MALARIA: The fight with immunity

27 Jul, 2011 : Michael Regnier

 Wellcome Images;A pair of wrestlers, 19th century watercolour

Evolution is a wonderful thing. Not least among its achievements is the human immune system, which has evolved complex mechanisms and cell-types to try and keep our bodies free from infections and parasitic invasions.
Unfortunately, evolution works for both sides: the threats to our bodies are constantly updating and improving themselves to get round our immune defences.
Take malaria, for example. Pregnant women are particularly susceptible to malaria infection and it has a high risk of disease and death for both mother and fetus. Research published this month has revealed a new way in which malaria evades the immune system in pregnant women. It is just the latest round in the long evolutionary contest between humans and malaria.

Malaria 0 – 0 Humans
The parasite that causes the most severe forms of malaria is called Plasmodium falciparum. When it infects us – through a mosquito bite, for example – it doesn’t just hang around in our blood waiting for our immune system to find and destroy it. Instead, it stows aboard our red blood cells and uses them to move through the body.

Malaria 1 – 0 Humans
In order to hijack our cells effectively, P falciparum has to force each red blood cell it infects to make certain non-human proteins, some of which appear on the cell’s surface. Our immune system can see these abnormal proteins and recognise them as a sign of trouble.
Our immune system identifies intruders by using antibodies as scouts. There are five types of antibodies – immunoglobulins A, D, E, G and M – that have slightly different characteristics and roles. For example, immunoglobulin G (IgG) is the most important for providing immunity against invaders but takes time to build up sufficient numbers. Immunoglobulin M (IgM) provides an early defence by stimulating another part of the immune system before the IgG element kicks in.
Having malarial proteins on their surface makes infected red blood cells vulnerable: IgG antibodies will bind to these proteins, stimulating the rest of the immune system to dispose of the infected cells.

Malaria 1 – 1 Humans
In addition, our bodies will make more of this particular IgG so that we are better prepared to recognise and deal with future infections.

Malaria 1 – 2 Humans
Of course, P falciparum has an answer. It frequently changes the surface proteins it makes in infected cells. Often it tweaks them just enough to make them unrecognisable to our antibodies, which puts the immune system right back to square one.
Even smarter, from the parasite’s point of view, is that the proteins it expresses on the red blood cells include some that direct the infected cells to leave the blood and hide in other tissues.
In pregnant women, P falciparum produces a protein called VAR2CSA that selectively binds to chondroitin sulphate A (CSA) in the placenta. As a result, infected cells build up in the placenta, which causes life-threatening inflammation.

Malaria 2 – 2 Humans

 IgM binding to a domain of the VAR2CSA protein

Professor Richard J Pleass

Our IgG antibodies are still capable of recognising VAR2CSA as a foreign protein, though. At least, they would be if P falciparum didn’t have one more trick up its sleeve, as revealed this month by a group of researchers based in Denmark, Ghana and Liverpool.
The VAR2CSA protein is not just a target of IgG. It can also be bound to by IgM. Unfortunately, IgM doesn’t bind to VAR2CSA strongly enough to elicit an immune response. Worse still is that it physically blocks IgG from binding to VAR2CSA, effectively shielding the malaria protein from the rest of the immune system.

Malaria 3 – 2 Humans
Malaria seems to have this sewn up. But it’s certainly not all over and we humans have one more thing in our favour: medical research.

Half-time team talk…
The researchers who showed how P falciparum uses IgM as a shield also showed that it leaves one vital part of VAR2CSA exposed: the bit that binds to CSA. The authors suggest that a vaccine could be developed to prime the immune system to recognise this Achilles heel.
At a stroke, this would prevent P falciparum from accumulating in the placenta as well as expose infected cells to the full force of the immune system. It would change the game in placental malaria and perhaps put us ahead in the evolutionary contest.

Reference
Barfod, L., Dalgaard, M., Pleman, S., Ofori, M., Pleass, R., & Hviid, L. (2011). Evasion of immunity to Plasmodium falciparum malaria by IgM masking of protective IgG epitopes in infected erythrocyte surface-exposed PfEMP1 Proceedings of the National Academy of Sciences DOI: 10.1073/pnas.1103708108

http://wellcometrust.wordpress.com/2011/07/27/the-long-game-fighting-malaria/#more-6076

MALNUTRITION: African rainfall data 'will improve climate predictions'

Mićo Tatalović : 22 July 2011

 Flickr/Oxfam International

Satellite data may help better predict future climate change in Africa

[LONDON] A comprehensive 30-year dataset of African rainfall could soon help test climate change predictions and improve climate models, according to a UK researcher.
David Grimes, who studies satellite data at the University of Reading, told SciDev.Net that his group will release the complete, open-access data set within a year.
Researchers can already provide good short-term forecasts of Africa's weather but lack the detailed and consistent long-term data needed for accurate climate predictions.
The new data come from a European Meteosat satellite that has been collecting data over Europe and Africa. The data will supplement the poor ground data on rainfall to help improve climate predictions, which are often contradictory.
"Some models predict an increase in rainfall in some areas, other models predict a decrease of rainfall in the same area, and part of the reason for that is that data coming out of Africa [are] very poor and very sparse," Grimes said.
Many experts think that climate change will make the African climate more variable, with more extreme events, such as this summer's drought in the Horn of Africa.
This increased variability may also raise the risk of floods. Geoff Pegram, emeritus professor at the University of KwaZulu-Natal in South Africa, expects "longer periods of dryness and, when we do have rain, it is likely to be heavier".
The lack of good rainfall data has prevented climate models making robust predictions about how the climate will change at specific locations.
The new data "can tell us whether the rainfall and the climate in particular areas, at particular times of year or seasons, have been changing in the past 30 years, and then we can compare that with what climate models predict," said Grimes. "If the climate models say the same thing as our data sets that would give us much more confidence in their future predictions."
Previous data sets have lacked consistency. The Global Precipitation Climatology Project, for example, has global rainfall data but uses different methods of calculation for different periods, said Grimes, making it harder to understand how the climate has changed.
Tufa Dinku, a researcher at the International Research Institute for Climate and Society at the Columbia University, United States, said: "This data set is unique in that it uses a single algorithm and single satellite sensor, which ensures the consistency of the time series. There is no other satellite rainfall product that goes back to 1983 at ten-daily time scale and spatial resolution of about five kilometres.
"But the dataset is as good as the number of stations used for calibration," he said. Before the data set can be used, it must be calibrated against ground data. Satellites provide rainfall estimates, but they must be compared with ground data to know how they translate to actual amounts of rainfall.
Grimes said that he is planning to run a series of workshops in Africa to calibrate the estimates against their rain-gauge data and train scientists on how to use the data set.
"Africa is the worst continent, outside Antarctica, for the distribution of rain gauges — that's really the reason we do the satellite monitoring, because if you just use the gauges you can't get a complete picture of what's happening," he said.
"If you don't know what the climate is to start with, then you can't really decide whether it's changing or not."
http://www.scidev.net/en/news/african-rainfall-data-will-improve-climate-predictions-.html

MALNUTRITION: Famine response needs better science communication

22 July 2011 David Dickson : Editor, SciDev.Net

 Flickr/Oxfam International

Poor communication of drought predictions prevents policymakers from taking action

The Horn of Africa drought exposes the continuing gap between our ability to predict disaster and to take effective humanitarian action.
Earlier this week, the UN declared the drought in southern Somalia had become so bad that it could be officially declared a famine — the first time the word had been applied to this region in almost 20 years.
The news came as little surprise to agencies that had been monitoring the lack of rainfall over the past year, which is partly linked to the La Niña event in the Pacific Ocean. They had predicted that a widescale shortage of food was highly likely to occur.
Despite these warnings, and the efforts of international agencies such as UNICEF to take pre-emptive action, the overall humanitarian response has so far been severely inadequate, and unable to prevent further deterioration in living conditions in the region.
The situation emphasises the gap between our rapidly increasing ability to predict disasters, thanks largely to advances in science and technology, and our capacity to generate the political will to carry out effective mitigation strategies.
One important obstacle is that politicians often feel uncomfortable taking decisions when the science is uncertain. So the way that scientific evidence is communicated by researchers and journalists can make a big difference.
But scientists desperately need better communication techniques to ensure that politicians are alerted to credible evidence of a looming humanitarian disaster. This must include ways of reassuring policymakers that, if predictions do not come true, they will not be rebuked for taking unnecessary (and potentially expensive) action.
And journalists too need to engage politicians much better when reporting the scientific aspects of disasters to help ensure that timely action is taken.

Satellites improve prediction
The good news is that modern technology, and in particular the widespread use of remote sensing satellites, has given us the power to predict disasters with far greater accuracy than ever before.
Admittedly there is some way to go before many African governments — with some notable exceptions, such as Nigeria and South Africa — are convinced of the need to make their own substantial investments in this technology.
But this failure has been more than compensated for by the commitments of international and developed-country organisations. Indeed, our ability to predict disasters is one of the major social benefits from investment in space technology over the past 50 years.
Weather prediction is not alone — advances have also been made in predicting volcanic eruptions, widespread flooding, and earthquakes and related tsunamis. In each case, monitoring now has the capacity to save thousands of lives.

