MFCM150: Food Security, Under-nutrition and Infectious Diseases.pdf

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FOOD SECURITY, UNDER-NUTRITION & INFECTIOUS DISEASES

r

'The best cure for malaria is a full cooking pot'- an old Tuscan
proverb.
The importance of food in health has been an intrinsic part of
Western science recognised the relationship
our cultural knowledge,
infectious
disease
only recently,
with
the
between
food and
Better food
association of famine with mortality due to infections,
supply has been associated with a decline in mortality , increase in
In our country
longevity and the modern rise of the human population.
,i k although acute starvation has been largely prevented, chronic hunger
is a reality for the majority of our people.
While people live
This
longer, the burden of infectious diseases is still with us.
article attempts to ask
the question whether the lack of food and
•chronic under-nutrition underlies out inability to solve infect ious
disease problems in India.
In the first part of the article, historical work based on the
rise of the human population and the relationship between famine and
infectious disease mortality are reviewed.
reviewed. In the second part of the
article development of food self sufficiency is retraced; then the
effect of structural adjustment policies and agri -exports in the
nineties on shifting of cropping patterns and falling percapita food
availability are outlined.
In the third part of the article, the
In the
effect of changes in food supply on nutrition are discussed,
fourth part of the article, the immunological links between under
-nutrition and specific infectious diseases are discussed. In the
fifth part of the article some of the problems of dealing wi th
nutritional problems in clinical practice are elaborated.
I. HISTORICAL LINKS BETWEEN FOOD SUPPLY AND INFECTIOUS DISEASES
The increase in the human lifespan and the rise of the human
population over the last century has been one of the most dramatic
changes of our times. Mckeown in a seminal study of the mortality data
from England and Wales, showed that the mortality decline due to major
infectious diseases was a result of better availability of food, safe
drinking water and sanitary reforms and preceded the use of specific
medical treatments or preventive measures. Of these he suggested that
food availability was the single most important factor in the
mortality decline.

European land was typically
of low productivity due to the shorter
growing season, low seed to yeild ratio and less fodder availability.
With the seizure of the colonies, the European countries were able to
cultivate their tea, coffee, sugar and spices using indentured labour
in the colonies and to accumulate capital.
The accumulation of
capital and largescale imports enabled a general improvement in
the
quality of nutrition and lifestyles.

The relationship between food supply and infectious disease mortality
was demonstrated in
studies of the major Indian famines of the
nineteenth and the early part of the twentieth century. In each of
these famines millions of people died.
Maharatna studying, four
famines of this period, showed that famine mortality correlated
closely to the grain price index (which was a measure of the severity
of famine and of economic hardship)<4) . Mortality during famine was
largely due to Malaria, Cholera, diarrhea and dyssentry, and malaria

was the single most impo^ant cause of death.
Each disease had a
particular temporal profile in relation to famine. Cholera deaths
occurred during the period of drought, those due to diarrhea and
dyssentry coincided with the rains, and the malaria mortality peaked
in the post monsoon period maximally in the year following the
drought.
He suggested that death due to undernutrition was mediated
through infectious diseases, but modified by environmental factors
such as water scarcity, congregation in camps (in the case of cholera)
and the monsoons in the case of malaria.

The major decline in mortality in India occurred after 1921 as
documented by Kingsley David and Sumit Guha (3). Sheila Zurbrigg
attempted to elucidate the reasons for this decline studying malaria
mortality in Punjab between 1868 and 1940. She showed that till 1908,
seasonal malaria mortality strongly correlated to the the degree of
flooding and to the wheat prices. However in the post— 1908 period the
malaria mortality decreased and ceased to be affected by wheat prices,
without any change in the clinical rates of malaria, infected musquito
rates or public health measures. She suggests that only explanation
for the mortality decline was improved famine relief.
Official
relief after 1908 was sanctioned before frank famine took place, and
based on increase in food grain prices and later also for flood
induced harvest losses.
Although chronic undernutrition was still
very common, people plunged less often into acute starvation.Sumit
Guha too suggests that tha possible reason for the post -1921
mortality decline was a fairly stable level of moderate malnutrition.
In actual fact during the period between 1900 to 1947, there was a
decline of per capita food availability of 25 %. Increasing exports
and adverse terms of trade compromised food availbility. Patnaik
suggests these policies resulted in the West Bengal famine of 1943 -44
during which 2-4 million people died. Therefore
detailed study of
food availability and food intakes are required before one can
substantiate the claim that decline in mortality was due to improved
famine releif and better food availbility.

