Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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304 Surgery and Healing in the Developing World
energy content, but more craving develops for animal fat because of its flavoring and
as an intermittent unreliable supply of a special treat.
Most high energy foods are seasonal and do not store well for the five months of
dry season so the bulk of the population continues to subsist on cassava. Despite its
low energy input, it has a low energy capacity to which an adult in this environment
is marginally adapted, given the hypothyroidism. Children, even with hypothyroidism,
are macronutrient deprived as well as micronutrient deficient in iodine and
have few energy reserves for enduring any intercurrent illness from the infectious
agents that abound in this environment.
A high percentage of the world’s food stock, in the field or in storage, is consumed
by rats. In this region baboons and buffalo, as well as rats, deplete the supply
of rice and peanuts but leave the cassava root in the field and in storage.
As dietary substitution is not always effective, perhaps advice on preparation of
the dietary food staple would be appropriate. Rather than soaking the cassava roots
in stagnant pits, encouraging preparation by soaking it in running streams would
seem to dilute and diminish the cyanide content in the course of the cassava preparation.
This advice is counterintuitive to the majority of the population who would
be principally concerned with losing some part of their food store in running water.
This counsel was called “zungu za wazungu,” in Swahili for the “white man’s madness,”
as were a number of other of nonacculturated suggestions. Even if this advice
were accepted by an educable population who could understand the reason for its
recommendation, it could not be generally followed. The tropics are marked by two
distinct seasons—the rainy season and the dry season—and advice on soaking in
running water would be impossible half the year.
If macronutrient supply is marginal and alternate preparation methods are impractical,
what other methods might be employed to relieve the iodine micronutrient
deficiency? In the developed world, the public health problem of iodine deficiency
has been addressed by the simple, but largely effective, global response of replacing
the deficient micronutrient in a ubiquitous, cheap, required nutrient. With the same
rationale as adding fluoride to water or vitamin D precursors to milk for consumption
by the population at risk, iodized salt was instituted over a century ago. This
simple additive solution largely brought the problem of cretinism and goiter under
control in the Western world, usually beginning with the high-frequency areas affected,
such as the Great Lakes region of the United States or volcanic mountain
regions of Europe.
Iodine supplementation through iodized salt might be delivered by commercial
food production methods and transportation systems in the market mechanisms of
a cash economy. But the same geographic features of mountainous and/or rain forest
terrain which isolate remote areas of the globe also expose food stocks to decomposition
in periodic wet and dry cycles. These would reduce iodine content even if
distribution systems were available. Salt itself becomes a precious commodity under
these circumstances, and if available, would be unlikely to be given to vulnerable
segments of the population, particularly children who may not have yet acquired or
developed a taste for this scarce and climate-sensitive condiment. Here men eat
first—children last—so foods cooked with salt would likely be consumed long before
the children were served. In a barter society, commodities introduced from the
outside become precious and are often hoarded for exchange by the relatively wealthy.
Salt and soap are the exchange commodities in Sasaland, which increased the value
and decreased the consumption of salt, skewing its distribution to the wrong end of