1214
CONFERENCE
Micronutrient deficiencies in On Nov 14,1991,the Centers for Disease Control (CDC) in Atlanta, Georgia, USA, hosted a one-day technical review of micronutrient deficiency diseases in refugee populations.* The workshop was convened because certain diseases found in refugees and other displaced populations (eg, scurvy, pellagra, and beriberi) have been neglected in the international dialogue on micronutrient deficiency diseases. Refugees dependent on international food aid now number 17 million and there are at least 15 million others displaced by war and civil strife but still within the borders of their own countries. The meeting found that despite international nutrition guidelines, relief programmes often fail to provide the minimum recommended daily allowances (RDA) of essential micronutrients such as vitamin A, thiamine, niacin, vitamin C, iron, and folic acid.l.2 During the past decade outbreaks of micronutrient deficiency disease affecting tens of thousands have been reported in refugee camps, mainly in Africa. Prevalence rates of scurvy in some camps for Ethiopian refugees are among the highest recorded this century: PopuDisease
Year
Location
lation
Prevalence
19823 Southern Somalia 150 000 19844 Eastern Sudan 50000 19854 North-west
Scurvy
Somalia
1-5% 22%
160 000
7--44%
170000 20000 285000 900 000 300000 Sudan 250 000 Thailand 150 000
1-2% 15% 0.5% 2-0% 0-2%
19895 Hartisheik, Ethiopia 1991*KassaIa, Sudan 19896 Malawi 19907 Malawi
Pellagra
1991* Malawi
Xerophthalmia 19858 Eastern 19859 Eastern
Beriberi
..
..
Iron-deficiency anaemia
19871ONorth-west Somalia
160 000 59-90% (children) 170000 10-13% (children) Unpublished data from Office of UN High Commissioner for Refugees’ and Save the Children Fund.t
19901 Ethiopia
Scurvy. Women refugees, especially during
pregnancy, increased risk of scurvy; and the risk increases with age. The most compelling risk factor is length of stay in refugee camps, reflecting duration of exposure to rations inadequate in vitamin C. The ration provided at the Hartisheik camp in Ethiopia in 1989, for example, contained an average of 2 mg of vitamin C per person per day; and experimental studies show that scurvy develops when the daily intake is less than 10 mgY Pellagra. More than 22 000 cases have been reported among 900 000 Mozambican refugees in Malawi since January, 1989. In 1990 alone, at least 18 000 cases were are at
J. Toole, F. L. Trowbridge, P. Nieburg, R. Yip, Deming, M. Serdula, K. Scanlon (Centers for Disease Control, Atlanta, Georgia); R. J. Waldman, (World Health Organisation, Geneva); R. Bhatia (Office of UN High Commissioner for Refugees, Geneva); A. Moren, P. Malfait, (Epicentre, Paris); Sue Berger, Kevin Sullivan (Emory University School of Public Health, Atlanta). Molly Bardsley (rapporteur).
*Participants:
R. Baldwin, M.
M.