11. FOOD SECURITY IN INDIA (2, 3)
In the first two decades after independence the government
increased food production by promoting fertilizer technology and high
yeiId ing varieties (HYV) in irrigated areas. At the same time it set
up two tiers of procurement of grain, by the central government
through the food corporation of India (FCI) and by state government
through various schemes, which would purchase unlimited amounts
through a minimum support price, A public distribution system (PDS?
consisting of a chain of fair price shops were set up to distribute
procured grain at issue prices lower than the procurement and handling
charges. This constituted the food subsidy which was on the average
10-12% of the final price.
The wheat revolution upto the 1970's in the north, especially in
Punjab followed by growing of rice in the same region as a commercial
crop constituted the growing intervention of the state in the food
economy. By the late 1980's over 90% of the wheat procurement and 66%
of the rice were supplied by the five states Punjab, Haryana, UP and
Jammu and Kashmir. Green revolution provided adequate grain for the
PDS. The economic gains however went to larger farmers in the absence

of land reforms, leaving behind the mass of peasants in poverty,
The
pre-independence trend of declining per head food availability was
reversed with a 17 % rise in grain production. However the PDS has had
problems of mismanagement, urban bias, lack of coverage of tribal
areas and lack of correlation between food supply and level of poverty
of the state. Studies show that the grain off-take was very low except
in the states of Kerala,
West Bengal, Tripura (all left governed
states:* and Jammmu and Kashmir. A number of regional parties which
came to power between 19S9 and 1991, instituted specific programmes to
improve food availabi1ity such as the mid-day meal scheme in Tamilnadu
and Gujarat and the Rs.2/kg of rice in Andhra Pradesh.
Upto mid 1991, national policy was geared to achieving higher
food consumption levels for poorer segments of the population. By
purchasing two fifths of the market supply, under the dual purchase
and price system the government played a major role in controlling
inflation
of
food
grain
prices.
Even
though
socio-economic
inequalities were widening, the price of grain was controlled and
people could buy it.

From mid-1991 the government started instituting structural
adjustment policies governed by the World Bank which included trade
liberalisation and agro-export promotion. From the second half of the
1980's there was a declining trend of coarse grain production and
growth of oilseeds. From 1990 -1996, the area under culivation for
coarse grains and pulses declined whereas that under wheat cultivation
remained stationary. Annual growth rates of food grain production have
decreased and have not kept up with the requirement of the growing
population, resulting in falling per capita food grain availability.
In contrast the decline in area of food grain production has been made
up by the increase in area under cultivation of cotton,
cotton, oilseeds,
sugarcane and horticultural crops.
Of the oilseeds,
oi Iseeds, soya bean
production has increased the maximum and most of this is used for
conversion to fodder cakes for export. The oil seeds are replacing
course grains in the low rainfall areas such as Andhra Pradesh,
Maharashtra, Madhya Pradesh, Gujarat and Rajasthan, threatening the
staple food of poorer people in these regions.

Rapid growth of livestock production for the cities and middle
east export has resulted in an
increasing diversion of grain
cultivated land into that for fodder food. Prawn cultivation for
export, has resulted in takeover of coastal agricultural land from the
farmers and irreparable salination of the soil.
The decrease in the food subsidy between 1992 to 1994 and the
accompanying price rise led to a predictable fall in the off-take from
the PDS. The mismanagement of PDS stocks in 1996 forced the government
to import 1.25 milion tonnes of grain. India may become an even more
substantial grain importer unless steps are. undertaken to step up food
grain production and protect the domestic producer.
B.WHY DO NORTHERN COUNTRIES PROMOTE AGRI-EXPORTS
(2)
The high standard of living of northern households is maintained
by a variety of imported products from tropical and subtropical
countries. Same of the changes in consumption patterns are a result of
increasing health consciousness such as the shifts to vegetable oils,
lean meat, fish, fibre containing cereals, vegetables and fruits. Only
a fraction of these demands can be met from the temperate countries.