Lost opportunities
Too often, however, advanced technical skills outstrip the humanitarian community's ability to make full use of the information that these technologies generate, leading inevitably to lost opportunities.
As Chris Funk, a climatologist with the USAID-funded Famine Early Warning Systems Network (FEWS NET), told SciDev.Net last week, the organisation's experts were frustrated that their early warnings of the drought in Somalia went largely unheeded.
Not enough had been done to ensure that the information was put to good use: "The technology has outpaced the response systems," said Funk.
The problem is not simply one of communication. For example, FEWS NET's food security alerts, one-page briefing documents, are a model of precise, authoritative information directed at decision-makers.
Rather, the challenges are to get decision-makers to take this type of information on board, and to develop timely and effective response mechanisms.

Reaching the policymakers
Considerable research is already being carried out into the ways that policymakers assimilate and use scientific evidence in the decision-making process. [1] But it is clear that much more remains to be done, particularly where such evidence is uncertain (as is frequently the case when it is based on modelling).
In particular, we need to focus on the way that the political process handles statistical evidence, given that this is seldom definitive and can often be interpreted in different ways.
For example, the public in countries likely to be affected can be encouraged to accept that the costs of inaction (such as not taking steps to mitigate the impacts of a predicted drought) can far outweigh the costs of taking action that later proves to be unnecessary. But the fact that the costs can fall on different populations complicates matters further.
More research is also needed into the most effective ways of linking warning signals to recommendations for action. Policymakers frequently turn to scientists to ask for guidance when faced with uncertain evidence, and the scientific community has a responsibility to explore and lay out the options — and their implications — even if the final decision must rest in the hands of politicians.
Journalists have a key role to play in all of these processes. One of their tasks is to raise the alarm among policymakers and the public about impending disasters — providing that this is done in a responsible, evidence-based manner.
Another is to find out from scientists and other stakeholders what the policy options are, and ensure that politicians are aware of them. Journalists are also in a good position to monitor whether politicians are taking action, and to expose those who fail to do so.
Each of these tasks requires confidence in reporting on evidence that may lack certainty. But a lack of responsible reporting, or of effective communication about impending disasters, may translate into a lack of mitigating action by politicians, with potentially devastating consequences.
http://www.scidev.net/en/editorials/famine-response-needs-better-science-communication-1.html

MALNUTRITION: Somalia: "It is a colossal outrage that the lessons of previous famines have been ignored," says Oxfam.

GENEVA, 27 July 2011 (IRIN)

Analysis: Horn of Africa aid must also build long-term resilience

 Photo: Dan Delorenzo/OCHA

The carcass of a camel that has succumbed to drought lies on a roadside in northern Kenya

The images of starving children bear grim witness to the extent of the crisis affecting millions of people in the Horn of Africa, but they also symbolize a failure to act in time, say aid experts.

"It is a colossal outrage that the warnings went unheeded, that the lessons of previous famines have been ignored," says Barbara Stocking, chief executive of Oxfam.
The crisis in the Horn of Africa, triggered by drought, conflict and high food prices, is affecting at least 11.6 million people, with two regions of southern Somalia suffering from famine. And the situation may well deteriorate.
But the crisis, experts say, could have been mitigated by mobilizing the necessary resources ahead of time. There is increasing evidence that helping people become more resilient to the naturally recurring cycles of drought is far more effective than responding after disaster has struck.
It is also sound use of donor money, they say. As such, helping farmers find alternative livelihood options, or teaching them to grow drought-resistant crops, is far more effective than providing food aid when the harvest has failed.
"We have hard evidence, including from Africa, that we need only five Swiss francs [US$6.20] per capita per annum to build up resilience,” said Mohammed Mukhier, who heads the Disaster Risk Reduction unit at the International Federation of Red Cross and Red Crescent Societies (IFRC).
“If you take the emergency response and emergency operations, you might need 200 francs [$250] per capita to deliver relief assistance for periods of just three or four months."
Humanitarian agencies and donors agreed at an emergency meeting in Rome on 25 July that the response to the crisis must address the immediate needs of the desperate population and help build resilience to avert similar crises in the future.

Risk reduction
Using donor money wisely is particularly urgent in view of the threats posed globally by natural disasters, including increasingly frequent storms, floods and droughts. Advocates of the risk reduction strategy argue that donors can no longer afford to provide funding for disasters primarily after the fact. The cost is rising and compromising regular development investment.

 Photo: OCHA

Intergrated Food Security Phase Classification (IPC) for eastern Africa

Yet, warnings of impending disaster in the Horn of Africa went largely unheeded.
"Measures that could have kept animals alive – and provided milk, and income to buy food – would have been much cheaper than feeding malnourished children, but the time for those passed with very little investment,” said Simon Levine, of the Overseas Development Institute. Now, "it is far too late to address anything but the worst symptoms", he wrote on the website of the independent British think-tank.
While massive funding often goes to post-disaster response, funds for preparedness and contingency planning are relatively scarce. Risk prevention is often hard to fund as it does not generate the same kind of media as a high-profile emergency response. Government donors answer to taxpayers and need to demonstrate impact – something that is difficult to do when disaster has been averted.
With donors mobilized - even if funds pledged still fall well short of the US$2 billion needed – the focus in the Horn of Africa is now on emergency as well as long-term assistance.
“Short-term relief must be linked to building long-term sustainability," said UN Secretary-General Ban Ki-moon. "This means an agricultural transformation that improves the resilience of rural livelihoods and minimizes the scale of any future crisis. It means climate-smart crop production, livestock rearing, fish farming and forest maintenance practices that enable all people to have year-round access to the nutrition they need."
Kanayo F. Nwanze, president of the International Fund for Agricultural Development (IFAD), stressed that building resilience in farming and herding communities required a long-term commitment. "But time - as we can see from the devastating situation in the Horn of Africa - is running out,” he told delegates at the meeting in Rome.
The challenge of seeking to avoid future food insecurity crises in the Horn of Africa is daunting. Conflict has severely hampered development and relief efforts in Somalia, and affects the mobility of pastoralists and their livestock, which is key to food security in the region.
But disaster risk reduction is increasingly seen as a humanitarian imperative, crucial to battling poverty and achieving sustainable development.
“Building resilience of farming and herding communities in East Africa requires a long-term, sustained commitment on the part of the region’s governments and the international donor community,” said Kevin Cleaver, IFAD's associate vice-president.

"The rains will fail. But let us not fail, too."

http://www.irinnews.org/report.aspx?reportID=93337

POVERTY: HORN OF AFRICA: Top 30 donors to the food crisis

NAIROBI, 26 July 2011 (IRIN)


BLOGGER'S COMMENT:
IT'S ALWAYS POPULAR TO CRITICISE THE USA -- BUT LOOK WHO GIVES THE MONEY!!

 Photo: Manoocher Deghati/IRIN

Donors are rallying to feed an estimated 11.6 million people affected by drought in the Horn of Africa (file photo)

After several appeals by the UN and other aid agencies, the international community is rallying to feed an estimated 11.6 million people facing starvation in the Horn of Africa.

According to the UN Office for the Coordination of Humanitarian Affairs, about US$1.1 billion has been committed, while the gap in funding stands at about $1 billion.

Below is a list of the top contributors to humanitarian funding in 2011 in Djibouti, Ethiopia, Kenya and Somalia; the figures in brackets indicate additional pledges that have not yet been committed as of 26 July:

CONTRIBUTOR CONTRIBUTION
1. United States $448,017,213($46,704,961)
2. European Commission $167,237,380($8,111,588)
3. Japan $90,386,480

4. UN Central Emergency Response Fund $86,298,912($11 million)

5. United Kingdom $65,334,968($122,734,183)
6. Canada $26,050,674($3,902,440)
7. Denmark $22,754,682
8. Sweden $20,175,100
9. Norway $22,187,271
10. Brazil $22,095,646
11. The Netherlands $13,635,563
12. Germany $13,159,162
13. Spain $12,194,066($4,977,729)
14. Switzerland $10,767,113($572,738)
15. Finland $7,701,130
16. Australia $7,455,698($47,169,811)
17. France $5,564,352($1,353,276)
18. Ireland $4,852,895($569,801)
19. Italy $3,012,512($1,430,615)
20. United Arab Emirates $1,927,649
21. Sudan $1,788,000
22. Islamic Development Bank $1 million
23. Russian Federation $1 million
24. New Zealand $762,777
25. Saudi Arabia $738,487
26. African Development Bank $507,898
27. Luxembourg $276,578
28. South Africa $146,199
29. Czech Republic $112,676
30. Estonia $42,254

Source: UNOCHA Financial Tacking Service
kr/ag/mw
http://www.irinnews.org/report.aspx?reportID=93331

POVERTY: BANGLADESH: Floods displace 20,000 in southeast

COX’S BAZAR, 26 July 2011 (IRIN)

 Photo: Ahmed Orko Nur/IRIN

Ainul Hoque has been displaced for a week

Heavy flooding in southeastern Bangladesh has forced more than 20,000 people from their homes in Cox’s Bazar and Teknaf districts, say local authorities.

“The homes of more than 20,000 people have been completely destroyed by the floodwaters,” Rafiqul Islam, district relief and rehabilitation officer (DRRO) for Cox’s Bazar, told IRIN, with another 84,000 homes partially damaged. “When the water recedes, many of these may also be inhabitable,” he said.
When the Bakkhali and Matamuhuri rivers burst their banks most of the displaced sought refuge in the more than 30 cyclone shelters in the low-lying area.
The newly displaced add to the more the 400,000 people already forced from their homes and unable to return due to rising floodwaters. When they will be able to return remains to be seen.
“When the water started rising, we were forced to leave our home and move to the hills. It has already been a week. My house is still submerged,” said Ainul Hoque, a resident of the Ramu sub-district of Cox’s Bazar.
So far at least seven people have died in the floods, say the authorities. Cox’s Bazar and Teknaf, both coastal districts, are prone to such disasters.
The severity of recent flooding has caught many by surprise. “Never in my life have I seen such flooding. The worst cyclones never submerged such a huge area for so long,” said Abdul Quddus, a resident of Piyemkhali sub-district of Cox’s Bazar.
Quddus and his family have been living in the local cyclone centre for almost a week.
“We are surviving on water and dry food provided by the local authorities. My home is gone, along with my seedbeds. I have no idea what I will eat the rest of the year,” the 46-year-old said.
According to the DRRO, rice and shrimp farmers have been badly affected by the recent flooding, with damage to the latter sector estimated at over US$3 million so far.

