John E. Gordon

Nutrition and Infection Field Study in Guatemalan Villages, 1959–1964

Initially, all three study villages had poor environmental sanitation, little medical care, high mortality, and frequent malnutrition. In one village supplemental feeding of the preschool population without other intervention gave an appreciable but limited improvement in disease incidence and physical growth. A program of preventive medicine and medical care in a second village had no effect on frequency of illness and led to no improvement in physical growth; deaths were fewer. Comparison was to a control village with no added services. Collateral studies increased the usefulness of the basic study and enlarged the results. The broader contribution of the study was better definition of the general health of young children. Most usefully, the size of the problem became measurable by case incidence instead of by the usual dependence on number of deaths. Quantitative information on morbidity revealed a burden of illness on preschool children beyond most estimates; it was greatest in the second year. A publ...

Preventive medicine and epidemiology.

Weanling diarrhea i.e. diarrhea that comes on when infants are transferred from a wholly breast-fed to a mixed breast bottle and supplementary food diet is no longer a major health problem in the advanced nations. It remains a major cause of infant morbidity and mortality in developing countries. Incidence statistics for the U.S. and for various regions of the world are cited. The infectious agents contributing to the etiology of the disease are described. In addition to infectious agents foods and medicines can trigger the disease. Evidence from field studies in the Punjab region of India is cited to show that the diarrheas and dysenteries common in early childhood are associated with weaning. They occur at the time of weaning because: 1) the introduction of foods other than breast milk increases the possibility of exposure to potential pathogens; 2) weaning is associated with a period of nutritional deficiency which can make the child more susceptible to infection; and 3) the diarrheas resultant from contaminated food in themselves lower the childs resistance to infections. Therefore it is seen that weanling diarrhea must be considered in both nutritional and infectional terms.

Applications of field studies to research on the physiology of human reproduction; lactation and its effects upon birth intervals in eleven Punjab villages, India.

A field study on lactation and its effects upon birth intervals was undertaken in 11 Punjab villages India. From a variety of sources genalogies parish records and special field studies it has been found that in societies practicing little or no birth control average birth intervals range from barely more than 2 years to nearly 3 years. Within populations older mothers tend to have longer birth intervals than younger mothers. The relevance of lactation to birth spacing has long been suspected. Several studies the first in 1942 have shown that when the infant survives the average birth interval is as much as a year longer than when the child is born dead or dies neonatally. This Khanna study provides a broad scope of prospective as well as retrospective data for approximately 1500 couples of childbearing potential over a 3-5 year period. It is evident that in the Punjab villages of the Khanna study lactation substantially prolonged postpartum amenorrhea. When an infant survived 1 month or more lactation usually lasted well over a year and the median length of postpartum amenorrhea was 11 months; whereas if the child was stillborn or died in the first month of life the mother did not lactate and the median length of postpartum amenorrhea was in the vicinity of 2 months.

A case study of birth interval dynamics

Abstract A birth interval free from pregnancy wastage may be viewed as the sum of three sub-intervals: (1) the period ofpost-partum amenorrhoea following a birth; (2) the menstruating interval extending from end of post-partum amenorrhoea to next conception; and (3) the months of pregnancy losses, then in addition to the above three components there is a fourth component, which may be termed ‘time added by pregnancy wastage’. A basic understanding of birth intervals requires the ability to relate the central tendencies and variability of birth intervals to the means and variances of these four components. The present analysis draws upon uniquely detailed materials from the India-HarvardLudhiana Population Study that took place in eleven villages of the Punjab, India, during the years 1953–59. Means and variances of post-partum amenorrhoea, menstruating intervals, and time added by pregnancy wastage are estimated for two broad age classes and the results related to corresponding statistics for total birth ...

Nutrition and infection field study in Guatemalan villages, 1959-1964. VII. Physical growth and development of preschool children.

