910

and a melt-down was prevented only by makeshiftrepair work and firemen spraying water. Therelease of a hydrogen bubble had never been fore-seen before the accident at Three Mile Island, andone wonders how many other accidents will take

place. We need large amounts of energy not onlyfor comfort but also for agriculture and industry:but, as the late E. F. Schumacher remarked,nuclear fission is a violent method of generating it.

Heat Disorders

FOLKLORE has it that good summers follow badwinters, in which case the British summer of 1979should be even better than that of 1976. If so, doc-tors may find themselves as busy as they have latelybeen in the cold weather because high ambienttemperatures, too, cause clinical troubles.I-3 Heat

cramps, for instance, are common in workers, accli-matised or otherwise, who exert themselves in hotconditions; the muscle pain is probably due to elec-trolyte imbalance and responds to simple salt sup-plementation. Heat syncope-vasovagal-like faintswith profuse sweating-follows acute exposure to ahigh environmental temperature in an unacclima-tised person, and can be observed in girls duringschool assemblies, in guardsmen on parade, andsometimes in doctors attending boring conferencesin summer. The heat exhaustion syndrome is muchmore serious. It develops insidiously over severaldays in hot weather and afflicts people who areeither ill or unacclimatised. At first the patientcomplains of vague headache, malaise, and fatigue;he sweats, and body-temperature remains normal.Then comes confusion and circulatory collapse,with rising body-temperature. And the final stage isheatstroke, with gross neurological change--con-fusion or psychosis, seizures, depression of con-scious level. In heatstroke the body-temperature isoften more than 40-6°C and sweating may be com-pletely absent; the patient has lost all ability to loseheat and without prompt treatment will die.A report from the Marine Corps Recruit Depot

in South Carolina highlights the problem of heatdisorders in young soldiers. In the summer of 1974COSTRINI and others4 were able to investigate, pro-spectively, 13 patients with heatstroke and 14 withheat-exhaustion. The total incidence of the two

syndromes amongst all the recruits was 0-3% andthe troubles arose in hot weather (mean 26-6°C;range 21—33°C), when they were very active physi-cally. Heatstroke, in particular, tended to arise inthe recruits who were poorly acclimatised. All those

1. Knochel, J. P., Beisel, W. R., Handon, E. G., Gerad, E. S., Barry, S. K.Am.J.Med 1961,30,299.

2. Shibolet, S , Coll, R., Gilat, T., Sohar, E. Q.Jl Med. 1967, 36, 525.3. Maegraith, B. in Price’s Textbook of the Practice of Medicine (edited by R.

bodley-Scott), p 368. London, 1973.

affected were moderately dehydrated and requiredintravenous fluids. Vigorous therapy was startedwithin 20 minutes: those with heatstroke were putin an iced-water bath where their limbs were

rubbed; those with heat exhaustion were coveredwith cold, iced sheets. Chlorpromazine was notused. All victims recovered, with no prolonged mor-bidity. Cardiac damage was not a feature-con-trary to experience in older patients.l The serum-enzyme changes observed were thought to be dueto skeletal-muscle and liver injury. Heatstroke wascommonly associated with relative hypoglycxmia,In children the effect of an unaccustomed heatwavewas well described from Melbourne, Australia, in1962.5 70% of the victims were less than one yearold, most of them having heat exhaustion. Twelvedied. A disturbing report from Newcastle uponTyne6 lately suggested that hot weather is not theonly precipitant. Five infants had been well

wrapped up to keep them warm during the courseof what was thought to be a mild non-specific ill-ness, and within twelve hours all showed featuresof heatstroke-fever, shock, and convulsions.Because of the rapid onset dehydration was not afeature. Four of the infants died, and the survivorwas left with severe cerebral dysfunction.

During the hot British summers of 1975 and1976 a close relation was detected between morta-

lity and environmental temperature. Tour8 cal-culated that, during the two weeks between June27 and July 10, 1976, in Greater London, therewere 700 more deaths than would have been

expected in ordinary summer weather. The excessmortality was largely confined to people over 65years old. In Manchester during the 1976 heatwaveLYE and KAMAL9 reported a threefold increase inmortality of geriatric inpatients, the mortalitybeing notably higher in the patients housed inmodern but poorly insulated wards than in theolder well insulated Victorian wards. Their impres-sion was that heat exhaustion was the main prob-lem and that those most at risk were patients whowere already seriously ill. Reports of heatwave

mortality have usually come from large cities andTOUT and otherslO suggest that the "urban heatisland effect" leads to local, very hot microclimates.

,

The successful management of heat disorders

depends on early recognition. The groups most atrisk are now well-known-the young, the old, the

; sick, and the unacclimatised manual worker.

. Apparently the autonomic mechanism for the dissi-’ pation of heat is apt to be overwhelmed in these

1

-

groups. Prompt salt and water repletion combined

4. Costrini, A. M, Pitt, H. A., Gustafson, A. B., Uddin, D. E Am J Mea1979, 66, 296.

5. Danks, D. M., Webb, D. W., Allen, J. Br. med J. 1962, ii, 2876. Bacon, C., Scott, D., Jones, P. Lancet, 1979, i, 422.7 Macfarlane, A., Waller, R. E. Nautre, 1976, 264, 434.8 Tout, D. G. Weather, 1978, 33, 2279. Lye, M, Kamal, A. Lancet, 1977, 1, 529.10 Clarke, J. F. Envir. Res. 1972, 5, 93

911

with tepid sponging is usually sufficient treatmentbut severe heatstroke calls for more rapid heat dis-sipation.