refugees
reported, and attack rates in certain camps were as high as 13%.5 More than 2000 cases were reported in 1991. Outbreaks of pellagra occurred during the first six months of the year when planned amounts of groundnuts (the main source of niacin) were not provided and the rations contained only 4-9 mg available niacin equivalents per day, compared with 7-5 mg in the planned ration and with RDAs ranging from 5-4 mg for infants to 20-3 mg for adults.2 Risk factors included young age, female sex, having an unemployed head of the household, residence in a closed camp rather than an integrated village, absence of groundnuts or fish in the diet, and lack of a home vegetable garden or domestic poultry. Biological requirements for niacin (and for thiamine and retinol) increase with increasing caloric intakes so the provision of adequate calories in the absence of sufficient micronutrients may lead clinical micronutrient deficiencies. Anaemia. Anaemia (Hb < 10 g/dl in children 0-5 years of age and pregnant women, < 11 g/dl in non-pregnant women, and < 12.5 g/dl in men) was especially common in young children and women of childbearing age, suggesting that the main risk factor is nutritional iron deficiency. Parasitic diseases such as malaria, schistosomiasis, and hookworm may exacerbate the problem, and iron deficiency may be compounded by vitamin C deficiency. Xerophthalmia. Relief agencies report that awareness of the importance of vitamin A supplementation has generally been raised and that guidelines for vitamin A supplementation in young children are now routinely followed. Nevertheless, one report described the absence of vitamin A in emergency medical kits supplied to Kurdish refugees on the Turkey-Iraq border in 1991. Sufficient data do not exist to evaluate the contribution of micronutrient deficiency diseases to the excess mortality in refugees during the emergency phase of relief programmes.9 The most common causes of death are protein-energy malnutrition and communicable diseases such as measles and diarrhoea. Most surveillance systems lacked the sensitivity and specificity required to attribute deaths to diseases such as xerophthalmia, scurvy, and pellagra, and the scarcity of diagnostic facilities and a low index of suspicion mean that such deaths are likely to be missed. We do know, from other settings, that there is a high case-fatality ratio in untreated patients with these conditions but micronutrient deficiencies may be underlying factors rather than direct causes of death.12-14 Workshop participants agreed that we have the knowledge to design and implement effective, affordable, and sustainable interventions to eliminate at least vitamin A and niacin deficiencies among refugees-and certain shortterm measures can be taken immediately to prevent most micronutrient deficiency diseases. A key issue is the lack of input by technicians into relief programme planning, implementation, and evaluation; and relief workers with access to information on micronutrient deficiencies have not
to
1215
been good at communicating the urgency of these problems and the availability of solutions to relief agencies. International relief organisations ought to focus on process (delivering food) rather than outcome (preventing mortality and morbidity among refugees). Health information systems in camps either do not exist or do not systematically monitor ration quantity and composition at the household level; one such system has been brought in at low cost by a non-government organisation in Malawi. Discussions on permanent solutions focused on dietary diversification, fortification, and supplementation: Dietary diversification might be achieved through increased food items, providing RDAs of micronutrients through routine ration distributions. A regular supply of fresh, vitamin-C-containing foods to large remote camps such as those in the Horn of Africa is difficult, and imported, fortified cereal blends could be substituted. Relief agencies do not do enough to promote vegetable cultivation in camps and donor agencies and local governments sometimes discourage refugees from exchanging portions of their ration for other foods in local markets. Fortification of maize flour with niacin is technically feasible but if whole cereal grain is distributed fortification locally requires close supervision of milling. Anyway dependence on fortified maize flour for all niacin needs would be undesirable since this might lead to a ration where most nutrients are provided in only one or two food items, and rations should probably comprise at least four items because interruptions to the supply of single items are inevitable. While fortification of cereal blends (with iron, B vitamins, and ascorbic acid) offers great potential, the cultural acceptability of these blends should be carefully assessed for each refugee community. The workshop identified a lack of standardisation in the fortification of donor-provided cereal and periodic shortages of items such as com-soya milk make it difficult to provide these commodities regularly. Fortification of milk powder with vitamin A is almost routine in Europe and the United States; however, the inclusion of milk products in general rations for refugees is no longer recommended because of the risk of provoking diarrhoea in children. Nonetheless recommendations that all milk products donated for supplementary feeding programmes in refugees should be fortified with vitamins A and D are not always heeded and fortification of ration foods with vitamin C is still problematic