Reviews of Protein Energy Malnutrition and The State of the Worlds Children 1994
Protein Energy Malnutrition
(1992) by John C. Waterlow (with contributions by A.M. Tomkins and S.M. Grantham-McGregor). Edward Arnold, London. 407 pages.
This book is classical John Waterlow at its best. In his long career, John Waterlow has made tremendous contributions to the understanding of protein metabolism, to the understanding of the clinical features of Protein Energy Malnutrition (PEM), and to the clinical treatment of Kwashiorkor and Marasmus. As a clinician-scientist interested in the clinically presented disease, Waterlow also developed a major interest in the aetiology of PEM, in the development and use of markers for the identification and assessment of the problem, and like many others, in approaches that might be effective in the amelioration of PEM in populations. In this book, Waterlow attempts to provide an integrated overview, a distillation of his understandings and interpretations of issues ranging from sub-cellular to world population levels. It is very difficult, if not impossible, to prepare a comprehensive review of such a broad field without being accused of being naive or superficial in some areas and overly detailed in others (the judgements varying with the reader). In writing the Foreword, the author recognized this limitation and indicated that I decided to have a go and to try to produce a book that might be interesting and useful to physicians and public health workers, especially in Third World countries, even if it did no more than act as a source of references.....I have not hesitated to express my own views on subjects that are controversial. The important part is not that the reader should agree with those views but rather that he or she should realize that differences in opinion exist and perhaps be stimulated to undertake studies that might resolve those differences.
To an amazing, but perhaps not surprising, degree, John Waterlow succeeded in accomplishing his goals. This book presents that blend of historical perspective, factual knowledge and personal interpretation that is of great value to the student be he or she in an industrialized or pre-industrialized setting. If it suffers a fault, it might be that for the not very astute student, the personal opinions (the my views on controversial matters) are not always clearly identified and the casual reader might take those views as accepted consensus. This is a very small price to pay for what John Waterlow has given us in return. The book is a narrative attempt by a highly regarded scientist to present his view of the world and most important, how he links the layers of discovery and understanding. That is the real educational value of this book. One may disagree with some of the practical inferences and conclusions that Waterlow derives but you will have learned much by attempting to understand the rationale presented.
As one might expect from the authors own background, the strongest parts of this book are those addressing protein metabolism, clinical manifestations of PEM, and the treatment of this disorder. Constituting almost half the book (Chapters 1 through 12), this should be compulsory reading for all clinical staff still faced with cases of severe malnutrition. Also as expected, the remainder of the book (addressing growth, assessment, requirements, feeding practices and possible approaches to amelioration of problems in the community) rests on a shakier foundations and reflects much more the opinions and judgements of the author. These chapters (13 through 20) should certainly be read by the student of public health but they cannot be taken as carrying the same authority for public health workers as did the chapters on the clinical manifestations and treatment for primary health care workers.
Perhaps a limitation of the books approach is the difficulty experienced by the author in moving back and forth between arguments and approaches relating to individuals (as in treatment) and to populations (as in population assessment or control programmes). This difficulty becomes apparent in chapters dealing with assessment of nutritional status in the community (Chapter 14) and the associated discussion of growth (Chapter 13). It also arises in the discussion of protein requirements. This should not be taken as a major criticism of the book. Rather, it might be seen as a warning. The interfacing of concepts relating to individuals and to groups is not easy; John Waterlow has presented his interface and drawn his conclusions; the reader must be sensitized to recognize that others draw different conclusions and inferences. Generally, but not always, the distinctions have little practical importance. Occasionally, the views and interpretations expressed are in substantive discord with the current direction of thinking and ultimately it is left to the reader to discern what is a description of consensus and what is a personal judgement on the part of the author.
This book will undoubtedly become one of the classic reviews of a major nutritional problem. It is worthy of that stature. John Waterlow has done the sort of job that only John Waterlow can do and we should all be deeply indebted to him for doing it. This reviewer would certainly recommend the book to all students of clinical nutrition and of public health nutrition; it is perhaps not a book for the uninitiated or uncritical.
George H. Beaton
The State of the Worlds Children 1994
by James P Grant, Executive Director of UNICEF. Published for UNICEF by Oxford University Press. 87 pages.
