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Special Articles

THE WORLD’S FOOD

SUBSISTENCE AND MAINTENANCE LEVELS

FROM OUR SPECIAL CORRESPONDENT

A PREPARATORY committee of the Food and AgricultureOrganisation of the United Nations reported to the

director-general (Sir John Orr, F.R.s.) on the nutritionalaspect of the problems which came before the specialmeetings of the F.A.O. from May 20 to 27. The chairmanwas Dr. A. Hughes Bryan (UNRRA, Washington), and themembers were Dr. John M. Cassels (U.S. Departmentof Commerce), Dr. L. A. Maynard (combined workingparty on European food-supplies 1944-45), Dr. A. P.Meiklejohn (UNRRA, London), Dr. E. P. Phipard (U.S.Department of Agriculture), Dr. W. H. Sebrell (NationalInstitute of Health, Bethesda, Maryland), Dr. J. B.Youmans (consultant on Nutrition to Surgeon-General,U.S. Army), Dr. W. R. Aykroyd (F.A.O.), and Mr. D.Lubbock (F.A.O.). -

The committee’s report recognises :1. An emergency subsistence food-consumption level,

needed to prevent the most serious undernutritionleading to disease and the danger of civil unrest. For

European countries this level is defined as an average dailyintake per head of 1900 calories, requiring a nationalaverage supply of not less than 2200 calories at theretail level.

2. A temporary maintenance level sufficiently high tomaintain populations in fairly good health, but not forrapid and complete recovery. For European countriesthis level is defined as an average daily intake per headof 2200 calories requiring a national average supply ofnot less than 2500 calories at the retail level.

The committee regretted the need for considering theselevels of consumption but felt that recommendations

regarding them would be of practical value in the

emergency.EMERGENCY SUBSISTENCE

Table I gives the individual calorie intake in thedifferent age- and sex-groups and various categories ofworkers at this level of consumption. It refers to

European workers and indicates the point below whichthe consumption of no section of the population shouldfall if serious consequences are to be avoided. The

figures are approximately 75% of those given in the"recommended allowances" of the National ResearchCouncil, U.S.A., and the table is supported by actual i

experience of the point at which severe undernutrition 1

becomes apparent among European populations. TABLE I-EMERGENCY SUBSISTENCE CALORIE INTAKE

These figures refer to the actual intake of calories, andassuming a population which as regards age, sex, andactivities is approximately the same -as that of the UnitedStates the average intake is about 1900. It is importantthat the relation of a per-caput calorie intake figureof this nature to the actual food position in any given

’ country should be clearly understood. Estimates of thetotal food-supplies available in a country are normallymade at the retail level ; that is to say, an allowance ismade for the loss of food between source and the retail ormarket level. Allowances for loss up to this stage shouldequally be made in the case of food allocations to deficitcountries.A number of other factors must also be taken into

consideration to ensure that no section of a population

has a calorie intake below the emergency subsistencelevel. These are household waste (where food is shortabout 3% is wasted), and the extent to which distribu-tion is equitable-which covers the proportion of farmto non-farm population, the access of urban populationsto food-producing areas, the ’extent of black markets, therelation of the economic position of the poorer section ofthe population to food prices, and the age-distribution ofthe population and the categories of workers included inurban groups. Allowing for all these factors it is neces-sary, in order to ensure that all sections of a givenpopulation obtain the emergency subsistence minimumof 1900, that the per-caput calorie figure obtained bydividing the total food-supplies by the number of thepopulation should be at least 300 calories in excess of theminimum. The committee point out that if the calorieintake of any section of the population falls below theemergency subsistence level for any length of time, thenpreparations must be made, in advance, for faminerelief measures, such as the provision of soup-kitchens,medical supplies, and hospital accommodation to dealwith the disease which follows semistarvation. It is toolate-to organise effective relief once famine has made itsappearance.