because of the instability of ascorbic acid. Supplementation with regular vitamin or iron tablets is logistically difficult in large refugee populations except fat-soluble vitamin A where supplements every 4 or 6 months will do. The frequency with which iron, folate, and water-soluble vitamins need to be given makes supplementation impracticable, except in the midst of a major outbreak of a particular deficiency disease. The workshop recommended the strengthening of surveillance for micronutrient deficiency diseases and the development of standard clinical case defmitions to be used on report forms used in refugee health information systems. Nevertheless, surveillance for some conditions may be problematic (eg, vitamin A deficiency and anaemia). Participants recommended routine surveillance for scurvy and pellagra, and periodic cross-sectional surveys of anaemia and xerophthalmia. There should be more focus on morbidity surveillance and on routine monitoring of ration quantity and composition (outcomes). WHO/FAO-defined RDAs for all essential nutrients should be provided in general food rations distributed routinely by major food
donors. Ideally, the source of micronutrients should be fresh food items; however, fortification or, rarely, be sometimes may supplementation required. Diversification should be promoted by supporting vegetable cultivation, small animal raising, and fish farming in camps as a routine component of all refugee assistance programmes. Constraints to bartering in local markets should be removed, as recommended at the international symposium on the refugee nutrition crisis held in Oxford in March, 1991. The prevention of vitamin A deficiency in young children is critical where refugees come from a region where vitamin A deficiency is highly prevalent; there is evidence of clinical vitamin A deficiency in the population; and the general ration provides less than 2500 IU per person per day. Since most general rations provided to refugees lack adequate vitamin A, supplementation of vulnerable groups should be routine. A full treatment course should be given to those with eye signs, to children whose weight-for-height is more than 3 Z-scores below the median of the WHO/CDC reference population, and to children with severe complications of measles. Niacin should be provided through the regular distribution of non-cereal ration foods, such as groundnuts or dried fish, especially when the staple grain is maize. The minimum dietary requirement is 66 mg available niacin equivalents per 1000 kcal and current guidelines recommend at least 1900 kcal per person per day. Where the supply of niacin-rich foods is unreliable maize flour should be fortified. A further safeguard would be a fortified cereal blend such as corn-soya. Local production of cereal blends such asfafa in Ethiopia; and likuna phali in Malawi may need to be boosted by relief organisations. Mass supplementation with vitamin B complex is only indicated as a short-term measure during an outbreak of pellagra. A daily allowance of 25 mg vitamin C, as recommended by WHO/FAO, may sometimes be difficult to attain but at least 15 mg must be provided if large scurvy outbreaks are to be avoided. Mass distribution of citrus fruits may not be feasible but more durable vegetables such as potatoes and cabbages should be tried and local cultivation of green peppers, kale, and mustard greens should be promoted. Processed cereal blends apart, a suitable food vehicle for fortification with vitamin C has not yet been identified. New technologies, such as the coating of whole cereal grain with ascorbic acid resin, should be assessed under field conditions Routine supplementation is inappropriate because vitamin C tablets need to be taken at least weekly. No ideal solution exists to prevent iron-deficiency anemia; animal products are expensive and difficult to distribute. Supplements of iron and folate should be given to vulnerable groups but they are not suitable for continuous distribution to entire communities. The best strategy is probably to provide fortified cereal blends. Where iodine deficiency is likely iodised salt or oil should be routinely distributed and where rice is the staple ration milled rice should not be distributed unless other sources of thiamine
(green vegetables, fish, meat) are provided regularly. Michael J. Toole
Atlanta, Georgia REFERENCES 1. World Health
Organisation. Requirements of vitamin A, thiamine, riboflavine, and niacin. WHO Tech Rep Ser 1967; no 362: 45-51.
2. United Nations Administrative Committee for Coordination/ International Nutrition Planners Forum. Nutrition in times of disaster. UN Committee for Coordination, Subcommittee on Nutrition newsletter, 1989.
1216
Magan AM, Warsame M, Ali-Salad AK, Toole M. An outbreak of scurvy in Somali refugee camps. Disasters 1982; 7: 93-97. 4. Desenclos JC, Berry AM, Padt R, Farah B, Segala C, Nabil AM. Epidemiological patterns of scurvy among Ethiopian refugees. Bull WHO 1989; 67: 309-16. 5. Centers for Disease Control. Nutrtional status of Somali refugees— eastern Ethiopia, September 1988-May 1989. MMWR 1989; 38:
displaced populations in developing countries. JAMA 1990; 263:
3.
455-56, 461-63. A, Le Moult D. Pellagra cases in Mozambican refugees. Lancet 1990; 335: 1403-04.
6. Moren
7. Centers for Disease Control. Outbreak of pellagra among Mozambican refugees-Malawi, 1990. MMWR 1991; 40: 209-13.
8. Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988; 66: 698-97. MJ, Waldman RJ. Prevention of excess
9. Toole
mortality in refugee and
3269-302. 10.
