History and Geography

In one form or another, PEM is undoubtedly as old as humankind, and indeed, the term marasmus has been used to refer to starvation for centuries. However, other than implying its incidence on the basis of reported past famines and general living conditions, the medical literature fails to mention PEM specifically until about the middle of the nineteenth century. It was around this time that concepts of malnutrition were beginning to develop, most notably among the new pediatric specialists in France and Germany, who were treating the numerous serious health problems of childhood, especially illnesses seen among foundlings and infants sent out to wet-nurse. One disorder, in particular, began to receive considerable attention. Known as mehlnahr-schaden, it was attributed to diets that were based excessively on flour, usually breads or thin gruels, with little milk or meat included.

At the same time, in the wake of colonial expansion, doctors in the field began to send back reports of a similar disorder from many tropical areas. Although the disease was initially thought to be caused by parasites (as virtually all diseases of the tropics were thought to be in the early days of diagno sis), by the 1920s a dietary etiology began to gain some acceptance. A proliferation of terms ensued, the more common being infantile pellagra, nutritional edema, infantile edema, starchy dystrophy, and fatty-liver disease. These were all describing, of course, what is now known as kwashiorkor, a term that was first used by Cecily Williams in the 1931-2 Annual Medical Report of the Gold Coast (now Ghana). She took the term from the local Ga language, in which it designates an ill child who has been "deposed" from the breast because of a new pregnancy.

Although terminological and etiologic arguments continued, by the 1950s the concept of kwashiorkor had become firmly entrenched in the nutrition literature and accepted by the medical community as a certifiable human disease resulting from a deficiency of protein. Continuing research into its causes and consequences led to the discovery of other syndromes and to the formulation of the more general concept of protein-calorie malnutrition. The word "calorie," however, was subsequently replaced by "energy" in the early 1970s when the international system of unit measures was adopted by the United Nations.

Some analysts argue that too much attention has been paid to kwashiorkor. They feel that researchers' obsession with this condition has diverted attention away from more important PEM problems and, in the process, has led to many inappropriate policy decisions because of a mistaken emphasis placed on the limiting role of protein. But a more plausible argument can be made that far less would be known about PEM today had it not been for the efforts expended on kwashiorkor. It provided the important first entry into the maze that PEM is now understood to be. In time, we hope, the full maze will eventually be mapped.

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