The 1994 State of the Worlds Children report should be read by anyone concerned about the future. Its about children, of course; but its also about development in the broadest sense: the kind of world we live in, where it seems to be heading, and how its progress might be re-directed for the benefit of all. Everyone - not just children, not just those in developing countries - since problems of poverty, population growth and environmental stress in this increasingly inter-dependent world threaten to engulf us all. The writing, as always, is vivid and visionary; but the proposals are practical and pragmatic, and deserve to be understood and discussed by as many people as possible. Indeed, this is an essential part of the argument, which calls for a change in the prevailing climate of ideas: ...political vision often appears to be circumscribed by opinion polls, and to extend only as far as the next election, whereas the widely acknowledged problems which threaten our own and our childrens futures require vision and action on a different scale in both place and time.
The report is presented in four sections. The first discusses the substantial progress made in recent years in improving the health, nutrition and education of children. This has occurred despite the relatively small proportion of government expenditures and of foreign aid currently spent on primary health care, basic education, safe water supply, and family planning. But greater priority will have to be given to these issues to ensure that the social goals agreed at the World Summit for Children in 1990 are attained in all countries by the end of the decade.
The second section discusses how past progress and future potential in these areas are threatened by the mutually reinforcing effects of poverty, population growth and environmental deterioration, referred to as the PPE spiral. This is presented in the larger context of managing a world-wide transition to a sustainable human future. Failure to achieve this, the report argues, will result in increasing economic disruption, political unrest, set-backs for democracy, and instability within and between nations. It is thus a matter of fundamental self-interest, as well as of altruistic concern... For poor countries to remain within the PPE spiral... is to invite disaster. But for four fifths of the worlds people to follow the path of development blazed by the one fifth who live in todays industrialised nations is to invite a disaster of a different kind. One criterion of a new definition of acceptable progress would be: can the developing countries, if they so choose, aspire to similar life-styles without exceeding the planets capacity?
The third section examines how achieving the basic human goals could make a fundamental contribution to resolving the PPE problems that threaten the future of society. The report considers the proposition that withholding certain low-cost health-promoting techniques will reduce child survival and thereby (it is alleged) limit population growth, and shows that the argument is incorrect, as well as unethical. On the contrary, the synergistic consequences of improving child survival, health, education and family planning services, with special attention to the status of women, might halve the size of the global population that will ultimately stabilize, which could be the determining factor for ensuring success in managing the transition to a sustainable future. The report quotes the Vice-President of the United States, who wrote that the Marshall plan took the broadest possible view of Europes problems and developed strategies to serve human needs and promote sustained economic progress; we must now do the same on a global scale.
Finally, nine revised statistical tables provide economic and social information for 145 countries with populations of 1 million or more, and less complete information for 41 less populous countries. Regional summaries are also provided.
The State of the Worlds Children 1994 can be obtained from the Oxford University Press, Walton Street, Oxford, OX2 6DP, Oxfordshire, UK. Oxford University Press also has outlets in New York Toronto, Delhi, Bombay, Calcutta, Madras, Karachi Peealing Jaya, Singapore, Hong Kong, Tokyo Nairobi, Dar-es-Salaam, Cape Town, Melbourne Auckland, and associated companies in Beirut Berlin, Ibadan, and Nicosia. The book is priced at £4.50 (UK) and $8.00 (USA).
In this section we include selected publishers announcements of new publications; these are not independent reviews, but are included to draw attention to new relevant material
Community Nutrition for Eastern Africa
(1993) by Ann Burgess and others. African Medical and Research Foundation (AMREF). 286 pages.
This book was written in response to requests for a short up-to-date low-cost nutrition manual. It is a practical book that identifies the tasks that health and other workers need to carry out in order to improve food security and nutrition at community level. It deals mainly with what community workers can do to help families and communities to assess, analyse and tackle their nutrition problems.
Good nutrition is essential for people to be active, healthy and able to fight infection. The aim of this book is to give information and ideas to community-based workers whose tasks include improving the food supplies and nutrition of families and communities. It is for health care workers, home economics and agricultural field workers, teachers, and community development and social workers. It will also be useful to the trainers and supervisors of these community workers, to students studying nutrition and to people producing nutrition education materials.
