The Red-Headed Africans

by JOHN F. BROCK, M.D.

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FEW persons would imagine that a search for red-haired Negroes in Africa could have any far-reaching significance in relation to world food supplies or the health of large numbers of people. Yet the red-headed African has turned out to be an important clue to the most serious and most widespread nutritional disorder of the world.

It is tempting to speculate on the possible effect of food deficiency, especially protein deficiency, on African peoples. Their backwardness has been attributed in the past mainly to the effect of tropical parasitic diseases and the enervating climate. It would now appear that protein deficiency is more important than either of these other factors.

The Negroes of Central and West Africa and the related Bantu people of Southern Africa ordinarily have jet-black, short, tightly curled hair. But under the influence of nutritional deficiencies, the color of the hair may be altered so that it takes on rather a reddish hue and later may become grayishwhite even in childhood, and at the same time the texture is altered so that it becomes finer and more delicate and loses some or all of its curl.

The name “kwashiorkor” was first used in medical literature in the Gold Coast Colony in 1933 to denote a disease characterized by these changes in the hair and by failure of growth and development shortly after weaning, together with waterlogging of the tissues, fatty degeneration of the liver, and a characteristic skin rash. The whole picture was believed to be due to some kind of nutritional disorder. In the next fifteen years, similar or related disorders were described from many parts of Africa under a variety of names, including “infantile pellagra.” During the same period, nutritional experiments showed that in a variety of animals, serious changes in the liver — among them fatty infiltration — could result from diets deficient in protein. It was suggested by doctors working in Africa and by nutritional scientists in other parts of the world that kwashiorkor, infantile pellagra, and diseases described elsewhere under a variety of names might all be fundamentally similar and might result from deficiency of protein in the diet.

In 1949, some of these nutritional theories were discussed at an International Nutrition Conference in Central Africa. Subsequently the World Health Organization invited me to undertake a survey of the equatorial belt of Africa from Zanzibar in the east to Dakar in the west, where kwashiorkor and related diseases were prevalent. The Food and Agriculture Organization sent one of its officials, Dr. Autret, to join me, thus ensuring adequate contact with the French-speaking peoples of Africa, and combining the biochemical and agricultural aspects of the problem with the clinical and nutritional. Our two-man team completed its survey in two months by air travel between the principal centers of the African equatorial belt, and subsequently made its report in Geneva.

Briefly, kwashiorkor is a disease of children from six months to five years of age. Throughout Africa the children are often kept at the mother’s breast for two or even three years, and it is unusual for the mother to have another child during this period. When another child does arrive, the previous child is displaced from the breast, and the disease has therefore been referred to by many African tribes as the “Disease of the Displaced Child.” Recently etymologists have pointed out that the term kwashiorkor, which means literally “red-headed boy,” can be interpreted as meaning “possession by a red or very bad devil" — presumably the devil of jealousy in the heart of the displaced child.

Throughout the greater part of the African equatorial belt, cow’s milk is not available, since cattle do not survive because of trypanosomiasis (sleeping sickness). African parents cannot afford to purchase canned milk or baby foods, and the result is that for several years after weaning, when protein is most needed for rapid growth and development, the child is fed an almost exclusively starch diet. The first weaning foods used in Africa vary from region to region but the common ones are mashed cooked bananas and cassava (manioc), both of which are gravely deficient in protein in relation to the needs of a growing child. Even corn when available is unsuitable, because the quality of its protein is defective. In very small areas a mush or pap of beans or nuts is used for the feeding of the weanling child, and there is evidence that this is protective against kwashiorkor because of its considerably greater protein content. Goat’s milk is almost unknown in tropical Africa. Eggs are small and scanty and often subject to a taboo, while meat and fish are unsuitable for a child without teeth unless they are premasticated or pretreated in ways that are not known to the average African.

The result of this protein malnutrition when the child is rapidly growing stunts his development and makes him puny, irritable, and apathetic. At first sight the child does not appear to be undernourished because the waterlogging of the tissues gives a false appearance of fatness. Closer examination, however, shows that the muscles are poorly developed. The color and texture of the hair change, and in many cases there is a change in the color of the black skin towards a reddish hue. Any one of a number of skin rashes may be present, but these rashes are variable and inconstant. Their great variety undoubtedly contributed to the delayed recognition of the fundamental similarity of diseases described under many different names.

The great majority of children suffering from kwashiorkor are cured within four to eight weeks by being fed skimmed milk powder reconstituted with water. In a high percentage of cases no other treatment is required until returning appetite leads to the consumption of a good mixed diet. Some very severe cases may result in death in spite of treatment with skimmed milk, but if the nurse in charge is patient and diligent most of the sufferers can be saved. Skimmed milk is better than whole milk because the intestine with its deficient secretions appears to be incapable of handling fat. Five years ago, the mortality from kwashiorkor was 60 to 70 per cent. Today it has been reduced to 5 to 10 per cent through correction of protein deficiency by milk protein. The transition from a miserable grizzling infant to a mischievous imp within four to eight weeks by appropriate feeding is a delight to observe.

How prevalent is kwashiorkor? In the small and primitive hospitals scattered between Zanzibar and Dakar there must at any given time be thousands of cases. For every case in hospital there are probably hundreds of equally severe cases scattered in the hinterland of inaccessible bush country. And for every case in hospital there are probably hundreds, if not thousands, of additional children whose health and vitality have been undermined, but not to a degree sufficient to induce the parents to bring them to hospitals. In Uganda, where the basic staple is cooked banana, it is possible that every child passes through a phase of kwashiorkor. Further, although Africa may be the worst affected continent, protein deficiency and kwashiorkor described under other names are certainly very prominent in Central America, in India, and in the Far East.