This paper evaluated and compared the growth and maturation of preschool children in 3 study villages in Guatemala. Specifically this study sought to determine the extent to which the observed growth responses could be attributed to the nutrition program in the feeding village or to the program of environmental sanitation and health services in the treatment village. Sequential measurements of height weight skinfold over triceps and head circumference were made for all preschool children but those of height and weight were the ones concentrated on for the 5 years of the study. Head circumference although equal at the start of the study increased for the boys faster than for the girls in the 3 villages. Preschool children of both sexes in the feeding village had greater head circumferences than their counterparts in the treatment or control villages. However in all 3 cases these measurements were significantly smaller than for comparable groups in the US. Increase in skinfold measurements with age was similar for boys and girls in all 3 villages. For gain in height with age the general patterns in the 3 villages were similar although children in the feeding village tended to grow faster in height than those in the other 2 villages. Rates of gain in weight with age followed a similar pattern. Average age-specific gains in height and weight were less among children in the treatment and control villages than in the feeding village. The maximum growth potential was generally greater for boys than girls although differences were not significant. Estimates for maximum growth potential for both sexes do not differ among the villages. For weight gain in children under age 1 there were no significant differences between the sexes among the 3 villages in maximum growth potential or growth acceleration. Boys and girls (ages 1-4) in the feeding village have significantly higher rates of gain in height and weight. No significant relationship was found between days of illness and height or weight gain. Clearly children in the feeding village displayed superior nutritional status as seen from growth curves and data on bone maturation and head circumference. However they were still significantly retarded when compared to well-nourished children. Actually the nutritional status of children even in the feeding village was far from optimal due to the irregular consumption of the food supplement. Their better growth performance may have been due to the nutrition education program rather than the supplementary feeding. The 1st hypothesis that the nutrition in the feeding village would improve nutritional status was supported by moderate gains in height weight bone age skinfold thickness and head circumference. The 2nd hypothesis was not supported; that the introduction of environmental sanitation disease prevention and medical care would reduce frequency and severity of disease to allow for an improvement in nutritional status.

Nutrition and infection field study in Guatemalan villages, 1959-1964. IX. An evaluation of medical, social and public health benefits, with suggestions for future field study.

Initially all 3 study villages had poor environmental sanitation little medical care high mortality and frequent malnutrition. In 1 village supplemental feeding of the preschool population without other intervention gave an appreciable but limited improvement in disease incidence and physical growth. A program of preventive medicine and medical care in a 2nd village had no effect on fequency of illness and led to no improvement in physical growth; deaths were fewer in number. Comparison was made to a control village with no added services. Collateral studies increased the usefulness of the basic study and enlarged the results. The broader contribution of the study was a better definition of the general health of young children. Most useful was that the size of the problem became measurable by case incidence instead of by the usual dependence on number of deaths. Quantitative information on morbidity revealed a burden of illness on preschool children beyond most estimates; it was greatest in the 2nd year. A public health approach based on concerned action against major factors social as well as biological can be expected to give better results than measures against any 1 singly or in succession even those as important as malnutrition or infectious diseases. (authors modified)

Nutrition and infection field study in Guatemalan villages, 1959-1964. I. Study plan and experimental design.

A prospective 5-year epidemiological field study (1959-1964) of nutrition and infection in children less than 5 years old in Guatemalan villages is described. Attention is directed to the following: the background (death rates disease incidence synergism of infection and nutrition age of attack and exploratory studies of nutrition and infection); and study plan (a longitudinal investigation experimental design and study objectives). Recorded deaths from nutritional disease are few and often are absent from offical lists. This is the case despite a prevailing malnutrition at childhood ages of such an extent that as many as 85% of village children aged 1-4 years have a deficiency in weight for their age more than 10% below the mean for middle-class families. A field study of deaths among children of 4 rural Guatemalan communities showed that 2/5 of those dying at ages 1-4 years had the signs and symptoms of kwashiorkor yet only 1 death at any age up to 15 years was listed officially as due to malnutrition. As the general result is that causes of death remain highly indefinite the preferred method is the direct survey of cases and deaths using the principles and techniques of field epidemiology. A synergism frequently exists whereby infectious disease has the capacity to precipitate an acute nutritional disease in persons of borderline nutritional status; conversely persons with manifest nutritional deficiency commonly experience a severity and frequency of infection beyond ordinary expectation. In nearly all less developed countries the incidence of both infectious disease and malnutrition is greatest among children under 5 years of age. The experimental design finally adopted combines the advantages of longterm epidemiological observation of a natural population (the control) and those of a direct controlled experiment to test specific hypotheses. The formally stated objectives of this longterm prospective epidemiological study of malnutrition and infectious disease in rural Guatemalan communities were as follows: to observe and describe the interactions of malnutrition and infectious disease among infants and young children through the 5th year of life in a rural population of a developing country where both classes of disease were highly prevalent; to measure the changes in nutritional status resulting from addition of supplementary food to the diet of breastfed children; to measure the results of integrated medical services; and to identify and evaluate the relative influence of other broad ecological factors involved in the frequency and severity of infectious and nutritional diseases of early childhood in rural populations of a developing country.

NUTRITION AND THE DIARRHEAS OF EARLY CHILDHOOD IN THE TROPICS.