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TEMPORARY MAINTENANCE

The minimum calorie intake per head per day is 2200,and the amount supplied should therefore be 2500calories at the retail level. Table 11 shows how thefigure of 2200 calories is arrived at.At this level of diet special attention is given to the

protein intake. The per-caput figure amounts to60 grammes of protein daily, of which 10% should be inthe form of animal protein. The committee state thatan increase of protein intake will hasten the speed ofrecovery and that a

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reasonably adequate " consumptionof animal protein is of value for psychological reasons.

TABLE II-TEMPORARY MAINTENANCE CALORIE INTAKE

NON-EUROPEAN COUNTRIES

The committee point out that in general non-Europeanpopulations are of smaller average size than Europeanpopulations, and that in warm climates their basalmetabolism and energy output may be lower. Theirhabitual calorie intake is smaller than that of Europeans,and the emergency subsistence and temporary main-tenance figures may generally be 15-20% below those intables I and II. Protein, in the committee’s view, shouldbe reduced by 10% only, but the recommendationabout animal protein would " be unrealistic," as suchpopulations normally consume little or none. Con-siderations regarding the relation between actual intakeof food and the amount supplied at the retail level willin general apply equally.

OTHER QUESTIONSDistribution.-The committee draw special attention

to the need for better distribution of food withincountries, and point out that this involves effective andequitable crop collection, price control, the discourage-ment of black markets, and the application of rationscales based on the physiological needs of the differentage, sex, and occupation categories within the population.

Governments responsible for seeing that food reachesthose most in need of it must give an accurate picture oftheir food situation, and their method and efficiency ofdistribution are important.

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MM:.—The committee emphasise the value of processedmilk in improving the nutrition of severely malnourishedpeople. The following minimum quantities of milk arerecommended for two priority classes :

Milk allowances proposedCategory Litres

0- 2 years 0-75 (whole milk)3- 5 ....... 0-50 (whole milk)6- 9 " ....... 0.25 (whole or skimmed)

10-17 ....... 0-50 (whole or skimmed)Pregnant and nursing mothers . 0 -50 (whole milk)

The milk used may be either liquid milk or (if this is notto be had) evaporated or dried milk. And the com-mittee specially recommend that in countries with awell-developed dairy industry an intensive effort shouldbe made to produce dried skimmed milk in maximumquantities for distribution to countries in need. Theybelieve that food imports into any country may berestricted in 1946 and 1947 and recommend that non-farm populations should be encouraged to cultivatevegetables for their own use and that plots of land andseed should be provided. They add that the consump-tion of vitamins A and C has been meagre in manyurban areas of Europe during the winter and spring of1946.

Vitamins.-Special categories of the population-pregnant and nursing mothers, infants and youngchildren-may benefit by receiving vitamins on medicaldirection. But the committee disapprove of indiscrimin-ate distribution of vitamins as being likely to produce afalse sense of security when the real need is for caloriesprovided by food.

POLIOMYELITIS IN BOARDING-SCHOOLS

RECOMMENDATIONS ON PROCEDURE

IN 1933 the Medical Officers of Schools Associationproduced a memorandum on the action appropriatewhen acute anterior poliomyelitis appears in a residentialschool. Recently the Headmasters’ Conference asked theassociation for a further statement on the subject,and to ensure that this embodied representative opinionthe council invited a number of medical bodies andGovernment departments to participate in preparing it.At its three meetings unanimous decisions were

reached by a committee consisting of Dr. F. M. R.Walshe, F.B.s. (Royal College of Physicians). Prof. H. J.Seddon (Royal College of Surgeons), Dr. A. M. McFarlane(Pathological Society of Great Britain), Dr. J. St. C.Elkington (Association of British Neurologists), Dr.Cyril Banks (Society of Medical Officers of Health),Dr. E. T. Conybeare (Ministry of Health), Dr. A. H.Gale (Ministry of Education), and four representativesof the Medical Officers of Schools Association-namely,the president, Dr. W. H. Bradley (medical officer of theMinistry of Health and sometime medical officer toDownside School), the hon. secretary, Dr. R. E. Smith(medical officer to Rugby School), Dr. G. 0. Barber(medical officer to Felsted School), and Dr. M. Mitman,medical superintendent of Joyce Green Hospital, L.C.C.