Part 1: Preparing to work with families and communities
1. The nutrition situation in eastern Africa
2. Recognizing and understanding nutrition disorders
3. Understanding the causes of nutrition disorders
4. Learning about a community
Part 2: Helping families to be well nourished
5. Working with communities
6. Improving food production
7. Buying more and better food
8. Planning families to match food and other resources
9. Planning, preparing and sharing good meals
10. Helping women and newborn babies to be well nourished
11. Encouraging breastfeeding
12. Feeding young children during and after weaning
13. Feeding other family members
14. Preventing and controlling disease
Part 3: Working with health care and other services to improve nutrition
15. Growth monitoring and promotion
16. Feeding programmes
17. Programmes to control vitamin A and iodine deficiencies
18. Dietary and supporting care of marasmus, kwashiorkor and anaemia
1. Food and nutrients
2. The important nutrients
3. Energy and nutrient needs
4. Sources and costs of nutrients
5. Collecting and using body measurements
6. Where to get more information
This book is available from: In Uganda: AMREF, PO Box 51, Entebbe, Uganda; in Tanzania: AMREF, PO Box 2773, Dar es Salaam, Tanzania; in South Africa: Trade Winds Press (Ply Ltd), PO Box 20194, Durban North 4016, South Africa; in USA: Boyd Printing Company, 49 Sheridan Avenue, Albany, NY 12210, USA; in UK: TALC, PO Box 49, St Albans, Herts AL1 4AX, UK; and in Kenya: Book Distribution Unit, AMREF, PO Box 30125, Nairobi, Kenya. Tel: 500950 Fax: 506112.
(Source: AMREF Kenya New Book Announcement, November 1993).
NGOs, Participation and Rural Development: Testing the Assumptions with Evidence from Zimbabwe
(1994) by Jessica Vivian and Gladys Maseko. Discussion Paper from UNRISD.
In recent years, non-governmental organizations (NGOs) have gained a higher profile in development recommendations and policy initiatives, as well as an increased share of development funding. In part, the rise of the development NGO sector is a result of a growing consensus that participation is necessary for development, and the belief that NGOs are best able to implement grassroots, participatory development strategies. This paper explores factors affecting the outcome of NGOs development strategies, focusing on NGOs operating at the local level. Research for the study was conducted in Zimbabwe, and, while some of the findings are context-specific, many of them will be much more widely relevant.
The study indicates that the individual organizations which comprise the development NGO sector make up a wide spectrum of organizational types, with a similarly wide range of project strategies and outcomes. Some NGOs are truly creative, independent and committed to the egalitarian and participatory ideals upon which they were founded. At the opposite extreme, others act essentially as members of a service industry, developing and carrying out their activities in response to requests from donors. The authors argue that it is the latter type of NGO - that which acts as part of a service industry - which is most likely to appear as a result of the current interest in NGOs as agents of development.
The authors analyse some of the reasons that rural development NGOs find it difficult to accomplish all that is expected of them. Among other questions, they discuss the logistical implications of truly participatory initiatives, the institutional constraints involved in reaching the poor, the complexity of the question of how to benefit rural women, the difficulty of going beyond the project approach, and the ambiguity of the concept of NGOs representing the grassroots.
The paper constitutes a critique, not of the NGO approach, but of the overwhelming expectations placed upon the NGO sector, especially in recent years. It suggests that the notable successes of some NGOs cannot readily be translated into lessons for the entire NGO community.
This discussion paper can be obtained from: UNRISD, Palais des Nations, 1211 Geneva 10, Switzerland. Tel: (41 22) 798 8400 Fax: (41 22) 740 0791.
(Source: United Nations Research Institute for Social Development (UNRISD) Press Release, April 1994)
Social Marketing of Vitamin A Rich Foods in Thailand: A Model Nutrition Communication for Behavior Change Process
(1993) by Suttilak Smitasiri, George A. Attig, Aree Valyasevi, Sakorn Dhanamitta and Kraisid Tontisirin. Institute of Nutrition, Mahidol University.
A nutrition communication-based study to combat vitamin A deficiency, one which makes use of social marketing techniques to promote the consumption of such foods, has been thought - but not often proven - to hold great promise for developing countries pursuing vitamin A deficiency reduction programs. To provide a proving ground for this theory, USAID sponsored the three-year Social Marketing of Vitamin A-Rich Foods Project from 1988-1991. This book sets out the projects progressive six stage process and highlights valuable lessons learned over the course of this successful program, one which entailed significantly improved knowledge, attitudes and practices in consuming vitamin A-rich foods; substantial improvement in vitamin A and nutritional status of the target population; and a high potential sustainability of project interventions. It also documents the pre-preproject development process including the importance of preliminary and formative research studies and advocacy in launching such intervention programs. While the emphasis is on vitamin A deficiency, the same process and lessons can be equally applied to other single micronutrient programs or ones aimed at addressing multiple micronutrients.