TNC's have shifted beef production to warmer countries such as
Mexico and El Salvador to increase lean meat production, displacing
human foodgrains by fodder crops. Prawn culture
is destroying
agricultural land in India and Thailand. Foreign owned mechanised
fishing fleets are displacing local fishing communities in the Indian
Ocean. TNC's are also displacing food grain by contracting the
production of fruits and vegetables.
The high standard of living is maintained by the low cost of
imported products. The costs are kept down by low wages and controlled
pricing. However the ultimate cost is borne by steady lowering of food
consumption and nutrition for large segments of poor people.
C. EXPERIENCE OF SAP-IMPLEMENTING COUNTRIES i
Mexico which had achieved food self-sufficiency in the 1960's,
is now an importer of maize, beans and wheat as a result of structural
adjustment policies. In the sub-Saharan African countries (all of
which have liberalised and engaged instrong export oriented drives in
the early 1980's) there has been a decline of cereal output and per
capita food availbility. In these countries most of the agricultural
land is us used for cultivation of. exported crops. By 1989 a
substantial part of sub- saharan Africa was in the midst of pre-famine
conditions, and actual famine was averted in 1992-93 by massive
foreign aid. Wage cuts, rising prices and elemination of food
subsidies have forced people to shift to poor quality high bulk foods
leading to
increasing
ill-health,
nutritional
deficiencies and
mortality. All these countries have seen rising rates of ill health
and mortality <7). Yaws and Yellow fever which were eleminated from
Ghana, have reappeared. The policies have ignored the profound
societal impact of AIDS on the community.

In many African countries the infant mortality rate during
1980-1985 (the SAP period) rose by 4-54 54, and the under 5 mortality
by 3.1—90.954.
A 10 country study concluded that the nutritional
status of children had declined in all but two countries.
Various
studies showed that at the end of the SAP period, the majority of
deaths in children were due to malnutrition.
In 1988 it was estimated
that one-million African children had died in the 'debt war'.
III. HOW MUCH HAVE OUR IMPROVEMENTS IN FOOD SECURITY IMPACTED ON
HUNGER AND UNDERNUTRITION :
In the post-independence period only 3 major famines have been
described.
In the 1966-67, Andhra Pradesh, Maharashtra and Bihar
suffered famine, resulting in an average calorie intake of 1100-1400
Kcal and many households subsisted on wild leaves and tubers.
60
shiploads of grain from the U.S. containing 7 million tonnes of wheat
were sent but could not prevent 3614 of families subsisting on a
starvation diet.
In 1987 the worst drought of the century occurred
affecting 15 states and 6 union territories. While the calorie intake
did not fall, the quality of food deteriorated but did not result in
starvation deaths. The successful prevention and management of recent
droughts has been due to increased food production, the PDS and
controlled food pricing.
While we have been able to prevent famine, the increased food
production has not been equitable. NNMB-NSSO survey in 1983-84 showed
that average food expenditure of families ranged from Rs.73-80 per
month, which was 70 % of the total household expenditure <8).
In
1989, the NNMB survey showed that the monthly household income was

Rs.60.
Therefore,
actually declined.

it

is

likely that household expenditure on

food

Comparison of dietary surveys in rural areas conducted between 1960-69
(Diet Atlas of India, 1969), NNMB Surveys 1975-79 and NNMB survey
1988-89, show the calorie intake increased statistically by 300 kcal ,
from 1960's to 1975, but have failed to register further increase from
1979-1989. While the average diets are marginally adequate, based on
the low cost diet recommended by ICMR, they are deficient in vitamin
A and Riboflavin.
However if one compares the composition of food
stuffs to that of a balanced diet, the diet is deficient in pulses,
green leafy and other vegetables, roots, tubers, fats, oils, milk and
milk products.
In fact the intake of pulses, roots and tubers have
declined from 1979—1989. Comparable studies with similar sampling
methods are not available before I960.
chiIdren according to
The weight-for-age status of pre-school children
Gomez's criteria showed a decline in the proportion of severe and
moderate malnutrition and corresponding increase in normal and mildly
malnourished children. The prevalence of severe malnutrition declined
from 15 % in the seventies to 8.7% in 1988-90, while the normals
increased only from 5.9 to 9.9%. Clinical assessment showed that
prevalence of severe FEM, Bitot's spots and angular stomatis had
declined. Still, 90 % of children are suffering from undernutrition.
In adults in rural areas, the same survey showed than more than 55 %
had a BMI < 18.5 which indicates chronic energy deficiency.
While
there was marginal shifts of the adult BMI and mean heights and
weights between 1975-79 and 1988-90, these are of questionable
significance.
The extent of chronic hunger is sharply debated. Whatever estimate is
used,
the
conclusion
that
the
problem of chronic
hunger
is
all-pervasive cannot be escaped.
IV.MALNUTRITION, IMMUNE RESPONSE AND INFECTION
The synergistic interaction between nutrition and infection was
described by Scrimshaw in 1968.
Infectious diseases are associated
with reduced food intake, increased requirements and this adversely
affects the nutritional status.
Deteriorating nutritional status
impairs immune function and modifies disease course and outcome.
A.IMMUNE RESPONSE IN FEM, VITAMIN A AND IRON DEFICIENCY
The adverse effects of REM (Protein energy malnutrition) on the immune
system are well documented
(9).
Cellular immune
response is
particularly affected. The total number of T Cells, especially CD4 (T
helper) cells are reduced.
In response to mitogens, T cells show
reduced proliferation and lymphokine production.
There is decreased
mobi1isat ion,
macrophage
mobilisation,
phagocytosis
and
interleukin-1
(IL-1)
production.
Malnourished children show impaired bactericidal
bacteric idal activity and
peroxide production by neutrophils, The humoral immunity is less
affected by FEM.
The levels of immunoglobulins are normal or
elevated.
Antibody response to immunistion with diptheria, tetanus
toxoid and measles vaccine has been shown to be adequate in FEM but
reduced in response to typhoid antigen .
Total complement and C3
levels are reduced
reduced.. Many of these changes increase with the severity
of malnutrition and reverse after treatment.
The role of vitamin A in maintaining mucosal integrity is well
known.
In vitamin A deficiency immunological studies show fairly
normal humoral and cell mediated immune response.
However in vitro
studies of nasopharyngeal cells show increased bacterial binding and