“The monsoon is a critical farming season and with the seedbeds destroyed, a tough challenge awaits us. Chakaria, one of the hardest hit sub-districts in the region, provides almost 80 percent of the vegetables in this region. The people of this area will have a very hard Ramadan [beginning on 1-2 August] this year,” said Islam.

 Photo: Ahmed Orko Nur/IRIN

A marooned house in Cox's Bazar

Deforestation
“Continuous raining of up to a week is nothing new in the monsoon. What is really surprising, however, is the unprecedented level of flooding here,” said Muhammad Babul Azam, a technical manager for CARE Bangladesh.
Widespread deforestation of nearby hills and woodlands is the likely causes, he said.
“When you flatten a hill and chop down trees, the soil is loosened. This loose soil then washes away and accumulates in the rivers and channels, reducing their capacity for holding water. Then, the rivers overflow very easily. As the channels are clogged up, the water cannot flow away,” he said.
Meanwhile, efforts to assist those affected are already under way, according to the DRRO. More than 300 tons of rice and other food relief have been distributed.
“The next phase of relief work - providing them with more food, purified water, building materials and other essentials - will start very soon,” Islam said.
According to the Bangladesh Meteorological Department on 26 July, light to moderate rain and thunderstorms are expected to continue in the area for the next 24 hours.
http://www.irinnews.org/report.aspx?reportID=93335

MALNUTRITION: Food Prices to Stay High Amid Underinvestment, Climate Change, IFAD Says

Sungwoo Park - Jul 24, 2011

Global food prices will remain high as underinvestment in agriculture over decades has left supplies unable to meet demand, according to a United Nations agency.

“We are just depleting our stocks and now we have this high population growth,” Kanayo F Nwanze, president of the International Fund for Agricultural Development, said in an interview. “Prices won’t come down overnight. They are going to stay high for some time to come.”
Global food costs tracked by the United Nations increased in June for the 10th time in the past 12 months, staying near a record on higher rice, sugar and dairy prices, while meat reached an all-time high. Aid to agriculture dropped to 4.3 percent of total assistance in 2008 from 18 percent in 1979, according to IFAD data.
“Food price crisis, food price hikes or food price volatility is not just a simple consequence of shortage of food because of weather conditions and climate change,” Nwanze said in an interview on July 22 in Seoul. “A primary cause is we’ve disinvested in agriculture over decades.”
Nwanze has urged the global community for more investments in rural development to help meet growing food demand led by emerging economies including China, India and Brazil. The 165- member nation agency works to combat rural poverty and hunger by providing low-interest loans and grants to developing countries.
Rice, the staple food for about half of the global population, has surged 65 percent in the past year on the Chicago Board of Trade. Corn, used in food and livestock-feed, has jumped 78 percent.

World Population
The United Nations has said that by 2050, food production must increase by 70 percent to feed an estimated world population of 9 billion people, up from almost 7 billion this year.
“The middle class is growing, their demand for better food is growing and they want more meat, which takes more grains,” Nwanze said. “Who is going to feed us in 2020?”
World grain stocks will probably slide for a second year in the 12 months through June 2012, dropping to a four-year low, as corn consumption outpaces production and dry weather hurts wheat prospects, the International Grains Council forecast in April.
“Climate change will compound the whole issue of food security,” Nwanze said. “The world is yet to understand implications of the impact of climate change,” he said. “We are not investing enough money.”

To contact the reporter on this story: Sungwoo Park in Seoul at spark47@bloomberg.net.
To contact the editors responsible for this story: Richard Dobson at rdobson4@bloomberg.net
http://www.bloomberg.com/news/2011-07-25/food-prices-to-stay-high-amid-underinvestment-climate-change-ifad-says.html

POVERTY: SOMALIA: Aid agencies gain access to Al-Shabab areas

MOGADISHU, 26 July 2011 (IRIN)

 Photo: Mohamed Gaarane/IRIN

The situation in the Al Shabab-controlled regions of Bakool and Lower Shabelle is getting worse, according to aid officials (file photo)

 Amid reports of rising child deaths due to malnourishment, Somalia's opposition Al-Shabab group has granted several aid organizations access to some of the south-central areas under its control, including Lower Shabelle, one of two regions the UN recently declared to be famine-stricken.

Since 24 July, officials of an international NGO, Kuwait Direct Aid, as well as those from the International Committee of the Red Cross (ICRC), have distributed food in Lower Shabelle.
The UN declared a famine in Bakool and Lower Shabelle regions on 20 July, saying that across the country, 3.7 million people – half the population - were in crisis, an estimated 2.8 million of whom are in the south.
Malnutrition rates are at 30 percent across the south, rising to 50 percent in parts of Bakool and Lower Shabelle. The highest death rates exceed six deaths in 10,000 per day, according to UN Children's Fund (UNICEF) data.
In most southern regions, UNICEF says, one in five children is severely malnourished, with one in three severely malnourished in the worst-affected regions, such as Bay.
The number of acutely malnourished children has risen from 476,000 in January (103,000 severely malnourished and 373,000 moderately malnourished) to 780,000 (340,000 severely malnourished and 440,000 moderately malnourished), according to UNICEF, with 82 percent of all acutely malnourished being in the south, representing 640,000 (310,000 SAM and 330,000 GAM).

Feeding centres
Mohamed Bashir Ibrahim, the managing director of Kuwait Direct Aid, told IRIN the NGO had opened two feeding centres in Lower Shabelle, catering for 24,000 children younger than 15. The agency now has feeding centres in three regions in the south, he added.
"With the collaboration of several other organizations, we went to Lower Shabelle in May 2011 to assess the situation in the area; we focused on 15 villages of 4,800 families," Ibrahim said. "We found that 70 percent of the children under five were acutely malnourished. Later, we contacted the area's administration and expressed the need to open the feeding centres.
"We were referred to the regional administration of Al-Shabab, who later allowed us to open two feeding centres in Lower Shabelle. Initially, we expected to feed at least 500 children daily in each of the feeding centres located in Kurtunwarey and Bulo-Mareen but the number increased to about 1,800 children of every age, including pregnant women and breast-feeding mothers. On average, at least 800 people now come to these feeding centres daily."
On 22 July, Ali Mohamed Rage (Ali Dhere), the Al-Shabab spokesman, told a press conference in Mogadishu that the situation in south-central Somalia was not as bad as was being reported. He said some aid agencies had agreed to operate in the areas under the group's control.
"The organizations we have banned from working in the areas we control are not included [among] the aid organizations we [have] allowed to work because they are not doing humanitarian [work]; on the contrary, they are doing political affairs," Rage said.
On 24 July, ICRC officials distributed food to 24,000 people in Bardhere, Gedo region, in south-central Somalia.

 Photo: Contributor/IRIN

Livestock carcasses in Lower Shabelle: The UN has declared the region famine-stricken (file photo)

Assessment
The Civil Society Council said in a statement: "In an assessment we have been carrying out in the past two months, we have found that at least 10 to 15 people, mostly children, die daily in the south-central drought-affected areas. About one-third of the drought-affected people have already reached Mogadishu, another third has crossed the borders into Ethiopia, Kenya and Yemen, while the majority of the remaining third are dying or are remaining in their homes too weak to move to other areas."
The group appealed to aid agencies to prioritize help for the latter group.
According to Ibrahim of Kuwait Direct Aid, the situation in Bakool and Lower Shabelle, both under the control of Al-Shabab, was getting worse.
"We are now planning to open new feeding centers in Sablale, Dacaraha and Qoryolay and the villages near the river to feed about 12,000 vulnerable people in these areas," Ibrahim said. "We feed about 150 malnourished children daily in Dhobley centre which we opened last week.”
In Mogadishu, a local journalist, Mohamed Abdi Hussein, told IRIN that an NGO, Muslim Aid, last week distributed relief to 5,000 families, comprising cooking oil, rice, sugar and flour. Most of the families live in Al-Shabab-controlled parts of the city, mostly in Km50 internally displaced persons camps.

Refugees queue at the UNHCR field office for tents allocation at Ifo camp, Dadaab, northern Kenya

http://www.irinnews.org/report.aspx?reportID=93333

POVERTY: KENYA-SOMALIA: Red tape adds to refugee woes in Dadaab

DADAAB, 26 July 2011 (IRIN)

 Photo: Tom Maruko/IRIN

Somali refugees await registration at Dadaab

 After walking for days to escape drought and insecurity, often barefoot and with almost no food or water, Somali refugees who arrive at Dadaab camps in northern Kenya are met with delays and red tape.