Yip R, Gove S, Hassan BF. Assessment of hematological status of refugees in Somalia. Presented at the annual meeting of the American Public Health Association (October 20, 1987, New Orleans).
11. Irwin
MI, Hutchins BK. A conspectus of research
on
vitamin C
requirements of man. J Nutr 1976; 106: 824-25. 12. Sommer A, Hussaini G, Tarwotjo I, Susanto D. Increased mortality in children with mild vitamin A deficiency. Lancet 1983; 1: 585-88. 13. Levine M. New concepts in the biology and biochemistry of ascorbic acid. N Engl J Med 1986; 314: 892-902. 14. Roe DA. A plague of corn: the social history of pellagra. Ithaca, NY: Cornell University Press, 1973: 1-7. 15. Report of an international symposium: responding to the nutrition crisis among refugees: the need for new approaches. (Oxford, March 17-20, 1991.) Oxford: Refugee Studies Programme, 1991.
VIEWPOINT European Boards and Colleges: europaeds or
urophobia? DENIS GILL
Harmonisation, integration, and mutual recognition are quintessential terms and objectives of the European Community (EC). Harmonisation in EC-speak encompasses the ideals of agreement in opinions and actions, with common goals and outcomes. The Maastricht meeting of December, 1991, signalled further moves towards EC integration on monetary and economic policies-but what about medical matters? Differences in language, practice, cultures, and expectations have so far tended to discourage movement of doctors between EC member states. This year we witness the beginnings of substantial changes. The European Board of Urology has led the way by publishing an application form for the 1992 European Board Examination in Urology. This examination will be held in Genoa in July (cost 250 ecu) and in each EC country in November. Successful candidates will receive a certificate from the Board and may use the title Fellow of the European Board of Urology. The examination will be open to all European citizens who have qualified as a urologist in an EC country and have certification of same. The European Union of Medical Specialists last year issued draft statutes entrusting the 27 monospecialist sections with the formation of European Boards. The aims of these Boards are to establish standards required for training of specialists, to make proposals for quality and syllabus of training programmes, to introduce processes for mutual recognition of equivalent training programmes, to facilitate movement of specialists within the EC, to monitor and interchange trainees, and to set up a European Board examination, which will be reserved for specialists who have received specialist training and who are recognised as specialists in their home country. The examination and diploma/fellowship will be optional for EC nationals who wish to move between states but compulsory for candidates trained in a country that is not subject to mutual recognition of training. The Confederation of European Specialists in Paediatrics (CESP), the monospecialist section representing paediatricians in the European Union of Medical Specialists (UEMS) and the EC, has produced a draft proposal to establish a European Board of Paediatrics as well as discussion documents that lay down minimum
requirements for paediatric training in Europe.2 Paediatrics includes primary care (office or community based), secondary care (hospital based), and tertiary specialist care (usually in children’s hospitals or units). Moreover, paediatric subspecialties (eg, cardiology, neurology, nephrology) are mushrooming; there will have to be discussions with subspecialist representative bodies such as the European Society for Paediatric Nephrology to establish criteria and standards for training, examination, and accreditation. Clearly there will be
room
for much debate. The
following questions spring readily to mind and there will be many more. 1. Should internal medicine represent all the adult
specialties such as rheumatology, cardiology, and endocrinology? 2. Does each subspecialty require a European Board? 3. Should paediatric cardiology be subject to paediatrics or to cardiology? 4. How will the European Boards relate to the established Royal Colleges in the UK and Ireland? 5. Despite current statements to the contrary, will Board certification become a requirement for specialist practice? 6. How will peer review be organised? 7. Will it be possible to ensure conformity/confidentiality/ confidence in examinations taking place in 12 EC centres in different languages? 8. Will each of 27 European Union of Medical Specialists monospecialist groups establish a separate Board and/or College? 9. Where will they be based and how funded? 10. Does establishment of Boards imply inspection and recognition of posts and training from a European perspective? It will take much time, planning, discussion, and agreement to establish European Boards along the lines of the proposed document, but they must and surely will ADDRESS: Department of Paediatrics, Royal College of Surgeons in Ireland, 123, St Stephen’s Green, Dublin 2, Ireland (Prof D. Gill, FRCPI).