decreased lysosomal enzymes levels in leucocytes.
Immunological
studies of iron deficiency have shown impaired batericidal activity of
leucocytes,
reduced cell
mediated
immune response
and
lowered
complement levels.
Immunological studies specifically on malnourished patients with
tuberculosis have shown low total-T cells counts, CD4 counts, reduced
T cell response to mitogen stimulation (PHA), reduced macrophage
phagocytosis and bactericidal killing in comparison to patients with
TB who were not malnourished and normal controls (10).The
immunological changes were more severe in malnourished children with
advanced TB disease reflecting their synergistic interaction. However
it has to be noted that children with advanced disease were mostly
malnourished, compared to patients with localised disease who were
better nourished.
B. CLINICAL STUDIES OF MALNUTRITION AND TB (10)
There have been documented increases in tuberculosis deaths
during situations of acute food scarcity, either natural or man-made.
Reversal of these effects following food availability, supports this
association.
Radiological evidence of tuberculosis was seen in 30.5
% of children with Kwashiokor in India and several parts of Africa.
Others have noted a close correlation between the age of distribution
of tuberculosis and Kwashiokor in children.
In an important study
from Hyderabad, it was found that children of normal, mild and
moderate malnutrition had higher rates of localised tuberculous
disease whereas those with severe malnutrition mostly had advanced TB
disease. Animal studies too have shown that food deprivation increases
succeptibi1ity to Mycobacterium tuberculosis.
Other studies have
shown that protective efficacy of BCS occurs in malnourished children
also.
In summary,
recent studies show that malnutrition p1 ays a
contributory role in the development of severe forms of TB. Better
nutritional status propably prevents the the progression of the
disease.
C. MEASLES AND MALNUTRITION
Measles places an unusual nutritional stress on children. The
nutritional state of the child at the time of development of measles
plays a subtle
role in determining post—measles morbidity and
mortali ty.

Hospital studies show that upto one—fourth of children who present
with marasmus and kwashiokor have a recent history of measles.
Prospective studies have shown that
children lose 2-12% of their
original body weight during the acute phase of measles and that the
weight gain in the post—measles period is slower than for normal
children. Marasmus and kwashiokor develop in 4% of children in the £>
months following measles. While all children who develop measles have
an acute loss of weight and delay in weight gain following
fol lowing the
illness, it is only children whose nutritional status is al ready
compromised who develop severe protein energy malnutrition.
Studies in Africa by Marley in the sixties showed that measles in
malnourished children was more severe and associated with higher
mortality.
While
hospitals
have
reported
complicated
measles,
community studies in India show that measles
is a less severe
illness.
Prospective
community
based
studies
in
India
have
demonstrated that the nutritional status at the time of development
of measles does not influence measles related morbidity or mortality.