Some wait up to two weeks to be registered as refugees, and longer to get food and shelter.
The sluggish pace of the registration process is partly because refugees may only register and receive ration cards at Ifo camp, at the centre of the three Dadaab camps set up to 10km apart.
Abdifatah Ahmed, chairman of the Dagahaley camp, told IRIN: "We request the [UN Refugee Agency] UNHCR to issue the ration cards in all the three camps as soon as possible to ease the pressure and immediately facilitate the distribution of food rations to the new arrivals."
The agency tries to register 1,000 refugees a day, out of the approximately 1,300 new arrivals, but they are limited by the number that Kenya's Department of Refugee Affairs (DRA) is able to process.
"We are sort of at their mercy,” said a UNHCR employee who declined to be named. The official said the DRA was working to increase its capacity to process new arrivals.
Often, they do not know what to do if they lose their ration cards, or who to contact to report cases of sexual and gender-based violence
At the start of registration, refugees are fingerprinted and photographed at Ifo camp to ensure they have not already been registered.
The UNHCR employee said many refugees tried to register more than once in an effort to get more food and assistance, but most were tripped up by a series of questions on family names and relationships.
Even after registering and receiving a ration card, some refugees wait for weeks to gain access to the food distribution that normally takes place twice a month as their data is transferred to the UN World Food Programme (WFP) and CARE, the agencies facilitating the general food distribution.
To speed up the delivery of humanitarian assistance to the new arrivals, reception centres were established across the three camps on 6 June, where new arrivals can access dry food rations for two weeks. They also receive non-food items like kitchen utensils and plastic sheets, and medical screenings where the malnourished are referred to hospital for feeding and stabilization.
Refugees who arrived in the 1990s, backed by the escalating emergency response of humanitarian aid workers and other external supporters, are filling some of the gaps as well. Community leaders in Dadaab camps have facilitated massive contribution drives of non-food items, food rations and some money from as far away as Nairobi, the Kenyan capital, and the coastal town of Mombasa, for the new arrivals.
But new refugees are hampered by poor access to information, such as where and when to look for general food distribution. Often, they do not know what to do if they lose their ration cards, or who to contact to report cases of sexual and gender-based violence. Many have no idea of the various services offered by the more than 20 aid agencies operating in the camps.
http://www.irinnews.org/report.aspx?reportID=93332

MALARIA: African leaders must invest in malaria prevention

July 25, 2011

In a Daily Caller opinion piece, Richard Tren, director of Africa Fighting Malaria, highlights a finding in a recent malaria report that the U.S. government and the Bill & Melinda Gates Foundation "were responsible for 85% of the steep increase in malaria funding between 2007 and 2009." But "[i]f 30 African heads of state were to give up their private jets, a fund of well over $500 million could be generated," Tren writes.
"Several benefits would arise were African leaders to put their money where their mouths are. First, it would help U.S. congressmen to convince the remarkably generous but hard-hit U.S. taxpayers that we have true partners in the fight against malaria and that it is worth appropriating money for this noble cause. Second, it would probably help to reduce the bias in R&D funding, directing money to areas, such as improved vector control, that are recognized as more important for African countries. Third, it would help in creating a much-needed culture of accountability and responsiveness in African politics," according to Tren (7/22).
http://www.news-medical.net/news/20110725/African-leaders-must-

MALNUTRITION: Somalia: The Vital Statistics of Hunger

July19, 2011

JOHANNESBURG (IRIN) - Louise Masese-Mwirigi, an analyst recording nutrition data in southern Somalia with her team, have on occasion had to turn away from a village because the local authority that consented to the survey a week ago is no longer in charge or may have changed their minds when they arrive. Fighting between the government, its allies and various armed groups in parts of Somalia has severely restricted humanitarian space.
“The situation is uncertain in Somalia and access is a problem - especially in the last two years in central and southern Somalia,” said Masese-Mwirigi, who works for the UN Food and Agriculture Organization’s Food Security and Nutritional Analysis Unit (FSNAU) for Somalia.
Armed with an electronic weighing scale and a metre-long board to measure the height of children, Masese-Mwirigi and her team, led by Mohamed Moalim, along with Action Contre la Faim (ACF), a food relief NGO, have carried out a survey in the Mogadishu region, where the capital is located.
The survey is the first in seven years. “It took a month of planning… we could access six districts but had to let go of the remaining three because of security concerns.”
A rapid assessment by FSNAU in Mogadishu in December 2010 picked up high levels of malnutrition based on the measurement of the middle upper arm circumference (MUAC) - a quick, easy and cheap approximate measure of malnutrition in children younger than five years. “We felt we needed more information through a comprehensive nutrition survey, given the rains had performed poorly and the MUAC results were indicating high levels of malnutrition in the town.”
The MUAC measurement uses a long strip of plastic with a series of colour-bands that is put around a child’s bare upper arm. The colours show the level of malnutrition: green indicates a 135mm circumference, which is normal; yellow - 125mm to 134mm - shows a risk of malnutrition; orange - 110mm-124mm means moderate malnutrition; red, for measurements less than 110mm, is an indication of severe malnutrition and risk of death.
In the past two years FSNAU have had to depend entirely on MUAC in parts of the conflict-hit areas. “It is less resource-intensive, and quick and ideal for emergency situations, but ideally we would like a more thorough survey,” Masese-Mwirigi said.

Detailed data
A thorough survey would take into account four variables - age, weight, height and gender - as well as the MUAC. Crude mortality rate (usually measured in deaths per 10,000 people per day in emergency situations), rate of disease prevalence, child care and feeding practices, household food security, and water and sanitation indicators, are also taken into account to understand the overall nutrition situation.
When two of the anthropometric variables are used together they are called an index. Three indices are commonly used to assess the nutritional status of children: weight for age (WFA), height for age (HFA) and weight for height (WFH).
These indices are then compared to a reference standard to get a sense of the severity and distribution of the nutritional problem in a country. The WFA of a child compared to a reference population will tell if the child is normal, overweight or underweight. HFA indicates whether the child’s height is normal for his or her age. If the child is not as tall as expected then he or she is stunted, reflecting a long-term, chronic problem - stunting is a good indicator of chronic malnutrition.
WFH is commonly used in acute emergencies to determine the scale of the crisis. It is often used when the child’s age is not known, and in countries like Somalia, where hardly any public records of births and deaths exist. WFH is regarded as a good indicator of acute or short-term exposure to a negative environment, such as a drought, as it reflects recent weight loss or gain. WFH is a measure of acute malnutrition.

Room for error
With so many measurements involved there is always a lot of room for error.
For instance a baby can often be not held properly to measure its length, or perhaps the child is not standing straight. Aid organisations are constantly trying to improve the skills of surveyors involved in taking measurements by organising training workshops periodically.
Determining the correct age can also be problematic. “We use the calendar of events to accurately determine a child’s age,” explained Masese-Mwirigi. Events like major natural disasters or elections can indicate when a child was born.
The other contentious issue in measuring malnutrition is what is considered average. The World Health Organization (WHO) provides a reference of growth standards, against which surveys calculate their deviations from the norm.
Yet the WHO growth standards might not be the norm for a particular ethnic population that is naturally long-limbed, like Kenya’s Maasai, or short-limbed, like the Gurkhas of Nepal. Even though the WHO standards were recently updated to better reflect human genetic diversity some experts feel country- or region-specific growth standards should be developed.
Prominent experts like Mark Myatt, Senior Research Fellow at the Division of Epidemiology, of the Institute of Ophthalmology, University College, London, feel MUAC is a much more accurate measure.
But that is not all. There are different scales of malnutrition. For individuals malnutrition can be moderate acute or severe acute.
To work out levels of malnutrition, WFA, HFA and WFH measurements are used to calculate and classify using what is known as the “percentage of the median” and “Z-scores”.
For instance, in expressing the WFH as a “percentage of the median”, a child’s weight is divided by the average weight for a child of that height, as provided in the WHO growth standards, and then multiplied by 100 percent. Fortunately, there is computer software that does the calculation.
The “Z-score” represents the difference between the observed weight and the median weight of the reference population, expressed in standard deviation units. When the percentage of the median is less than 70 percent, and the Z-score is less than -3, or oedema is present, the child is said to be suffering from severe acute malnutrition.

GAM or SAM?
Populations are described as severe acute or global acute. “Global acute malnutrition (GAM) refers to the total cases of moderate acute and severe acute malnutrition (SAM) in a population,” Médecins Sans Frontières (MSF), the medical NGO, notes in their useful manual, A Beginner’s Guide to Malnutrition.
GAM is calculated with the Z-score defined as a weight-for-height index less than -2 standard deviations from the mean weight of a reference population of children of the same height.
A GAM value of more than 10 percent generally identifies an emergency. Commonly used thresholds for GAM are less than five percent (acceptable), between five and just under 10 percent (poor), between 10 percent and under 15 percent (serious), while anything more is critical.
Clinical signs such as bilateral oedema - swelling in the feet, legs or face caused by an extreme shortage of protein - are a separate indicator of severe malnutrition in children.
“We recorded a GAM rate of 15.2 percent for Mogadishu in our survey,” said Masese-Mwirigi. In Somalia the FSNAU has been recording GAM rates of 15 percent and above for a long time, GAM rates of over 15- 20 percent indicate a critical nutrition situation, while rates over 20 percent are seen as very critical. The GAM rates reported in Mogadishu town are high, also given that there are a large number of feeding interventions in the town.