The publication is available from: Ms Paiwan Tantivatanasathain, Division of Communication and Behavioral Science, Institute of Nutrition Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom 73170, Thailand. Tel: (662)441 9035-9 Fax: (662) 441 9344. The publication itself is free of charge; a charge of US$8 is made to cover postage and handling per copy.
(Source: INMU Communication, 10 February 1994).
Rapid Assessment Procedures to Improve the Household Management of Diarrhea
by Elizabeth Herman and Margaret Bentley. International Nutrition Foundation, Boston, MA. 86 pages.
This manual guides the reader to rapidly collect, analyze, and use the information about the cultural context of diarrhoea. Its purpose is to identify household and behavioural factors that are characteristic of the local culture and facilitate the development, implementation and monitoring of programs for the control and prevention of diarrhoea. Rapid assessment procedures (RAP) are used to determine peoples beliefs about how the body works, the causes and consequences of illness and other factors that influence the household response to diarrhoea. Separate sections present the RAP methods; information for diarrhoea case management; a field guide for conducting a study; and options for applying the study results.
The manual may be ordered from: The International Nutrition Foundation, Charles St. Sta., PO Box 500, Boston, MA 021 14-0500, USA. Tel: (617) 227-8747 Fax: (617) 227-9405. Industrialized country citizens US$10.00 plus $2.00 postage and handling (add $0.50 each additional copy). Developing country citizens: US$5.00 plus $3.00 postage and handling (surface) per book, $4.00 air.
(Source: INFDC, 1994)
The Children of Santa Maria Cauque. A Prospective Field Study of Health and Growth
by Leonardo J Mata. MIT Press, Cambridge MA. 395 pages.
A limited number of copies of this book are available at a reduced price through the International Nutrition Foundation for Developing Countries, Charles St. Sta., PO Box 500, Boston, MA 02114-0500. Tel: (617) 227 8747 Fax: (617) 227 9405. List price $37.50. Price if ordered through above address: S20.00 plus $6.00 postage and handling (surface).
(Source: INFDC, 1994)
SOS for a Billion - the Conquest of Iodine Deficiency Disorders
A new ICCIDD book SOS for a Billion - the Conquest of Iodine Deficiency Disorders edited by Hetzel and Pandav was launched at the recent Regional Meeting in Quito, Ecuador, by Mr James Grant, Executive Director, UNICEF.
This book records the coordinated global strategy against iodine deficiency which has been identified as the most common preventable cause of mental defect in the world today.
The book charts the success f this programme in the last five years through the global partnership or people and governments from many affected countries, key international agencies like the WHO, UNICEF, International Council for Control of Iodine Deficiency Disorders (ICCIDD), Kiwanis International and the Salt Industry at national and international levels.
It also describes the national programmes and strategies being implemented with special reference to the use of iodised salt, and country-level progress with successful case-studies in Asia, Africa and Latin America. The concluding part describes the monitoring and verification processes required to ensure that this scourge can be totally eliminated by the year 2000.
The book has many illustrations and provides an up to date account of the remarkable progress towards the World Summit Goal of Virtual Elimination of IDD by the year 2000.
For information contact: ICCIDD, c/o Health Development Foundation, 8th Floor, Samuel Way Building, Womens and Childrens Hospital, 72 King William Road, North Adelaide, 5006, Australia. Fax: 61 8 204 7221.
(Source: ICCIDD Communication, 31 May 1994)
Vitamin A and Breastfeeding: A Comparison of Data from Developed and Developing Countries
(1994). Wellstart International. 112 pages.
Vitamin A deficiency is rare among breastfed infants, even in regions where vitamin A deficiency is endemic. Through its work in the promotion of optimal breastfeeding practices, Wellstart International is in a unique position to act as a bridge between the community of professionals working to promote breastfeeding and those working to prevent vitamin A deficiency.