CONFERENCE
Micronutrient deficiencies in On Nov 14,1991,the Centers for Disease Control (CDC) in Atlanta, Georgia, USA, hosted a one-day technical review of micronutrient deficiency diseases in refugee populations.* The workshop was convened because certain diseases found in refugees and other displaced populations (eg, scurvy, pellagra, and beriberi) have been neglected in the international dialogue on micronutrient deficiency diseases. Refugees dependent on international food aid now number 17 million and there are at least 15 million others displaced by war and civil strife but still within the borders of their own countries. The meeting found that despite international nutrition guidelines, relief programmes often fail to provide the minimum recommended daily allowances (RDA) of essential micronutrients such as vitamin A, thiamine, niacin, vitamin C, iron, and folic acid.l.2 During the past decade outbreaks of micronutrient deficiency disease affecting tens of thousands have been reported in refugee camps, mainly in Africa. Prevalence rates of scurvy in some camps for Ethiopian refugees are among the highest recorded this century: PopuDisease
Year
Location
lation
Prevalence
19823 Southern Somalia 150 000 19844 Eastern Sudan 50000 19854 North-west
Scurvy
Somalia
1-5% 22%
160 000
7--44%
170000 20000 285000 900 000 300000 Sudan 250 000 Thailand 150 000
1-2% 15% 0.5% 2-0% 0-2%
19895 Hartisheik, Ethiopia 1991*KassaIa, Sudan 19896 Malawi 19907 Malawi
Pellagra
1991* Malawi
Xerophthalmia 19858 Eastern 19859 Eastern
Beriberi
..
..
Iron-deficiency anaemia
19871ONorth-west Somalia
160 000 59-90% (children) 170000 10-13% (children) Unpublished data from Office of UN High Commissioner for Refugees’ and Save the Children Fund.t
19901 Ethiopia
Scurvy. Women refugees, especially during
pregnancy, increased risk of scurvy; and the risk increases with age. The most compelling risk factor is length of stay in refugee camps, reflecting duration of exposure to rations inadequate in vitamin C. The ration provided at the Hartisheik camp in Ethiopia in 1989, for example, contained an average of 2 mg of vitamin C per person per day; and experimental studies show that scurvy develops when the daily intake is less than 10 mgY Pellagra. More than 22 000 cases have been reported among 900 000 Mozambican refugees in Malawi since January, 1989. In 1990 alone, at least 18 000 cases were are at
J. Toole, F. L. Trowbridge, P. Nieburg, R. Yip, Deming, M. Serdula, K. Scanlon (Centers for Disease Control, Atlanta, Georgia); R. J. Waldman, (World Health Organisation, Geneva); R. Bhatia (Office of UN High Commissioner for Refugees, Geneva); A. Moren, P. Malfait, (Epicentre, Paris); Sue Berger, Kevin Sullivan (Emory University School of Public Health, Atlanta). Molly Bardsley (rapporteur).
*Participants:
R. Baldwin, M.
M.