In studies conducted at Vellore, the rate and type of complication of
measles was different in well fed children of lower and upper
socioeconomic background. It was suggested that other factors such as
personal hygeine, feeding practices
during the illness and poor
environmental
condition
which
are
related
but
separate
from
malnutrition could influence the severity of measles.
Cell mediated response is important in protection against measles.
Severe and fatal measles has been reported in immuriosuppressed
children. Protective cell mediated and humoral responses develop
during measles, irrespective of the nutritional status of the child.
Although the specific immune response develops rapidly , measles is
associated with a general immunosuppression especially affecting cell
mediated immune functions lasting for upto 3—6 months following the
episode. This is thought to be responsible for the comp 1ications that
take place.

While there has been concern about the use of live attenuated measles
vaccine in malnourished children, studies do not show any ill effect.
Malnourished children mount a good immune response to the vaccine and
this infection is not associated with the immunosuppression that
occurs with actual measles.
Blindness is a well known complication of measles. During the acute
phase of the illness children develop a superficial punctate keratitis
which is due to active viral proliferation in the cornea. However
following the acute episode, children develop keratomalacia which is
thought to be due to vitamin A deficiency, Therefore the nutritional
status of
the child
may determine
the development
of
eye
comp 1icat ions.

D. The relationship between PEM and diarrheal disease (?)
Hospital based studies show that marasmus and Kwashiokor as
freqently associated with diarrhea and respiratory infection.
Host
community studies however show that the frequency of diarrhea is not
different in malnourished compared to normal children.
However all
studies consistently show that diarrhea in all grades of malnutrition
is of greater severity and duration and is associated with higher
mortality.
E. The effects of vitamin A and iron deficiency on infections (9)
Several reports show increased mortality in children with
xeropthalmia. However it it is not clear whether this effect is due to
Vitamin A deficiency or the general nutritional status.
Othes have
noted that there is a higher prevalence of infections in children with
xeropthalmia. Two studies have showed that vitamin A supplementation
to children in the community could reduce mortality, but this was not
substantiated in a third study conducted in Hyderabad.
Some studies of iron deficient children have shown higher ratesof infections, but others have not demonstrated
the findings.
Similarly a community intervention could not demonstrate a change in
morbidity in response to iron supplementation. Another study in iron
deficient rubber plantation workers showed higher prevalence of
diarrhea and respiratory diseases.
A conflicting report by Murray
reported reactivation of malaria, brucellosis and TB among Somali
tribes in response to iron therapy.
Thus iron may have a variable
effect depending on the nutritional state and the environment.

Review of the studies shows the limited nature of the data that is
available especially in the adult population on the relationship of
under nutrition and infectious diseases. The relationship between the
two is clearly complex and varies from disease to disease. While there
does not seem to be a straight forward etiological link between nutri
tion and infection, malnutrition clearly modifies the severity of
illness, increasing morbidity and sometimes mortality.

V. NUTRITION IN CLINICAL PRACTICE
The emphasis in clinical nutrition has been on diseases of western
ipidemias,,
society,diabetes,
hypertension,
hyper11ipidemias
obesity
and
atherosclerotic vascular disease which are diseases of dietary excess.
In contrast,
in non-western societies where undernutrition and
infectious diseases are the most important problems, dietary advise is
rarely given except for gross nutritional deficiency. There is no
infectious disease in the world whose treatment includes a specific
dietary reccomendation. In
contrast, in Ayurveda and Siddha every
treatment includes specific dietary therapies.
In western medicine nutritional treatment involves restriction of
calories, proteins, fat and salt. These recommendations do not include
improvements in the quality of food. Critically ill patients in the
intensive care unit are often deprived of feeding, surviving on less
than 500 kcal/day supplied by intravenous fluids. The supposed reason
for this is that studies in the ICU do not show clear benefit of
feeding in critically ill patients. However this is against our
instinctive reasoning that food is an intrinsic part of getting
better. Traditional sanatorium treatment fur TB included milk, eggs
and meat. These recommendations are no longer advised as they have not
shown to be efficacious . In the TB research centre trials comparing
domiciallary and sanatorium treatment, women fared better with
sanatorium treatment possibly because they could rest and have better
food, than had they been at home. However this fact is ignored and
domiciallary treatment is interpreted to be as effective as sanatorium
treatment. The majority of the patients who visit our hospitals are
deficient in calories , proteins, vitamins, calcium or iron. Most of
the time we ignore these deficiencies prefering to diagnose the
"disease" and to treat with specific drugs.