Prices of the staple grains - maize and sorghum - have gone up by between 52 and 95 percent in most markets. FSNAU reports that in some areas prices have doubled and even tripled since 2010.
In 2011 the major rainy season began late and was poorly distributed across time and place in southern Somalia - the second bad season consecutively, as the first harvests in January failed.
A smaller cereals harvest, low stocks and poor access because of continued conflict to Bakara, the main market in Mogadishu, have made basic foodstuffs harder to get and more expensive.
http://harowo.com/2011/07/19/somalia-the-vital-statistics-of-hunger/

MALNUTRITION: International support needed to curb child malnutrition in Niger – UNICEF

 21 July 2011

A child in Niger awaits the food that will stop him sliding into malnutrition

21 July 2011 – The Government of Niger needs international support to curb alarming levels of child malnutrition, as well as deal with its underlying causes, says the United Nations Children’s Fund (UNICEF).
The agency said in a news release issued on Wednesday that more than 15 children in 100 suffer from acute malnutrition, as shown by the National Nutrition Survey that was released this month.
The prevalence of global acute malnutrition (GAM) among children under five years old in Niger is back to the same levels experienced in June 2009 – 12.3 per cent – registering a decrease of more than three points (16.7 per cent) from the previous survey conducted last November.
“The nutritional status nevertheless remains above the emergency threshold of 10 per cent for seven of the country’s eight regions,” UNICEF stated.
The survey found that children aged six to 23 months account for a large share of the nutritional burden with one in five children affected by GAM and 4.2 per cent of them by severe acute malnutrition (SAM), the most severe form of malnutrition.
UNICEF said that these figures have dropped comparing to June 2010 but remain well above those that prevailed in June 2009 before a serious food and nutrition crisis struck the nation.
The survey revealed “unacceptably high” rates of chronic malnutrition for all age groups which follow an upward trend having registered an increase by five points to 51 per cent in June 2011.
“The prevalence of this form of malnutrition, harmful to the psychological development of children, illustrates the cumulative effects of recurrent episodes of malnutrition in children and reveals the urgency to act upstream to address the disease by offering children a healthy diet soon after birth,” UNICEF stated.
Malnutrition has enormous consequences: morbidity and mortality increase, poor educational achievements and lower productivity, according to Dr. Maimouna Guéro, nutrition director at the Ministry of Public Health in Niger.
She advocates practices such as exclusive breastfeeding within the first hour of the child’s birth and up to six months, which UNICEF pointed out is a “free, cheap and effective” way to give children a good start in life.
Only 27 per cent of Niger’s mothers exclusively breastfeed their children up to six months, according to the latest child survival survey conducted in 2010.
http://africabusiness.com/2011/07/21/international-support-needed-to-curb-child-malnutrition-in-niger-%E2%80%93-unicef/

MALNUTRITION: Somalia: It is the worst drought in 60 years, and still thousands of starving people arrive at camps intended for half as many

 Emily Dugan : 24 July 2011

 AFP/ GETTY IMAGES

Women rushing for a feeding centre after passing soldiers of the Transitional Federal Government (TGF) who try to contain the crowd at Badbaado

The blue plastic band around Shamsa Samow Mohammed's wrist resembles the passes worn by countless teenagers at music festivals. But for her, and her family, it is nothing less than a ticket to survival.
The mother of six walked with her husband and children for 17 days through the desert after the family's crops failed at their home in Dinsoor, a town in Somalia.
Yesterday, she arrived at a UNHCR reception centre on the outskirts of Ifo, one of three major refugee camps at Dadaab, in northern Kenya.
After queuing for hours in the heat, each family is given a numbered and colour-coded band and told to wait. When the number on Shamsa's wristband is called out, the family will be given enough supplies to create a makeshift home, including a tarpaulin, cooking utensils, a mat to sleep on and some maize flour.
Breast-feeding a wide-eyed baby and with several of her younger children leaning on her for support, the 30-year-old described their journey: "We had no food and no water while we walked. It was so hard going through the desert, but we had no choice. We were farmers but the land could not be cultivated with no water. I thought we were all going to die of starvation if we stayed."
Southern Somalia is one of the worst-hit regions in a drought that has worked its way across the Horn of Africa. While many countries in the region, including Kenya, have been affected by the lack of rain, in Somalia the problem has been exacerbated by persistent conflict between the Islamist al-Shabab group and government forces.
The United Nations says nearly four million people face starvation in Somalia alone. In all, it is estimated that some 12 million East Africans have been affected by the drought, which some have called the worst in 60 years. Since the crisis began, hundreds of thousands have travelled to Dadaab, now the world's largest refugee camp.
Unfortunately, Dadaab itself is also showing signs of drought. The parched land is full of dust whipped up by warm winds, and the ground is cracked and dry.
As Shamsa talks about her family's story of survival, her husband, Ibrahim, leaps up in a sudden burst of energy. Their number had been called. As he struggles back from the centre with a large bag of maize, his wife says: "I think we will be alive now." She is smiling for the first time.
But the family's future may not yet be as secure as they hope. Until they are officially registered at the camp's centre – which will take their names, photos and fingerprints – they will not have the ration cards that give them reliable access to food. Because of a major backlog, the number left unregistered is expected to reach 30,000 this week, meaning that those arriving in the camps now are unlikely to get a reliable supply of food until the middle of September.
Magdalen Nandawula, Oxfam's programme manager at Dadaab, said the speed and scale of the influx over the past two months has left services, designed for fewer than half this number of people, seriously stretched. "Last year we were receiving 10,000 people in a month. Now since June alone we've received more than 57,000 people. This means congestion in existing camps, and many are forced to live outside the camps where there is no infrastructure at all: no latrines, structures or water."
The EU Commissioner responsible for Humanitarian Aid & Crisis Response promised yesterday to do all that is possible to support those struggling from extreme drought across the Horn of Africa, pledging to boost aid by €27.8m (£24m).
"We commit to do as much as we can," Kristalina Georgieva said, speaking during a visit to Dadaab. "We really appreciate what the Kenyan government and people are doing. We have a responsibility to share."
The Kenyan government has said it is overwhelmed by the flood of refugees, including those fleeing the parts of southern Somalia that the UN declared on Wednesday were suffering from famine. Relief efforts inside southern Somalia continue to be hampered by the refusal of the al-Qa'ida-inspired al-Shabab – who control both areas declared by the UN to be famine-struck – to lift an aid ban on several foreign aid groups.
The new EU funding comes on top of almost €70m Europe has already contributed to assist those suffering the worst regional drought in decades affecting Ethiopia, Kenya, Somalia, Djibouti and Uganda.
Many of the families in Dadaab are travelling without the men, who have been left behind to protect their land. Mohammed Ajan Ibrahim, 35, is the exception. He arrived with his four children in a truck yesterday morning, having left his wife at the Somali border to bring their one remaining possession: a donkey and cart.
"We couldn't leave the donkey and cart. I think it will take her a day to get here and then I hope to find her in a town nearby." But with more than 380,000 people now in the camps and the surrounding area he may struggle to find her.
More than 50,000 people are now living in scattered shelters outside the camps. Aid agencies have been putting in water tanks to these new makeshift camps, but they are struggling to keep up with demand.
While families make homes in the wilderness with no running water, a brand new facility with brick buildings, water, taps and electricity lies unopened, following a political dispute within the Kenyan government.
The camp, called Ifo II, has been ready to house 40,000 refugees since last year, but sources say the government is afraid that opening such a state-of-the-art facility will attract even more refugees. Kenya says that it cannot be opened for "security reasons".
Earlier this month the Kenyan Prime Minister, Raila Odinga, assured the international community that "the camp is now open to cover for the increasing influx of the fleeing refugees", saying that residents would settle in within 10 days. Today, however, it is 10 days since he made that pledge and still the camp lies empty.
Just a few miles up the road, people are sleeping under hastily assembled twigs and scraps of fabric. Some have been forced to make camps on flood plains, and risk their homes being washed away when the rainy season comes.
Yet, at Ifo II, there are houses, pristine latrines, water taps, five primary schools and a secondary school – all going unused.
The schools are of particular concern to Unicef, which says education rates at those arriving at the camp have plummeted. Just five years ago, more than 70 per cent of the school-age children arriving had some form of education. Now the number is roughly 35 per cent, thanks to the worsening of Somalia's infrastructure.
For most families arriving now, however, education is the least of their concerns. Child malnutrition rates have soared in Dadaab, with health centres full of skeletal children.
At a hospital outside Ifo I, which is run by the German charity GIZ, tiny infants resembling bundles of bones lie listlessly on beds, watched over by their frightened mothers.
Malnutrition was already a problem at the camp and is only being made worse by the new arrivals. Fatima Gedi, 24, has lived in the camp since 1992, but limited access to food has left her one-year-old son, Mubarek, starving.
"My son started off with diarrhoea, coughing and vomiting and now they say he is malnourished. They say there are no drugs for him. The services provided at the camps used to be fine, but now it's much harder to get help."
Dr Hamza Sheikh, who works on the hospital's malnutrition wards, says: "The number of children under five with malnutrition is rising all the time. It is still a problem in the camp, but the main problem is new arrivals. Around 30 per cent of children under five now arrive malnourished."
Rashma Kule, 18, tries desperately to feed a mug of milk to her two-year-old daughter, Arfon Omar, in the hospital's stabilisation centre. Arfon's shoulders are so narrow that her dress hangs straight down from her neck and her limbs hang like twigs. She looks half her age, lying motionless with breathing tubes up her nose.
"I arrived two months ago from Bardere with my husband and two children. Arfon has been getting treatment for seven days now. We had eight herds of sheep and goats in Somalia, but now it is all gone.
"We were so scared on the journey; it took us 15 days to walk. But we had to come here, if we'd stayed we would have died."
Next to the bed are Rashma's flip-flops. A novelty from a New Year gone by, they read "Happy 2010". It is doubtful that 2010 was a happy one for the Kule family, and, with another child still sick back at the camp, it is unlikely that 2011 will be much better.
http://www.independent.co.uk/news/world/africa/a-moment-of-joy-inside-the-worlds-largest-refugee-camp-2319561.html

MALNUTRITION: Moringa Oleifera 'miracle' tree

Jul 20, 2011 : Mhlaba Memela
A "MIRACLE" tree from India and West Africa has been touted as a solution to the world's malnutrition problem, according to research by a scientist at the University of KwaZulu-Natal.
The leaves of the Moringa Oleifera tree contains more vitamin A than carrots, more calcium than milk, more iron than spinach, and more vitamin C than oranges.