refugees
reported, and attack rates in certain camps were as high as 13%.5 More than 2000 cases were reported in 1991. Outbreaks of pellagra occurred during the first six months of the year when planned amounts of groundnuts (the main source of niacin) were not provided and the rations contained only 4-9 mg available niacin equivalents per day, compared with 7-5 mg in the planned ration and with RDAs ranging from 5-4 mg for infants to 20-3 mg for adults.2 Risk factors included young age, female sex, having an unemployed head of the household, residence in a closed camp rather than an integrated village, absence of groundnuts or fish in the diet, and lack of a home vegetable garden or domestic poultry. Biological requirements for niacin (and for thiamine and retinol) increase with increasing caloric intakes so the provision of adequate calories in the absence of sufficient micronutrients may lead clinical micronutrient deficiencies. Anaemia. Anaemia (Hb < 10 g/dl in children 0-5 years of age and pregnant women, < 11 g/dl in non-pregnant women, and < 12.5 g/dl in men) was especially common in young children and women of childbearing age, suggesting that the main risk factor is nutritional iron deficiency. Parasitic diseases such as malaria, schistosomiasis, and hookworm may exacerbate the problem, and iron deficiency may be compounded by vitamin C deficiency. Xerophthalmia. Relief agencies report that awareness of the importance of vitamin A supplementation has generally been raised and that guidelines for vitamin A supplementation in young children are now routinely followed. Nevertheless, one report described the absence of vitamin A in emergency medical kits supplied to Kurdish refugees on the Turkey-Iraq border in 1991. Sufficient data do not exist to evaluate the contribution of micronutrient deficiency diseases to the excess mortality in refugees during the emergency phase of relief programmes.9 The most common causes of death are protein-energy malnutrition and communicable diseases such as measles and diarrhoea. Most surveillance systems lacked the sensitivity and specificity required to attribute deaths to diseases such as xerophthalmia, scurvy, and pellagra, and the scarcity of diagnostic facilities and a low index of suspicion mean that such deaths are likely to be missed. We do know, from other settings, that there is a high case-fatality ratio in untreated patients with these conditions but micronutrient deficiencies may be underlying factors rather than direct causes of death.12-14 Workshop participants agreed that we have the knowledge to design and implement effective, affordable, and sustainable interventions to eliminate at least vitamin A and niacin deficiencies among refugees-and certain shortterm measures can be taken immediately to prevent most micronutrient deficiency diseases. A key issue is the lack of input by technicians into relief programme planning, implementation, and evaluation; and relief workers with access to information on micronutrient deficiencies have not
to
1215
been good at communicating the urgency of these problems and the availability of solutions to relief agencies. International relief organisations ought to focus on process (delivering food) rather than outcome (preventing mortality and morbidity among refugees). Health information systems in camps either do not exist or do not systematically monitor ration quantity and composition at the household level; one such system has been brought in at low cost by a non-government organisation in Malawi. Discussions on permanent solutions focused on dietary diversification, fortification, and supplementation: Dietary diversification might be achieved through increased food items, providing RDAs of micronutrients through routine ration distributions. A regular supply of fresh, vitamin-C-containing foods to large remote camps such as those in the Horn of Africa is difficult, and imported, fortified cereal blends could be substituted. Relief agencies do not do enough to promote vegetable cultivation in camps and donor agencies and local governments sometimes discourage refugees from exchanging portions of their ration for other foods in local markets. Fortification of maize flour with niacin is technically feasible but if whole cereal grain is distributed fortification locally requires close supervision of milling. Anyway dependence on fortified maize flour for all niacin needs would be undesirable since this might lead to a ration where most nutrients are provided in only one or two food items, and rations should probably comprise at least four items because interruptions to the supply of single items are inevitable. While fortification of cereal blends (with iron, B vitamins, and ascorbic acid) offers great potential, the cultural acceptability of these blends should be carefully assessed for each refugee community. The workshop identified a lack of standardisation in the fortification of donor-provided cereal and periodic shortages of items such as com-soya milk make it difficult to provide these commodities regularly. Fortification of milk powder with vitamin A is almost routine in Europe and the United States; however, the inclusion of milk products in general rations for refugees is no longer recommended because of the risk of provoking diarrhoea in children. Nonetheless recommendations that all milk products donated for supplementary feeding programmes in refugees should be fortified with vitamins A and D are not always heeded and fortification of ration foods with vitamin C is still problematic