This committee has (1) prepared a note to headmasters,(2) drafted a letter which headmasters may find valuableif they are called upon to communicate with parentsin an emergency, and (3) revised the section on polio-myelitis for the new edition of the association’s Code ofRules for the Prevention of Communicable Diseases in

Schools, which it is hoped to publish in 1947.

NOTE TO HEADMASTERS

Poliomyelitis is known to be an infectious illness. Itis infrequently fatal but may lead to paralysis with apermanent disability of movement though not of anyother bodily function. In dealing with it the welfare ofboth the patient and the community has to be considered.

Experience shows that in residential schools only anextremely small percentage of the boys is attacked andthat case-to-case infection is not common. In a carefully

supervised school the risk of spread after the recognitionof the initial case or cases is not large but cannot bewholly excluded. This being so, some parents may wishto remove their child. No objection should be raised tothis, but parents who remove their boys should beadvised that in doing so they assume a responsibility forisolating them, both in transit to their homes and whileat home, from all young children and adolescents for aperiod of at least three weeks. A boy who has beenexposed to the disease may, although himself well, harbourthe infection. There are no readily available means ofdetecting such a " carrier " who may possibly spread theinfection by sneezing or coughing or via the bowels.Simple hygienic precautions based on this knowledge willdo much to prevent spread.The known epidemiological facts do not allow of a

dogmatic ruling about school dispersal when a singlecase is recognised. The disease is notifiable to themedical officer of health for the district in which it occurs.The school doctor will communicate with the publichealth officers who may have information concerningthe occurrence of other cases in the locality and whoshould be consulted before any decision is taken by theheadmaster. The occurrence of subsequent cases willundoubtedly increase parental anxiety and on thisaccount alone the wisest course may then be to dispersethe school for at least three weeks. In any event theschool should be quarantined, all school meetings andoutside fixtures being cancelled for the time being.SUGGESTED BASIS OF LETTER FROM HEADMASTER TO

PARENTS

A case of poliomyelitis, commonly known as infantileparalysis, has occurred at the school. The nature andpossible results of this illness make it desirable thatparents should consider the following points which areput before them as part of the advice on this subjectrecently given by a representative body of doctors tothe Headmasters’ Conference of which I am a member.Although poliomyelitis is rarely fatal it may lead to

paralysis and varying degrees of permanent disabilityof movement but not of any other bodily function. Itis an infectious disease and in dealing with it the welfareof the community has to be considered as well as thatof the patient. Experience shows that in residentialschools relatively few boys are attacked and that exten-sive outbreaks are not common. In a carefully supervisedschool the risk of spread after recognition of the initialcase is small though it cannot be completely excluded.

It is appreciated that in these circumstances someparents may wish to remove their boys. No objectionis raised to this but parents who do so should realisethat they must assume responsibility for isolating theirboys both on the journey home and afterwards from allyoung children and adolescents for a period of at leastthree weeks. A boy who has been exposed to the diseasemay, although himself well, harbour the infection. Thereis no means of detecting such carriers, who may spreadthe infection by sneezing and coughing or from the bowels,and simple hygienic precautions against these possibilitiesshould be taken.

If after arrival home a boy develops a temperatureor complains of headache or stiffness or pains in the neckand back he should at once be put to bed and a doctorconsulted. If you decide to remove vour son the medicalofficer of health in your district will be informed.

If, as may well be, you decide to leave your son atschool, his education will continue. The school doctor isin touch with the public health officers and all possible stepsare being taken to check the spread of infection. Furtherexpert medical opinion will be obtained if necessary.For the time being the school is in quarantine and alloutside fixtures are cancelled. It is hoped to resumethe normal school activities in about three weeks’ timebut in any event you will be informed when this can

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be done.-

THE DISEASE AND ITS CONTROL

The following is the new section drafted for the Codeof Rules under the heading of Poliomyelitis and Polio-encephalitis.

Infectious Agent.-A specific filtrable virus.Source of TM/ecMoM.—Discharges from the nose, throat,

and bowels of infected persons or articles recently soiled