With support from the US Agency for International Development, Office of Nutrition, Wellstart International has published Vitamin A and Breastfeeding: A Comparison of Data from Developed and Developing Countries. The vitamin A status of lactating women, the effect of maternal vitamin A status on the vitamin A content of human milk, and the adequacy of breast milk as a source of vitamin A have been summarized in this report, as well as the impact of maternal vitamin A supplementation on the vitamin A content of human milk, and on the health of breastfeeding women and their infants.
Assuming nutritional deprivation to be more likely in countries with higher child mortality levels, data from countries with under 5 child mortality levels of 21 or greater (developing) are compared to data from countries with under 5 child mortality levels of 20 or less (developed). All reports of vitamin A activity were translated into retinol equivalents (RE) to allow comparison among studies. Reported values for vitamin A in human milk were divided by the time after delivery during which the samples were obtained (1-6, 7-13, or 14-21 days; 1-2, 3-4, 5-6, 7-12, 13-24, or more than 24 months). The studies were further divided by whether the birth was term or preterm (defined as less than 37 weeks gestation).
A 5-page summary of the report has been sent to all Wellstart Associates, and information from the document has been integrated into Wellstarts Lactation Management Education (LME) curriculum. Wellstart Associates are encouraged to collaborate with vitamin A deficiency prevention programs in building in-country expertise to establish and sustain optimal infant feeding practices. In this and other related ways, Wellstart International is functioning as a liaison and conduit of information between the vitamin A and breastfeeding communities. Health professionals working in vitamin A deficiency prevention programs who are interested in collaborating with Wellstart Associates are encouraged to write to Wellstart International Corporate Headquarters at the address below for information on Wellstart Associates working in their country or region.
A limited number of copies of the full 112-page report are available in English and Spanish. Requests from developing countries should be sent to the APHA Clearinghouse on Infant Feeding and Maternal Nutrition, 1015 15th Street, NW, Washington, DC 20005, USA, (202) 789-5600, (202) 789-5661 (FAX). Requests from developed countries should be sent to Wellstart International, Corporate Headquarters, 4062 First Avenue, San Diego CA92103, USA, (619)295-5192, (619)294-7787 (FAX). Please include a money order for US$10. Abbreviated 5-page summaries are also available without charge in English, Spanish, French and Russian.
(Source: Vicky Newman, M.S., R.D., Wellstart International)
World Bank - Population, Health & Nutrition Department, New Publication to be Released in Autumn 1994
Anne Tinker and several others are in the process of finalizing the document entitled Womens Health and Nutrition: Making a Difference. It will be available to the public by Autumn 1994, and presents a comprehensive discussion of the issues surrounding womens health and nutritional status, with operationally-based recommendations for addressing the problems unique to women and girl children.
(Source and contact for further information: Leslie Elder, Population, Health & Nutrition Department, The World Bank, 1818 H Street, N.W., Washington, D.C., USA)
The following resource information has been provided by the Clearinghouse on Infant Feeding and Maternal Nutrition of the American Public Health Association (APHA), 1015 Fifteenth Street, NW, Washington, D.C. 20005. Phone: (202) 789 5600 Fax: (202) 789 5661.
Manual de Temas de Salud Reproductiva Para Promotores Comunitarios de Salud
(1993) by A A Chavez, AHLACMA, Tegucigalpa, Honduras. Spanish.
Practical information about reproductive health for community health workers working in rural or marginal urban areas assists the health worker plan and design training sessions for teachers, mothers, fathers and the community. Seven topics are covered: reproductive health and sexuality, reproductive risk, pregnancy, breastfeeding and infant feeding, family planning, sexually transmitted diseases and issues of child survival. Simple illustrations and clear language make it easy to read and use.
Available from: Asociacion Hondurena de la Lactancia Materna (AHLACMA), Col. Lomas de Guijarro, Edificio SCORPIO, Apartamento 2B, Avenida Republica Dominicana, Apartado Postal #3465, Tegucigalpa, Honduras.
Lactation Management Training in a Kenyan Hospital
(1992) by K. Blyth, A. Mukuria and R. Musoke, BASICS Information Centre, Arlington, USA.