because of the instability of ascorbic acid. Supplementation with regular vitamin or iron tablets is logistically difficult in large refugee populations except fat-soluble vitamin A where supplements every 4 or 6 months will do. The frequency with which iron, folate, and water-soluble vitamins need to be given makes supplementation impracticable, except in the midst of a major outbreak of a particular deficiency disease. The workshop recommended the strengthening of surveillance for micronutrient deficiency diseases and the development of standard clinical case defmitions to be used on report forms used in refugee health information systems. Nevertheless, surveillance for some conditions may be problematic (eg, vitamin A deficiency and anaemia). Participants recommended routine surveillance for scurvy and pellagra, and periodic cross-sectional surveys of anaemia and xerophthalmia. There should be more focus on morbidity surveillance and on routine monitoring of ration quantity and composition (outcomes). WHO/FAO-defined RDAs for all essential nutrients should be provided in general food rations distributed routinely by major food
donors. Ideally, the source of micronutrients should be fresh food items; however, fortification or, rarely, be sometimes may supplementation required. Diversification should be promoted by supporting vegetable cultivation, small animal raising, and fish farming in camps as a routine component of all refugee assistance programmes. Constraints to bartering in local markets should be removed, as recommended at the international symposium on the refugee nutrition crisis held in Oxford in March, 1991. The prevention of vitamin A deficiency in young children is critical where refugees come from a region where vitamin A deficiency is highly prevalent; there is evidence of clinical vitamin A deficiency in the population; and the general ration provides less than 2500 IU per person per day. Since most general rations provided to refugees lack adequate vitamin A, supplementation of vulnerable groups should be routine. A full treatment course should be given to those with eye signs, to children whose weight-for-height is more than 3 Z-scores below the median of the WHO/CDC reference population, and to children with severe complications of measles. Niacin should be provided through the regular distribution of non-cereal ration foods, such as groundnuts or dried fish, especially when the staple grain is maize. The minimum dietary requirement is 66 mg available niacin equivalents per 1000 kcal and current guidelines recommend at least 1900 kcal per person per day. Where the supply of niacin-rich foods is unreliable maize flour should be fortified. A further safeguard would be a fortified cereal blend such as corn-soya. Local production of cereal blends such asfafa in Ethiopia; and likuna phali in Malawi may need to be boosted by relief organisations. Mass supplementation with vitamin B complex is only indicated as a short-term measure during an outbreak of pellagra. A daily allowance of 25 mg vitamin C, as recommended by WHO/FAO, may sometimes be difficult to attain but at least 15 mg must be provided if large scurvy outbreaks are to be avoided. Mass distribution of citrus fruits may not be feasible but more durable vegetables such as potatoes and cabbages should be tried and local cultivation of green peppers, kale, and mustard greens should be promoted. Processed cereal blends apart, a suitable food vehicle for fortification with vitamin C has not yet been identified. New technologies, such as the coating of whole cereal grain with ascorbic acid resin, should be assessed under field conditions Routine supplementation is inappropriate because vitamin C tablets need to be taken at least weekly. No ideal solution exists to prevent iron-deficiency anemia; animal products are expensive and difficult to distribute. Supplements of iron and folate should be given to vulnerable groups but they are not suitable for continuous distribution to entire communities. The best strategy is probably to provide fortified cereal blends. Where iodine deficiency is likely iodised salt or oil should be routinely distributed and where rice is the staple ration milled rice should not be distributed unless other sources of thiamine
(green vegetables, fish, meat) are provided regularly. Michael J. Toole
Atlanta, Georgia REFERENCES 1. World Health
Organisation. Requirements of vitamin A, thiamine, riboflavine, and niacin. WHO Tech Rep Ser 1967; no 362: 45-51.
2. United Nations Administrative Committee for Coordination/ International Nutrition Planners Forum. Nutrition in times of disaster. UN Committee for Coordination, Subcommittee on Nutrition newsletter, 1989.
1216
Magan AM, Warsame M, Ali-Salad AK, Toole M. An outbreak of scurvy in Somali refugee camps. Disasters 1982; 7: 93-97. 4. Desenclos JC, Berry AM, Padt R, Farah B, Segala C, Nabil AM. Epidemiological patterns of scurvy among Ethiopian refugees. Bull WHO 1989; 67: 309-16. 5. Centers for Disease Control. Nutrtional status of Somali refugees— eastern Ethiopia, September 1988-May 1989. MMWR 1989; 38:
displaced populations in developing countries. JAMA 1990; 263:
3.
455-56, 461-63. A, Le Moult D. Pellagra cases in Mozambican refugees. Lancet 1990; 335: 1403-04.
6. Moren
7. Centers for Disease Control. Outbreak of pellagra among Mozambican refugees-Malawi, 1990. MMWR 1991; 40: 209-13.
8. Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988; 66: 698-97. MJ, Waldman RJ. Prevention of excess
9. Toole
mortality in refugee and
3269-302. 10.