NUTRITIONAL QUESTIONS IN BANGLADESH

IN 1973-74, many hundreds of thousands were

reported as dying of acute starvation in Bangladesh,particularly the northern provinces of Dinajpur andRangpur. The poor who had been dispossessed of theironly realistic source of food-the land farmed by theirfamilies-were forced into the larger cities or the shan-ty-town developments around them. Since that time ofparticular trouble, the harvests, as elsewhere in SouthAsia, have been good. Between 1973-74 and 1977-78,total foodgrain production in Bangladesh increased byalmost 13% and wheat production alone increased somefourfold. Nevertheless, the growing unemployment andincreasing proportion of rural landless, estimated at

50c( of all rural households and still rising at a rate of4? a year, belie the impression of economic progress. 1In addition, food imports have remained high, over 1-6million tons in 1978, almost all of it in the form of foodaid. The urgent need for intervention has generatedsome excellent and far-sighted reports. For example, aNutrition Survey of Rural Bangladesh in 1975-76showed that, despite the pace of technology advancessuch as the introduction of high-yield varieties of riceand wheat, average dietary intake was actually lowerthan in the previous decade; at least one-third of house-holds were consuming less than 80% of their estimatedcalorie requirements:2 As hard evidence of the effects ofsuch a deficiency in dietary intake, about 20% of theyoung children were both wasted and stunted (that is,they showed signs of acute as well as chronic undernu-trition). Under the age of five years, fully a quarter ofthe children had severe, or third-degree, malnutri-tion-a figure to be set against 3% or less ia most of thepoorer countries of Latin America. Furthermore,amongst several specific nutrient deficiencies, there wasa very high prevalence of vitamin-A deficiency threaten-ing sight.Bangladesh’s Third Nutrition Seminar, held in Dacca

on March 22-24, reflected the preoccupation of thecountry’s nutrition community with these enormous

problems, and there were several encouraging signs. Forinstance, one of the keynote speeches brought it out thatfood production, or even food availability in the market,by no means ensures that the food reaches those whoneed it most: "Bold agrarian reform is perhaps someanswer to inequity or maldistribution." Discussion of thepolitical structures which determine the distribution offood between the haves and the have-nots is still unusual

amongst nutritionists. A further positive sign was in-volvement not only by the Institute of Nutrition andFood Science of Dacca University, which sponsored theseminar, but also by the Institute of Public Health andButrition under the Ministry of Health. It was good to

1 Jannuzi, F. T., Peach, J. T. Report on the Hierarchy of Interests in Landin Bangladesh. Agency for International Development, Washing,DC, 1977; Khan, A. R. in Poverty and Landlessness in Rural Asia. Inter-national Labour Organisation, Geneva, 1977.

2 Nutrition Survey of Rural Bangladesh, 1975-76, Institute of Nutrition andFood Science, University of Dacca, Dacca, 1977.

3. Cash, R A. Tropical Doctor, 1979, 9, 25.

see these two groups working together. Not surprisingly,in a country where the interaction of undernutritionwith diarrhoeal disease is generally so disastrous for theyoung child, the fiercest debate was between those whofavoured oral prepackaged solution for rehydration andthose who wanted mothers to make up the salt and

sugar mixture at home. Those who favoured prepackag-ing were left trying to explain how they would deliverthe packets into remote rural areas and whether themother would be able to afford even a subsidised price.The do-it-yourself school had gathered little hard evi-dence about the reliability of home-prepared solu-

tions-particularly on the frequency of dangerous con-centrations of sodium. In this sphere cross-cultural

comparisons seem very unreliable; the results need to bereassessed for each new geographic area, even within aparticular country.3 Another session focused on thechoice of weaning mixtures, and an ideologically similarset of options emerged. The laboratory nutritionists haddeveloped preparations of dried- packaged foods-fishmixtures high in protein, and more exotic but culturallyunknown substitutes such as algx. Those working withthe poor mothers of undernourished children were moreinterested in preparations based on locally available

grains, legumes, and oils which, though slightly inferiornutritionally, might be more within the range of theirincome.What conclusions could be drawn from the meeting?

There was recognition of the importance of identifyingvulnerable groups and biasing nutritional strategies intheir favour. Without this kind of emphasis it is difficultto see how anything substantial can be achieved. (Onepaper at the meeting identified some food crops-coarsegrains and sweet potatoes-which might be particularlyencouraged because they tend to be produced and con-sumed by low-income groups.) Less compelling was anemphasis on achieving results through interministerialcommittees, councils, and secretariats. These have beentried in many countries and the results are sadly predict-able. For, when there is no real responsibility there is noreal authority, and hence no impact in the countryside.Where a genuine political commitment exists, no suchapparatus has been necessary. In the absence of such acommitment the whole apparatus is ineffectual. Indeed,the same can be said for nutrition as a whole, thoughperhaps not to nutritionists. For the countries whichhave most convincingly countered malnutrition duringthe past three decades have done so largely by non-nutri-tional means-in Taiwan and South Korea throughrapid economic growth with attention to distributionalissues, in China, Vietnam, and Cuba through majorsocial change. In none was nutrition addressed expli-citly. Outside a rather small circle of nutritionists andagriculturalists there is still a belief in Bangladesh thatthe remedy for hunger in the population can somehowbe found in the absence either of rapid and participatorygrowth or of great social change. Yet the most successfulprojects in the country-e.g., BRAC and Gonoshas-

thaya Kendra-work on a different basis.4 The oddsseem stacked against traditional approaches.

4. Ahmed, M. BRAC: Building Human Infrastructures to Serve the Rural

Poor; and The Savar Project Meeting the Rural Health Crisis in Bangla-desh. International Council for Educational Development, Essex, ConnU.S.A., 1977.