costly drug regimes?
On the positive side, after years of sterile debate, all now agree that nutrition is essential. Understanding what this means, and ensuring that effective nutrition interventions are factored into programmes, is now our challenge. Telling poor people to eat a balanced diet, or relying on interventions that do not address the nutrition crisis, are not going to win the war. We need real, practical, workable African solutions.
As the HIV virus replicates, it robs its host of selenium and the amino acids cysteine, glutamine, and tryptophan. Other micro-nutrients, including the vitamins A, B6, B12 and E, and the mineral zinc, play a critical role in the maintenance of immune function and overall metabolism. Persons living with AIDS suffer from extreme deficiencies of all of these nutrients, which are responsible for depressed CD4 (cluster of differentiation 4) counts, vulnerability to infections and cancers, dementia, depression, diarrhoea, muscle wasting, neuropathy and skin diseases.
The science of bio-available nutrition should be the basis of modern health care. When people living with HIV/AIDS are nutrient replete, they are better able to defend themselves against opportunistic infections, and the progression of their disease is delayed. The need for ARVs is postponed and their toxicity is reduced. Compliance and effectiveness are improved. All this reduces pressure on the health system in a cost-effective way. The South African Health Minister's warning of the dangers of using strong drugs on malnourished people with empty stomachs is valid.
Children in Africa suffer from iron deficiency which masks medical conditions such as tuberculosis (TB) and malaria, making them more difficult to diagnose and treat. The rampant spread of drug-resistant TB in people living with HIV/AIDS is in my view a direct result of a lack of focus on nutrition in programmes. The link between drug resistance, poor compliance and nutrient deficiencies warrants urgent investigation.
The American President's recent announcement to extend international aid to eradicate malaria in Africa highlights the issues raised. President Bush and his wife declare in their media announcements that 'the experts tell them that with drugs, mosquito nets and insecticides, malaria can be addressed'. There is no mention of nutrition, so the effectiveness of the proposed expensive interventions remains in question.
Africa has lived with malaria for centuries. Why experts miss the obvious role played by the food chain in this crisis is a mystery. And why they do not engage with state-of-the-art bio-available nutrition so as to better understand the role it could play in the management of recent African pandemics is an even greater mystery.
It is my conviction that with good nutrition people will be more resistant to malaria and TB and that drug regimes will be more effective. This concept has not been incorporated into interventions.
The medical profession has a short memory. It forgets that the great pandemics of the past, such as cholera and plague, were not solved by the pharmaceutical industry. They were solved by engineers and town planners. Doctors once knew that diseases such as TB were the product of poverty, poor nutrition and poor housing. TB declined as these were addressed. The Chinese conquered a fatal viral epidemic, Keshan's disease, by addressing a single micronutrient deficiency. Today, national health services have become national treatment services, with little emphasis on causation and prevention. With this mindset, international interventions in Africa are failing.
Confront most doctors on this issue and they will agree that nutrition is key. But getting doctors to engage with nutrition as a science and to implement it in patient management is another issue. They become confused. Where they accept that nutrients are not medicines, even when they bring health to a diseased body, they cannot bring themselves to dispense appropriate nutrients, arguing either that this will encourage dependence, or that food and nutrition are a private issue, and if handed out, should be cheap. Ironically, where doctors believe that nutrients are in fact treatments, there are incessant demands for clinical trials, designed around drug trial protocols, to prove the obvious that nutrition is good for you.
Meanwhile Africa's nutritional crisis is not seen, heard or understood. Africans have moved away from their traditional foods without any understanding of the role the present food chain plays in compounding the health issues facing the continent. Imported food aid, commercially grown and processed, is dumped with little understanding of the nutritional and health implication.
The reality is our continent has run out of time. If I were given one magic wish to save our continent from inevitable demise, I would 'wave my magic wand' and raise the priority given to a primary nutritional approach that mobilises available funds for state-of-the-art nutrition. If we are to survive as a continent, we are going to have to make our people nutrient replete. This is my New Year wish for 2007.
To all non-governmental organisations (NGOs) and those vested with the responsibility of intervening in our continent, my prayer for the New Year is that you stop and re-evaluate what you are doing with your eyes focused on nutrition as the first priority. Then bring on the drug regimes, the international experts, the US Presidential initiatives, Bill Clinton and Bill Gates, but bring their well-meaning efforts on nutrient replete human beings. Only then will the tide change for the better when we can all get on with the job of rebuilding our continent with healthy, empowered citizens who can take their rightful place in the global village.
April 2, 2007
"Reproduced with permission - The Communication Initiative "