Acute diarrheal disease is a syndrome which includes several specific intestinal diseases. The clinical manifestations in any particular group of patients seldom relate to a single infectious agent.1 Although most cases are probably of infectious origin, a definable agent is usually lacking. Clinically, the diarrheal diseases of specific nature cannot be distinguished from each other, nor from the larger group which has no recognized microbial agent.2 Because of these limitations, a program for community control of the disease is based practically on epidemiological distinctions within the general syndrome.3 This practice is especially useful in developing countries where control facilities are limited and much diarrheal

Acute intestinal infection in Alaska.

THE ARCTIC is no longer the isolated, almost legendary part of the world that it once was. The military consequences of an atomic age, the press for natural resources, and the demands of international air travel bring increasing numbers of people to arctic and subarctic regions, with a consequent need for information on medical problems incident to life in cold climates (1). Epidemiological investigation in the arctic has a peculiar fascination; so little has been done that almost every observation is a contribution to knowledge. This satisfaction is tempered, however, by the realities of fieldwork in a physical environment demanding beyond most others. Hotels are not to be found in the far north; even a modest lodging house is rare; and the hospitality of what may be no more than a chance acquaintance becomes priceless. Travel is arduous. Long trips by commercial airline and local travel by boat, bush plane, and dog sled to collect information on a few hundred people are not unusual. A diet that includes whale meat and seal liver, although admittedly these are delicacies, still takes some accommodating. The intestinal infections are an attractive starting place in arctic epidemiology because the mass behavior of these diseases has been well worked out through long study in temperate and tropical regions. Also, the required bacteriological procedures are relatively simple, a consideration of moment in the arctic where field conditions are as difficult as they are. Alaska was chosen as the first study area. As a cultural and administrative part of the United States, conditions were good for communication and cooperation. The primary purpose was to determine under arctic conditions the mode of transmission of acute infectious diarrhea of man, and to learn something of prevalence and seasonal incidence. Also, intestinal parasites of dog and man were surveyed in two villages, and the ecology of fish tapeworm was examined in one area. Recurring outbreaks of enteric disease have been recorded among Eskimo populations of Alaska for at least a century and a half, along with dramatic epidemics of smallpox, measles, and influenza. In 1807, Unalaska was devastated by an epidemic, presumably of bacillary dysentery, and the Klondike gold rush of the late 19th century brought outbreaks of dysentery and typhoid fever (2). Salmonella typhosa and other salmonellae were isolated repeatedly after the first public health laboratory was established in 1936. Seventeen cases of typhoid fever occurred in Anchorage and its Dr. Gordon is professor of preventive medicine and epidemiology, and Dr. Babbott, formerly associate in epidemiology, Harvard School of Public Health, Boston, Mass., is now assistant professor of preventive medicine and epidemiology, University of Pennsylvania Medical School, Philadelphia. This .study was sponsored by the Commission on Environmental Hygiene, Armed Forces Epidemiological Board, and supported in part by the Office of the Surgeon General, Department of the Army, Washington, D. C.

Childbirth in rural Punjab India.

The high infant mortality of 159/1000 live births in typical rural villages of the Punjab India was due more to environmental causes than to factors related to obstetrical care. Compared with industrialized countries of the West the neonatal death rate was 4 times the expected level whereas the postneonatal rate of the remaining 11 months of the 1st year was 18 times greater. Neonatal death rates averaged 76/1000 live births over a 2-year period and perinatal rates averaged 89/1000 deliveries. 3/4 births were attended by untrained midwives 6% by midwives with a brief elementary course of instruction and 15% by persons with midwifery and brief nursing training. The remaining 3% included delivereis by physicians by friends or relations or unattended. Practitioners of indigenous medicine did not practice obstetrics. The trained village midwife had the best record of accomplishment as judged by perinatal death rates 56/1000 deliveries. Neonatal death rates were almost twice as great for untrained as for trained attendants. Differences in professional qualifications had little influence on choice of attendant at childbirth. With rare exceptions demanded by complications all deliveries were in the home and the attendant in 97% was a midwife of the village where birth occurred. Risk of death for infants as judged by either perinatal or neonatal death rates was greatest among the 1st born and those of late pregnancies. Maternal death rate as estimated for a small sample was excessively high. Tetanus neonatorum was a common cause of death among infants delivered by both trained and untrained midwives. The greatest difference in deaths according to delivery by trained or untrained attendants was in postnatal asphyxia which was 3 times as frequent among infants delivered by untrained midwives. All deaths from cerebral birth injuries were among children delivered by untrained midwives.