In an effort to protect children against diarrhoeal morbidity and mortality, the PRITECH project supported a lactation training program in a Kenyan hospital to promote breastfeeding practices. A team attended the Wellstart Lactation Management Education Program. Following the training, the team conducted in-country research on knowledge, attitudes and practices at the hospital and developed a curriculum for use in training hospital employees. Lessons learned include the importance of having a senior-level administrator or manager in the multidisciplinary team for training, the need to train trainers in participatory methodology to effectively carry out hospital training, the advantages of carrying out the training program in-country and the need to branch outside of the hospital to work with community educators to provide breastfeeding information and mother support.
Available from: BASICS Information Center, 1600 Wilson Blvd., Suite 300, Arlington, VA 22209, USA. Single copy available at no charge.
Breastfeeding Management and Promotion in a Baby-Friendly Hospital - an 18-hour Course for Maternity Staff
(1993) UNICEF, New York.
This manual outlines the basic training needed to improve staff skills for the implementation of the Ten Steps and the Baby Friendly Hospitals Initiative. It contains lecture outlines and suggestions for group activities, discussions and self-tests. Reference lists are included at the end of each chapter for further information.
Available from: UNICEF, Training Coordinator, Baby Friendly Hospital Initiative, 3 United Nations Plaza, Room 252, New York, NY 10017, USA. English and Spanish. Free to developing countries; other countries US$40.00.
Resources from the APHA Clearinghouse
Children for Health
(1993) edited by H. Hawes and C. Scotchmer. TALC, St. Albans, United Kingdom.
This is a book for anyone who works with children and for children - those who plan programs, write materials, train teachers and health workers and who work with children and their families in communities and schools. Children for Health includes all the messages explained in plain language about practical, low-cost ways to protect childrens lives and health published in Facts for Life in 1989 by UNICEF, UNESCO and the World Health Organization. A new chapter on the mental and emotional development of children has been added. The book outlines learning activities for children to take back and share with their families and communities.
Available from: Teaching Aids at Low Cost (TALC), PO Box 49, St. Albans, Herts, AL1 4AX, United Kingdom. Fax: 727 44 846852. £2 plus postage and handling.
Learning to Listen to Mothers: a Trainers Manual to Strengthen Communication Skills for Nutrition and Growth Promotion
(1993) by J. Vella and V. Uccellani. Academy for Educational Development, Nutrition Communication Project, Washington, D.C.
Emphasis is given to strengthening two-way communications skills rather than weighing and charting procedures in this manual for training community health workers and their supervisors in growth monitoring activities. Designed for a two-day workshop, the training consists of six sessions based on participatory principles. Throughout the manual, notes for the trainer are included on ways to organize and conduct the sessions. The manual has been field tested in Bolivia, Honduras, India, Indonesia, and Mali.
Available from: Academy for Educational Development, Nutrition Communication Project, 1255 23rd St., Washington, D.C. 20037, USA. English. Single copy available free to readers in Asia, Africa and Latin America, others US$4.
The following publication information is extracted from the 1993/94 Appropriate Health Resources & Technologies Action Group (AHRTAG) publications list. AHRTAG is a UK based international development agency, established in 1977, which supports the goal of health for all by promoting primary health care.
Dialogue on Diarrhoea
A quarterly newsletter for health workers and educators covering all aspects of diarhoeal diseases. Available in English, Chinese, French, Portuguese (Africa Only), Spanish, Tamil and occasionally in URDU.
Baby length measurer
Illustrated leaflet with instructions for making and using a wooden measurer. Price: Free
Breastfeeding resource list
Lists more than 50 organisations around the world which promote breastfeeding and contains a section on publications and audiovisual materials.
Price: Free to developing countries. Please enquire about price for readers elsewhere.
Leaflets originally published as inserts in Dialogue on Diarrhoea on controlling cholera, growth monitoring, persistent diarrhoea, and shigellosis (available separately). Price: Free.
Primary health care course directory: 1993/94
Lists over 120 health and health related courses in the UK relevant to people in developing countries.
Price: Free to developing countries; £6.00/US$12.00 to individuals elsewhere; £8.00/US$ 16.00 to organisations elsewhere. Discounts available on bulk orders.
For further information contact: AHRTAG, 1 London Bridge Street, London SE1 9SG, United Kingdom. Tel: (44 71) 378 1403. Fax: 44 71 403 6003.
Source: International Geographical Union (IGU) Commission on the Geography of Famine and Vulnerable Food Systems. Newsletter, No.2, April 1994, p.1.