Distribution

At one time the general geography of PEM seemed straightforward. Kwashiorkor existed in the year-round wet tropical forest zones of Asia, Africa, and Latin America, where root and tree crops make up the predominant food staples. By contrast, marasmus was found in wet/dry areas because of seasonal or longer shortages of the staple cereal grains. Marasmus also predominated in the cities as a result of the substitution of bottlefeeding for breastfeeding. Changing etiologic knowledge has put this neat generalization to rest, and, in point of fact, little can be said about the precise distribution of PEM. Field surveys are limited in number, and many of them are of small sample size. Additionally, studies are difficult to compare because of temporal differences and differences in measurements. About the best that can be done with the data at hand is to portray a rough regional patterning, knowing that there will be many shortcomings and, in the process, hope to identify the main trouble spots. Two recent studies have attempted just such an exercise; one has used the more widely available weight-for-age information, whereas the other has relied upon weight-for-height (wasting) calculations, converting other measures where possible. Both have employed USNCHS growth standards and a variable sample of countries within the parameters of the World Health Organization's re-gionalization scheme.

What emerges from these two efforts is a focus of PEM in the Southeast Asia region. Some 52 percent of preschool children are estimated to fall below 80 percent of the weight-for-age standard, led by Bangladesh with 91 percent and India with 75 percent. No country in the region shows a prevalence of wasting (defined as greater than 2 standard deviations below the norm) among 12- to 23-month-olds under 10 percent. Once again, Bangladesh and India are at the upper extreme, with 53 percent and 43 percent, respectively.

Both the Africa and Eastern Mediterranean regions show 35 percent deficient by the weight-for-age criteria, and of the countries included in the surveys, only Yemen and Mali stand above 50 percent. Wasting totals are generally in the vicinity of 10 percent, but there are two countries that register exceptionally high totals: Malawi (36 percent) and Somalia (66 percent).

On both measurement scales, the less developed countries in the Americas fare much better. The regional below-weight-for-age average is 21 percent, and all countries except one show a less than 10 percent incidence of wasting. That lone exception is Haiti, where the figure is calculated at 18 percent, still far lower than figures for many places in Asia and Africa.

Limited trend data suggest some lessening of the incidence of PEM since the 1960s, an observation supported by declining infant and child mortality rates. This is true even in Africa, where scenes of famine have created the image of spreading malnutrition. Still, there is little room for complacency, given the magnitude of the problem that remains and the fact that poverty has proved to be intractable in many areas. Certain populations, notably landless rural laborers and the rapidly growing numbers of urban unemployed, seem to be sinking ever deeper into poverty and therefore could well be expe riencing an increase in PEM. Also, wars and civil strife provide ideal breeding grounds for PEM. The examples of Ethiopia and Kampuchea are vivid reminders of what can happen in the wake of political turmoil.

James L. Newman

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