And the protein quality in the leaves rivals that of milk and eggs, said Dr Samson Tesfay of the University of KwaZulu- Natal's horticultural science department.
Tesfay, who completed his doctoral thesis last year on avocados as a source of energy and antioxidants, was conducting laboratory tests on Moringa seeds.
The Moringa Oleifera, also called the drumstick tree for its long, thin, triangular seed pods, has been used by Indian people for centuries.
Tesfay said it was unique in that every part of it can be used for beneficial purposes.
"It has medicinal, therapeutic, nutritive and practical uses," he said.
He said the immature seed pods, full of essential amino acids, can also be eaten raw or cooked.
"In parts of Southern and East Africa, Moringa trees have been cultivated for water purification," he said.
But with earth's oil reserves running low, one of the Moringa tree's potential uses, said Tesfay, was as a raw material for the production of bio-fuel.
Tesfay added that the tree, which can tolerate drought and survive in poor, sandy soils, does not require expensive farming methods.
The iLembe district municipality on the KwaZulu-Natal North Coast has collaborated with Tesfay on a Moringa plantation project which plans to enlist small-scale emerging farmers to grow the trees and harvest the pods for biodiesel processing.
Tesfay hopes to raise awareness of the nutritional value of the tree to fight malnutrition.
http://www.sowetanlive.co.za/news/2011/07/20/ballyhoo-over-rare-miracle-tree

MALNUTRITION: Guatemala: conditional cash transfer program

Lomi KrielJuly 20, 2011 09:55

Supporters of Guatemalan presidential candidate and former First Lady Sandra Torres, hold banners as they gather at Constitution square in Guatemala City, on July 17, 2011. The banners read "Work for the people" and "Sandra does fulfill!". (Johan Ordonez/AFP/Getty Images)Though for decades, Guatemala has had one of the highest rates of chronic malnutrition in the world – one in every two children are stunted – the issue has barely entered the country’s political discourse. Guatemala is the only Latin American country to have failed to decrease its malnutrition rates even as countries with greater income inequality, such as Brazil, or those who are poorer, like Bolivia, made advances.
During his 2007 campaign, President Alvaro Colom pledged to make malnutrition a priority. In addition to food distribution – giving rice, beans, and nutritional supplements to the poorest of the poor -- the government’s strategy focuses on a conditional cash transfer program called “My Family Progresses.” The government pays poor mothers a stipend in exchange for proof that their children are attending school and regularly receiving health check-ups and other preventative services, including growth monitoring, important for identifying and helping malnourished children.
Wildly popular throughout Latin America and the Caribbean, conditional cash transfer programs have generally been viewed as successful: cutting poverty, reducing income inequality, increasing access to educational and health services and, important for policy makers, doing so relatively cheaply.
In Guatemala, however, the program has been mired in criticism, partly due to a lack of transparency and accountability and partly because of Guatemala’s politics and history of corruption.
Colom placed the program under an inter-institutional body not accountable to Congress and chaired by his wife. An astute politician, Sandra Torres has eyed her husband’s seat for years. Critics charged the initiative was a political tactic to reward Colom’s supporters -- who are overwhelmingly rural and indigenous and helped him barely beat his conservative opponent in 2007 -- as well as shore up support for Torres’ inevitable campaign, which she officially declared in May.
Colom is the first left-of-center candidate to rule Guatemala in more than five decades. After attempts at social reforms, particularly land redistribution, the country’s last leftist government was toppled in a U.S.-led coup, catapulting Guatemala into a 36-year-long civil war.
Colom eventually improved the program’s transparency and accountability, but shoddy oversight hasn’t helped its credibility. An investigation last year by one of Guatemala’s biggest newspapers, El Periodico, found many of the identification documents registered in the program belonged to the same individuals. Health workers call the program “The Bar Progresses,” referring to husbands pocketing stipends for alcohol and other frivolities instead of food as intended.
The program has also been blamed for further weakening the already broke Ministries of Health and Education. Over the past two years, Guatemala’s health budget sunk to 1 percent of the gross domestic product because of the global financial crisis, Guatemala’s low tax collection rates, and its skyrocketing population growth. Transferring millions to fund the conditional cash transfer program only added to the crisis.
Critics say additional kids in a classroom hurt rather than help if the budget doesn’t compensate for the increase. The same goes for an already over-burdened health system where many key medications aren’t arriving, some health workers haven’t been paid in months, and many rural communities see a physician only every 30 days. Guatemalan’s health minister has said it would take three times the budget to fund current health needs.
“The health system is really an anemic system,” said Dr. Baudilio Lopez, a project development specialist at the U.S. Agency for International Development (USAID.) “They have almost no resources and the few resources they have aren’t well invested.”
A Mi Familia Progresa spokeswoman didn’t respond to requests for an interview. According to an impact assessment by the Inter-American Development Bank, participating families have higher rates of vaccinations in children younger than two, school enrollment increased by 5 percent, and household consumption increased by up to $8 per adult per month. Its impact on chronic malnutrition remains unknown.
Because of the country’s budget crisis, the future of the program itself also remains unclear. According to figures released last week, it is running short at least $100 million, meaning it could collapse in just two months. Critics said political considerations prevented the program’s dire financial straits from becoming public earlier.
“It’s an irresponsibility of the former first lady, who was running these programs, because for electoral purposes,” the likely collapse wasn’t adequately anticipated, Rosa Maria de Frade, a congresswoman and president of the Legislative Transparency Commissio, told the Guatemalan newspaper Siglo Veintiuno.
Guatemala’s presidential elections are set for September, and Otto Perez Molina, a former head of military intelligence who barely lost to Colom in 2007, is all but assured victory.. In recent polls, his closest opponent was Torres who trailed behind by about 30 percentage points. In late June, electoral officials denied Torres eligibility based on a constitutional clause restricting relatives of the president from running.
Perez Molina, who represents a conservative right-wing party, has said he would continue Mi Familia Progresa, and has vowed it would receive better oversight. What remains to be seen is if a Perez Molina government has the will and capacity to succeed at tax reform, crucial to properly funding the conditional cash transfer program and the education and health ministries on which it relies.
<http://www.globalpost.com/dispatches/globalpost-blogs/global-pulse/my-family-progresses>

MALNUTRITION: Guatemala: The drain of malnutrition

Lomi KrielJuly 18, 2011

Isabella Hernandez and her children stand outside their home high in the mountains in Cajola, Guatemala. Hernandez, 37, is a single mother who must support her children on less than $1 a day.

PHOTO BY: Arturo Godoy

CAJOLA, Guatemala — High in the mountains, a narrow and practically impassable mud trail leads to the dirt-floor shack where Isabella Hernandez is rhythmically patting tortillas, the main source of sustenance for her nine children.
A wisp of a woman, clothed in her community’s signature colorful dress, Hernandez is illiterate and a single mother who ekes out her family’s existence on less than $1 a day. Nearly 60 percent of this mostly indigenous Mayan town lives in such extreme poverty.
On this day a health worker had come to weigh and measure the children while delivering a nutritional supplement for the poor. A veteran in the hunger wars, Julissa Garcia knew what she would find. Sure enough, they were not only underweight but about half a foot shorter than the minimum recommended height for their age. Known as stunting, such a height deficit is a key indicator of chronic malnutrition.
“Almost all the kids here are malnourished,” said Garcia, who has pioneered a support group for Cajola mothers with stunted children.
It is communities like these that President Barack Obama’s Global Health Initiative (GHI) is focusing on in Guatemala. Slow in its implementation and hampered by little new money, GHI is targeting Mayan women and children in the mostly indigenous Western Highlands, a mountainous area with a single maize harvest per year. The strategy’s cornerstone is reducing one of the highest rates of chronic malnutrition in the world. According to the United Nations Children’s Fund, only Afghanistan and Yemen fare worse. Half of all Guatemalan children under five are stunted and in the Western Highlands, it's seven out of 10.
“These children have been lost. They can’t learn, they can’t be productive.”
~Dr. Baudilio Lopez, project development specialist at USAID office in Guatemala City.Called the “invisible killer,” chronic malnutrition isn’t necessarily a lack of food but a shortage of the right kind. Faced with insufficient nutrients, especially protein, the body compensates by simply stopping to grow. More importantly, brain capacity and productivity is reduced by as much as 40 percent. That can’t be recouped.
Such a lack of nutrients is obvious in Hernandez’s small shack. Lunch is their highlight, when the children fall silent as they shovel down tortillas flavored by salt, potatoes, and plants their mother picked in the fields. They eat while they can. Their bellies will predominantly rely on hot maize drinks for the rest of the day.
There are no beans or eggs. Meat is a rare luxury.
Garcia gasped when she saw how the three middle boys, each more than a year apart, essentially weigh and measure the same — at or below the minimum recommended amount for the youngest. It’s difficult, however, to gauge the effects of stunting on their cognitive development. None of the Hernandez children have ever attended school and all are illiterate, most speaking mainly their indigenous language of Mam.
The magnitude of the problem is stunning, as are the consequences. Such children are particularly susceptible to diarrhea and other illnesses. Chronic malnutrition is the single biggest contributor to the deaths of children under five. As concerning is the effect on their brains, thus the consequence on Guatemala itself.
“These children have been lost,” said Dr. Baudilio Lopez, a project development specialist at the Guatemala City office for the U.S. Agency for International Development (USAID.) “They can’t learn, they can’t be productive.”
GHI, which Obama unveiled two years ago, has been slow to implement, according to critics. And, due to the U.S.’s own budget woes, it has been hampered by less funding than expected. In Guatemala, USAID received basically the same level of funding, about $14 million, over the past two years, and just over $16 million for FY 2011. Cuts are likely ahead, given Washington’s budget crisis.
Nutrition efforts will also benefit from funding to Obama’s global food security initiative, which channeled about $25 million annually into Guatemala over the past two years.
The amount of funding pales in comparison to the seven other GHI focus countries. Guatemala’s GHI program receives by far the smallest amount of aid, just 1/37th received by Kenya, which has a $600 million GHI budget.
Still, officials at USAID and the Centers for Disease Control and Prevention, GHI’s two main implementing actors here, remain buoyant. They say the tightened focus on specific global health issues in a targeted geographic area combined with better collaboration among U.S. agencies is revolutionary.
For their part, Guatemalan health officials say they have never worked so closely with U.S. agencies.