During bedside rounds or in the clinic, doctors rarely ask patients
about their food habits; have you eaten this morning or what did you
eat today? The focus is on the “disease" and diet is an unimportant
part of care relegated to the nurse, dietitian or the family. Doctors
often prefer to give a drug than to spend time explaining a diet or
relying on dietary restrictions to acheive the same effect. On the
other hand for patients, food and rest are as if not more important
than the drugs. This kind of difference in perception of dietary
treatment is an aspect of the doctor-patient relationship of western
med ic ine.
Very often patients have to starve in order to buy their medicines and
then have to take them on an empty stomach. Diabetics who have to
struggle to buy insulin suffer from hypoglycemia for lack of food.
Patients who are admitted to hospitals may find the hospital diet too
expensive and have to buy food from hotels that is not nutritious or
hygenic, making them prone to other infections.

The place
relegated
to nutrition
intreatment
is
reflected
in
curriculum development and the importance given to the nutritionist in
the hospital. Medical undergraduates have little exposure to nutrition
as a science. In the hospital the nutritionist is seen as someone who
looks after the dietary department and not as a member of the treating
team. Clinicians rarely have discussions with the nutritionist
regarding the care of their patients.
Why is it that despite the existing knowled
ge demonstrating the links between undernutrition and infecton,
dietary advise has not entered the paradigm of infect
infectious
ious disease
management.
Are
we
waiting
for
randomised
clinical
c
1 in ica1
trials
demonstrating the benefit of improvements in the diet in preventing
and treating infectious diseases. Or is
it that vaccines and
antibiotics are seen as an easier method of dealing with the harshness
of our socio-economic realities.
VI. CONCLUSION :
This article attempts to review the relationship between food
supply, under nutrition
and infectious diseases.
Review of
historical studies suggest that increase in longevity of life and
reduction of infectious diseases has been related to improvement in
food security.
In India, while the green revolution and PDS system
have improved per capita food production and famine averted, the
average
daily
food
intake
remains
marginally
adequate
and
qualitatively inferior.
Although severe forms of malnutrition have
been replaced by mild to moderate forms, 90 7< of under 5 children are
still malnourished and more than half of adults are chronically energy
deficient.
Structural, adjustment policies in India have seen rising
agri—exports and food prices and falling per capita grain production.
The experience of other structurally adjusting countries suggests that
these changes are harbingers of falling food intake, undernutrition
ill health and pre-famine situations.

Analysis of immunological studies show that nutrition is a critical
determinant of host immune response in specific infectious diseases,
especially the cell immediated immune response. Clinical data on the
relationship between under nutrition and infectious diseases is
scanty, especially for adults illnesses. The available evidence does
not support, a causative relationship between undernutrition and
infectious disease. However malnutrition clearly results in increased
severity and rising mortality from infectious diseases.
It is
therefore likely that a large amount of morbidity and mortality can be
avoided with better nutrition.

Clinical nutrition has focussed on diseases of western society and
this is reflected in the absence of dietary therapies for infectious
diseases. Dietary treatments are restrictive and not aimed at
improving the quality of food. The relative lack of importance given
to nutrition is reflected in curriculum development, the role of the
nutritionist in the hospital,in the day to day care of the patient and
the emphasis given to drug versus dietary treatments.
A variety of issues emerge from the foregoing discussion,
If
people were better nourished, would less amount of TB reactivation
take place, would treatment response be better, relapse rates lower,
would malaria mortality be less, would suffering and death due to

diarrhea and respiratory infections be less. Since the links between
nutrition, infection and childhood mortality are obvious, the focus of
nutritional research and intervention has been in this age group. But
what about adults, most of whom are chronically energy deficient.
Despite the overwhelming evidence in favour of a nutrition-infection
relationship, the importance of nutrition in adult infectious diseases
is down played. If our economic policies are resulting in falling food
intake and poorer nutritional status, what are the likely infectious
disease consequences? If nutrition is an important determinant of
infections, should we not incorporate demands for better quality and
equitable distribution of food in our strategy for control of
infectious diseases? Should we not lobby for increased jobs, better
earning capacity, land reforms , protection of ordinary workers from
the effects of inflation of food prices and small farmers from
multi-nationals?
Are the nutritional recommendations of western
medicine changing food tastes in such a way as to alter food security
in poorer nations thereby having adverse effects on infectious
disease .
Unless we have the courage to effect changes in the primary
determinants of health such as nutrition, we may not be able to impact
significantly on the infectious disease problems of our country.

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Utsa

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in

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Chapter 9, P.

BCG

Bhaskaran.

Tuberculosis
106-117.

and

vacc inat ion.

P.

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