Yip R, Gove S, Hassan BF. Assessment of hematological status of refugees in Somalia. Presented at the annual meeting of the American Public Health Association (October 20, 1987, New Orleans).
11. Irwin
MI, Hutchins BK. A conspectus of research
on
vitamin C
requirements of man. J Nutr 1976; 106: 824-25. 12. Sommer A, Hussaini G, Tarwotjo I, Susanto D. Increased mortality in children with mild vitamin A deficiency. Lancet 1983; 1: 585-88. 13. Levine M. New concepts in the biology and biochemistry of ascorbic acid. N Engl J Med 1986; 314: 892-902. 14. Roe DA. A plague of corn: the social history of pellagra. Ithaca, NY: Cornell University Press, 1973: 1-7. 15. Report of an international symposium: responding to the nutrition crisis among refugees: the need for new approaches. (Oxford, March 17-20, 1991.) Oxford: Refugee Studies Programme, 1991.
VIEWPOINT European Boards and Colleges: europaeds or
urophobia? DENIS GILL
Harmonisation, integration, and mutual recognition are quintessential terms and objectives of the European Community (EC). Harmonisation in EC-speak encompasses the ideals of agreement in opinions and actions, with common goals and outcomes. The Maastricht meeting of December, 1991, signalled further moves towards EC integration on monetary and economic policies-but what about medical matters? Differences in language, practice, cultures, and expectations have so far tended to discourage movement of doctors between EC member states. This year we witness the beginnings of substantial changes. The European Board of Urology has led the way by publishing an application form for the 1992 European Board Examination in Urology. This examination will be held in Genoa in July (cost 250 ecu) and in each EC country in November. Successful candidates will receive a certificate from the Board and may use the title Fellow of the European Board of Urology. The examination will be open to all European citizens who have qualified as a urologist in an EC country and have certification of same. The European Union of Medical Specialists last year issued draft statutes entrusting the 27 monospecialist sections with the formation of European Boards. The aims of these Boards are to establish standards required for training of specialists, to make proposals for quality and syllabus of training programmes, to introduce processes for mutual recognition of equivalent training programmes, to facilitate movement of specialists within the EC, to monitor and interchange trainees, and to set up a European Board examination, which will be reserved for specialists who have received specialist training and who are recognised as specialists in their home country. The examination and diploma/fellowship will be optional for EC nationals who wish to move between states but compulsory for candidates trained in a country that is not subject to mutual recognition of training. The Confederation of European Specialists in Paediatrics (CESP), the monospecialist section representing paediatricians in the European Union of Medical Specialists (UEMS) and the EC, has produced a draft proposal to establish a European Board of Paediatrics as well as discussion documents that lay down minimum
requirements for paediatric training in Europe.2 Paediatrics includes primary care (office or community based), secondary care (hospital based), and tertiary specialist care (usually in children’s hospitals or units). Moreover, paediatric subspecialties (eg, cardiology, neurology, nephrology) are mushrooming; there will have to be discussions with subspecialist representative bodies such as the European Society for Paediatric Nephrology to establish criteria and standards for training, examination, and accreditation. Clearly there will be
room
for much debate. The
following questions spring readily to mind and there will be many more. 1. Should internal medicine represent all the adult
specialties such as rheumatology, cardiology, and endocrinology? 2. Does each subspecialty require a European Board? 3. Should paediatric cardiology be subject to paediatrics or to cardiology? 4. How will the European Boards relate to the established Royal Colleges in the UK and Ireland? 5. Despite current statements to the contrary, will Board certification become a requirement for specialist practice? 6. How will peer review be organised? 7. Will it be possible to ensure conformity/confidentiality/ confidence in examinations taking place in 12 EC centres in different languages? 8. Will each of 27 European Union of Medical Specialists monospecialist groups establish a separate Board and/or College? 9. Where will they be based and how funded? 10. Does establishment of Boards imply inspection and recognition of posts and training from a European perspective? It will take much time, planning, discussion, and agreement to establish European Boards along the lines of the proposed document, but they must and surely will ADDRESS: Department of Paediatrics, Royal College of Surgeons in Ireland, 123, St Stephen’s Green, Dublin 2, Ireland (Prof D. Gill, FRCPI).