"It's the first time that U.S. agencies sat at a table with the Ministry of Health to jointly plan" health strategies, said Dr. Edgar Gonzalez, who is heading GHI efforts for the Ministry of Health.

The initiative faces challenging obstacles. The percentage of Guatemala’s total population that is chronically malnourished has barely budged for more than a decade, despite efforts to reduce it. Guatemala is in many respects a tale of two countries. It is ranked 13th among the nations with the greatest level of income inequality, according to the United Nations Development Program. A semi-feudal society, 2 percent of the population owns about 70 percent of productive land. And though Guatemala’s average per capita income is $2,700, half of its 14 million residents live on less than $2 a day.
Most of the poor work as sharecroppers and are vulnerable to effects of global warming and natural disasters. As one of the top 10 countries most affected by both, Guatemala over the past two years experienced the heaviest rains in decades and severe drought as global food prices increased and remittances from the U.S. dropped.
Moreover, Guatemala’s notoriously weak government hasn’t made many inroads in addressing the problem, partly owing to one of the lowest tax collection rates in the world and a history of corruption. The impending presidential elections will likely overhaul government for the fourth time since 1996 making continuity in programs yet another challenge.

The plight of the Mayans
Most affected by malnutrition are the Mayans, who make up 40 percent of the country and have twice the rate of stunting of the non-indigenous. All poor health indicators basically double among the indigenous. They have lived in entrenched exclusion for decades, since before a leftist government effort at social reform, particularly land redistribution, sparked a U.S.-backed military coup in 1954 and catapulted the country into decades of civil war. More than 200,000, the majority indigenous civilians, were killed in one of Latin America’s most violent armed conflicts.
The 1996 peace accords made some advances, but more than 70 percent of Mayans continue to live in poverty. Many are geographically isolated, pushed into remote areas either fleeing persecution or seeking space to farm. They predominantly speak one of 24 Mayan languages. High illiteracy rates and traditional Mayan beliefs further complicate health efforts.
El Quiche is one of Guatemala’s poorest and most populous states, indelibly stained by the civil war. Of the indigenous civilians killed during the civil war, eighty-three percent of all identifiable victims were Mayans from this mountainous region. There’s only one factory here and, as one of the most food insecure regions in the country, agricultural yields are slim.
Seventy percent of children under five are chronically malnourished. Families migrate between the sugar and coffee harvest seasons to survive, but the economic crisis has meant less work. It is here that USAID, through its implementing partner Save the Children, has overseen a promising program in combating malnutrition. Similar efforts are occurring across the Western Highlands.
Faced with finite resources, protein and vegetable consumption is virtually non-existent among Mayan families. More than a fifth of all Guatemalan pregnant mothers have anemia, which is caused by a lack of iron and increases the risk of hemorrhage and the chances that infants will be born underweight and suffer cognitive impairment.
For years, aid workers concentrated mainly on food distribution and still, in Quiche, a majority of families receive donated beans and rice to help them survive.
In 2006, Save the Children surveyed their target communities here and found, to their surprise, that they didn’t recognize malnutrition as a problem. Their concerns were a new road or clean water, a school. This is a national phenomenon. In a study conducted last year, less than 1 percent of Guatemalans, who tend to believe they’re naturally short, identified malnutrition as a concern. Stunting, however, is not genetic. A World Bank study found Mayans in southern Mexico are taller than in Guatemala. Those raised in the United States reach normal heights.
In Quiche, Save the Children devised a strategy to tackle chronic malnutrition on a broader scale: education on what foods to eat, assistance with providing those foods, and most importantly, the election of community leaders to head the process, encouraging ownership to make it self-sustainable. In Chacaguex, for instance, Antonio Acabel was given several goats. With milk high in protein, goats also require far less land and food than cattle. As his herd multiplies, Acabel spreads them among the community, prioritizing families with young children.
“Before,” Acabel said, “no one drank milk because it’s too expensive.”
As the local farm leader, Acabel was trained how to more efficiently farm maize and which plants within his reach are high in protein. Instead of fertilizer, he uses goat manure – longer-lasting, better for his crops, and saving him $20 every three months. Today he hosts community workshops on better farming practices. His tiny vegetable garden is meticulously organized with each plant carefully labeled – proof of a man proud of and grateful for his work.
Such a simple premise, really: supply a bit of capital and show how to use it.
“It changed my life and that of the community,” Acabel said. “Before we didn’t have anything.”
Another initiative is a rigorous training process for “mother leaders” in the community. A liaison between health care workers and indigenous mothers, they teach women how to cook high-protein plants within their reach. Using bright diagrams of women in traditional dress, they show what kinds of food to provide children, in what quantities, and when. They urge the necessity of exclusive breast-feeding up to sixth months and how to combine it with food after that – key in preventing chronic malnutrition. Only half of Guatemalan infants under six months are solely breastfed.
“Before we didn’t know these things,” said Alma Cecilia Real Ajcot, 27, a mother leader who oversees food distribution. “Now that they have taught us how it is, we can do it.”
The concept of mother leaders has been wildly successful. They are friends and neighbors, inspiring trust, and familiar with traditional Mayan beliefs that might cause or worsen health problems. The phenomenon of mal ojos, for example, the idea that you can get sick if someone gives you a bad look, means mothers often only seek medical attention once it’s too late.
Most importantly, the women speak the same language.
“Sometimes we can’t even pronounce their names correctly,” said Marta Picasa, a nurse at a tiny health center outside of Quetzeltenango. “With us they will not have the same level of confidence.”

Gender wars
In Totonicapan, Guatemala’s poorest region, where 82 percent of all children under five are malnourished, USAID is funding a similar program aimed at educating Mayan men, who control most family decisions. Women, for instance, can’t seek medical attention without spousal permission – a critical contributor to Guatemala’s high maternal death rates. Men may also not understand or support why their wife wants to buy vegetables, say, instead of corn or rice.
They are taught the necessity of birth control as experts say chronic malnutrition and poor family planning are closely linked Indigenous families in some regions average 10 children but support them on an income barely enough for two. Malnourished mothers give birth to malnourished babies. Though Guatemalan’s use of birth control has doubled to 50 percent, many indigenous women still use it secretively, as men tend to equate contraceptives with infidelity.
Yet behavioral change can only accomplish so much if poor families can’t buy food. In conjunction with Feed the Future, Obama’s global food security initiative, officials said they would continue linking rural farmers directly to bigger markets to improve their income. Near the tourist attraction of Lake Atitlan, for example, USAID helped indigenous farmers form an agricultural cooperative, building a storage shed to prepare their vegetables. Before, these farmers worked alone and hawked their wares in the village market, which were purchased by middlemen, transported to Guatemala City, and sold to international vendors. Now the farmers sell directly to Wal-Mart.
Officials said they would also expand on programs encouraging employment for Mayan women. An extra dollar per month in a Guatemalan mother's hands achieves the same weight gain in a child as roughly 14 times more earned by the father, according to the Population Council, an international non-profit. USAID is also teaching communities how to organize to demand potable water from local governments. In rural communities, access to safe drinking water is scarce.

Making do with scarce resources, the success of GHI depends to a large degree on Guatemala’s Ministry of Health. One of the most fragile arms of a weak government, its slow collapse has been the subject of continuous media reports. Many health workers haven’t been paid in months and in some areas medical supplies simply stopped arriving. Patients transported by ambulance must often pay their own gas. Part of the problem is that its budget has been slashed to fund a conditional cash transfer program aimed at poor mothers, a cornerstone of the government strategy to combat malnutrition. The program has been widely criticized for the lack of oversight and transparency. Guatemala’s upcoming presidential elections will likely also affect GHI implementation.
In the dirt-floor shacks of Cajola, the scramble for survival continues. One of the biggest sources of help to Hernandez have been Peace Corps volunteers, who built her a stove so she no longer cooks on open fire. At 37, Hernandez’s breezy humor lights up her delicate features. Two months ago, she nearly died after hemorrhaging during her last pregnancy, arriving at the emergency room bruised from a fight with her ex-husband.
Like their community, the lives of the Hernandez family are isolated. None attend school because, while it’s free, the mother said the extras on books or pencils would break her budget. So the effects of their malnutrition remain unknown, likely forever.
Her spouse pays her $25 a month though it varies depending on his drinking. She relies on handouts, water from her neighbor’s well and nutritional supplements from the health center. She has a small maize crop. Life here continues like it always has, with the same limited future. Recently, however, Hernandez saved up money to buy two piglets, which she hopes to breed.
“I don’t have the capital right now,” she said in her native language of Mam. “But I would like a good business with my pigs. That way I can maintain my kids.”
She smiled. Then the youngest cried, so she sat down to breastfeed, leaving her teenage daughter in charge of lunch – tortillas, the same as yesterday, all the days before that, and what tomorrow would bring.
http://www.globalpost.com/dispatch/news/health/110714/ghi-targets-chronic-malnutrition-guatemala

MALNUTRITION: biological manifestation of a social disease

July 12th, 2011 by Claudio Schuftan

LETTER TO A STUDENT WHO IS PLANNING TO SPECIALISE IN PUBLIC HEALTH NUTRITION

IT IS THE GRASSROOTS ‘PULL’ THAT IS MISSING, AND WE ARE NOT PUSHING GRASSROOTS MOBILISATION STRONGLY, AS WE SHOULD.

All lower-income countries need new generations of leaders in public health and in nutrition, with a new vision and energy. What about the even younger generation, of students who are already committed, perhaps passionately, to what they believe public health nutrition stands for, and who are planning a career – maybe a lifetime – in our profession? This column is addressed to them, in the form of a letter to a student. So:

Dear candidate,
So you want to join our guild of public health nutritionists. Good! I hope you will now allow me to give you a few words of advice, some of warning, some of encouragement.
I start with an issue that has worried public health nutrition workers for many years now, namely how we have been doing professionally in the international arena. Over the years, many of us have shared this concern. Before you embark on your professional journey, you need to see this and other issues. What we have experienced can help you better to judge what you are most probably going to get involved with, in your future career. That is why I am writing you this letter.
I am one of those who do not share the feeling that international public health nutrition is much healthier today than it was ten years ago. The academic training we are giving our new graduates in public health nutrition still often is of limited relevance. This is perhaps more so for students from the South, especially when trained in universities in the North, where they have to go through core curricula that include courses of no relevance to them.
In judging the most important advances in nutrition in the last ten years, many of our colleagues think these have been greatest in preventing and treating micronutrient deficiencies. This comes as no surprise. Most nutritionists still like ‘silver bullet’ fixes. These are ‘technical’, and the technical realm is the one in which they feel more at home, and more in command.

The main issues are structural

But malnutrition is really a political problem. It is the biological manifestation of a social disease. Some other colleagues think that advances in our field in the last ten years have included greater community involvement in nutrition programmes, and increased attention to care practices addressing women and children. This is so, up to a point. But I feel most colleagues do not really have a better, action-oriented understanding of the causes of malnutrition now, than they had in the 1990s. This was the decade in which we agreed that the correct conceptual framework of the causality of malnutrition is one that considers malnutrition as an outcome of different levels of causality. These are basic and underlying as well as immediate, and social, economic and environmental as well as behavioural and biological. All these levels and dimensions need to be addressed at the same time.

For the same period, colleagues have said that we have not come up with comprehensive designs for a better management of nutrition interventions. For them, this explains why we have not been effective in addressing protein-energy malnutrition. But design and management are not the main shortcomings of the last decade, or even the last thirty years. The main problem is the top-down, often curative and palliative thrust of the interventions. Also, it still amazes me that some colleagues even think that failures can be attributed to insufficient attention having been paid to the importance of nutrition counselling. This just shows their ethnocentric bias. ‘Counselling’ does not begin to address the basic problems of impoverishment and inequity that are at the root of malnutrition the world over.
The same bias can be found when colleagues think that reduced funding for nutrition projects is the major problem or constraint to achieving better results in the battle against hunger and malnutrition. Let us face it: If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!
I further disagree with colleagues who think the issue of lack of coordination among United Nations and other aid and development agencies providing nutrition services is central to our non-success in our work. The causes of this confusion or even conflict are ultimately related to issues of control, egos, and ‘old boy networks’, although there are also a number of genuine points of contention among agencies, some clearly ideological in nature. Yes, the non-coordination exists, and it is a disappointment. But it is not the main obstacle to faster progress.
Lack of commitment by governments to meaningful nutrition interventions is another excuse that is made too often, as a blanket statement, almost as a slogan. This said, I do accept that bureaucratic obstacles are a great burden. I know this after working for six years in ministries of health in Kenya and Vietnam, the latter a country where the politics are right, but where it takes a long time to get anything done.
But taken together, I cannot agree with the reasons given above as to why public health nutrition is ineffective. The major negative factors are structural, and are to do with the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment of those whose right to nutrition is being violated, every day of their lives.

The main issues are political
One of the real issues at stake is the genuine empowerment of claim holders, the people who are suffering from malnutrition. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to reduce malnutrition on the scale that is needed. It is the grass-roots pull that is missing and, as professionals, we are not pushing grass-roots mobilisation strongly, as we should. Will this be covered in your curricula? I am a skeptic.
On UN and other aid and development agencies, the big issue is that there are just no real good role models. Interagency competition and rivalry is often disguised as technical, but is actually political and ideological. My experience is that none of these agencies is really engaged in making empowering and sustainable changes with a potential to win the battle over malnutrition. Your generation, dear candidate, will have to give these agencies new, bolder directions. They are not immune to the political discourse. Some need to be challenged, even confronted, for as long as they keep to their conservative, outdated positions.
Very few of your future professors, dear candidate, are sold on the position I present to you here. They tend to be dogmatic and conservative, sticking to outdated or obsolete concepts, and a paradigm I think is fading. This is a challenge for you as well as for them. Take your stand. We take political stands based on adopting a consistent overall philosophy, which is to say, an ideology. This puts us in opposition to those with different ideologies. It is best not to adhere to our positions as the ‘only’ ones, but as those we stand for. It is good to believe you are right, when you enter into a discussion on the deep-rooted problems of hunger and malnutrition, even when you later come to see that you need to shift your position, just as long as your revised position remains consistent. Dialectics is about change. This includes recognising and amending your own mistakes.
By now, dear candidate, I hope you can sense that politics are at the very centre of international public health nutrition. This means that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current and future education, as well as all that you will see out there in the job market that is waiting for you shortly. What this points to dramatically is the almost taboo question, so rarely addressed, asked or answered: ‘How would you classify yourself politically?’ Why is this not asked in the first place?
It is said that, on micronutrients and breastfeeding, more concrete achievements are possible. This is precisely the silver-bullet type option many of our colleagues choose. Why should addressing tougher underlying and basic intersectoral issues be seen as impossibly difficult? These are what will ultimately lead to sustained improvements in public health –if we all put our hearts and minds to the task. Nutritionists in your generation need to face the more difficult choices and challenges in the battle against malnutrition and its real causes.
Properly understood, public health nutrition is part of the larger development perspective. I see it as being our point of entry to the big picture where it rightfully belongs, according to the integrated conceptual framework of the causes of malnutrition. Nutrition will keep its rightful identity in such an approach. To be taken seriously, our discipline has to be engaged with all aspects of development; if it stays territorial, it will remain only marginally relevant.
Are the impediments to public health nutrition too great?
Dear candidate, the current condition of international public health nutrition will continue to pose increasing frustrations and challenges for you. My acute concern is seeing how politically uninterested so many of your generation, particularly in North America and Western Europe, have become.
Those who say that international public health nutrition was just one fashion that now has had its day might be right, after all. If so, this is because our vocation may have turned out to be irreversibly irrelevant in global terms in addressing malnutrition, the rates of which are now rising again. It is just tough trying to beat the gigantic odds of inhumane and often outrageous economic globalisation, structural adjustment, and expanding ‘market economies’, that have no room for the problems of impoverished people.

But international public health nutrition must not and cannot be a passing fashion! We invite you to join in. If leaders and citizens turn their back on problems like these, they are part of a movement towards an inhumane, unjust and unsustainable world that will have gone wrong, for ever.

Yes, you can make a difference
In closing, dear candidate, I convey to you my confidence and optimism that our work has the ability to make a difference. The question is, what difference, and what for. Routine, pat solutions will not do. It is not a matter of an increasing number of activities in international public health nutrition starting to take place again in low-income countries. It is a matter of what kind or type of activities. Issues of inequality and of the right to nutrition are at the base of the problems at hand. And if nutrition is used as a way to revert such inequalities, I will be an optimist. But we need your upcoming generation, dear candidate, to get the job done. Perhaps you can start by questioning the curriculum you will be exposed to.
I have worked in many places on most continents, and this, in my experience, is what awaits you if you decide to join us. I see your role as a potential agent of change. I hope that, by now, you have a sense of what motivates us, the older workers who keep going as best we can, and of what we stand for. Principles include those that are ethical and social. Motivation can include romantic approaches such as those of charity and the desire to help the needy, but what’s most needed are political approaches that attempt to fight inequalities and injustice by empowering people to fight for their own rights.
Unfortunaytely, many of our commitments and energies wane as we get older, dear candidate. Do what is bold, now that you are young. Reach for the stars.

Claudio Schuftan
Ho Chi Minh City

http://www.socialmedicine.org/2011/07/12/health-activism/letter-to-a-student-who-is-planning-to-specialise-in-public-health-nutrition/