But the far-reaching and insidious effects of protein deficiency do not end with the child. Although he gets some protein from meat, fish, nuts, and beans, protein intakes are marginal throughout the lives of vast numbers of people in the African tropics and elsewhere. In these areas cirrhosis of the liver is very prevalent and appears not to be a result of alcoholism. In some parts of Africa, 60 per cent or more of apparently healthy young adult males are found to have cirrhosis of the liver if they come to autopsy following accidental death. This cirrhosis of the liver is associated with endocrine abnormalities and sterility, and it finally leads to primary cancer of the liver, which is hardly known in temperate climates but is the commonest cancer in African and some other equatorial peoples. Nutritional study in animals in the last decade has shown that cirrhosis of the liver and primary cancer of the liver are due solely or in the main to deficiency of protein. If this also applies to man, then the recovery of the African child from kwashiorkor when he gets his teeth and puts them into solid protein foods is only temporary.

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HOW are kwashiorkor and the other probable results of chronic protein deficiency to be prevented in the future? If cattle can be made to thrive in the tropics, a suitable indigenous food for the weanling child will be available. But the cure for cattle trypanosomiasis is not yet available, although extensive research is being done on certain drugs which may turn out to be effective. Goat’s milk may possibly be an answer; but unless they are carefully controlled, goats are very destructive of natural vegetation. The importation of canned milk and milk products is certainly no answer, since Africa cannot afford to pay for imported foods.

Vegetable protein mush prepared from indigenous beans and nuts may be one solution. Another plan is to let the mother digest and assimilate those protein foods which her young infant cannot manage, and supply them through her breast milk. This would mean the encouragement of the traditional practice in Africa of prolonging breast feeding into the second or even third year of life. There has been a tendency in the past for missionaries and educators from the West to persuade African mothers that with their poor diet and the heavy work which they must do, it is wiser for them to wean their children at the six to nine months age which is conventional in Western Europe. Perhaps this has been wrong advice. For one reason or another, the traditional African practice of long lactation has been associated with a degree of family spacing which has been advantageous and which could well be retained. It should not be forgotten that kwashiorkor is a disease of the displaced child.

But apart from the problem of protein foods for the weanling child, there is still the problem of protein foods at all ages in equatorial Africa and in other parts of the equatorial world. Although fish is undoubtedly important wherever people live by the sea or lakes or rivers, it is unlikely that Africa will reach anywhere near enough animal protein production for its population in the next few decades. At present the regular consumption of animal protein is the prerequisite of certain privileged groups in Africa, such as the Batussi aristocrats of Ruanda-Urundi and the Masai of Southern Kenya.

The remedy in Africa lies in stimulating the production and consumption of vegetable proteins such as the legumes. Ruanda-Urundi is the most heavily populated part of Africa but it shows less evidence of protein deficiency than most areas, for the simple reason that every peasant cultivates a small patch of beans. This remedy for protein shortage could be multiplied throughout Africa by well-directed agricultural extension methods.

Kwashiorkor in Uganda has been cured by enriching the banana staple, on which the disease develops, with soya-bean flour. Unfortunately, this striking advance was demonstrated with soya bean which is not indigenous to the African continent. But we may expect that this curative experiment will soon be repeated with the many beans or legumes which are indigenous, and that they will be as effective as the Asian soya bean which was chosen for the tests because its value had already been demonstrated as a vegetable protein supplement to the starving people of Europe just after the close of World War II. In Ruanda-Urundi a missionary has made a collection of more than twenty varieties of indigenous bean. The next step will be to demonstrate that vegetable protein in one or another combination can be an adequate substitution for animal protein as a long-term preventive of protein malnutrition.

Even if some animal protein is necessary as a supplement to diets based on the cheaper sources of vegetable protein, the quantity required as a supplement will be small. And for such supplementation fish will certainly be adequate, for it is one of the richest of animal proteins. Already in Africa nutrition is comparatively good wherever the people live by seas, rivers, or lakes and consume fish. Other parts can gradually be supplied by developing fish-pond farming on the Chinese pattern, and by developing sound and cheap methods of fish curing which will be applicable in humid tropical climates.

With a little further research the field will be set for the specialists in agricultural extension. There is enough knowledge already to start them off on effective programs.

The great inertia of traditional apathy, superstition, and ignorance will be overcome only with difficulty, but there can be no real awakening of Africa until protein needs are met. The leaders of African nationalism have so far shown great interest in political rights but very little interest in the elementary needs of the malnourished masses. The development of the mind and spirit of the masses towards intellectual and spiritual freedom is certainly necessary. But is this possible among people who are chronically starved of protein, the raw material from which all tissues of the body, including the brain, must be built?

Two questions are often asked. 1) What about tropical parasites? 2) Can programs of rural agricultural extension be made to work among completely uneducated people? Both can be answered with considerable confidence.

Tropical parasites will undermine far more effectively the vitality of malnourished people than of those who have good diets. Tropical parasitism and tropical malnutrition constitute a vicious circle. Ideally they should be tackled simultaneously, but if only one is to be tackled, then it should be malnutrition. Modern drugs and antibiotics show promise of dealing very effectively with the parasites, but without better nutrition the ultimate results will be poor.

As to the second question, examples can be quoted from many parts of the world of the responsiveness of the most primitive peoples to education in food production. The appeal of this kind of education is universal. Even the most superstitious food taboos are easily overcome by demonstration. When I first visited Ruanda-Urundi in 1944 there was a serious famine and people were dying of starvation by the hundreds beside lakes teeming with edible fish. There was a local taboo on the eating of fish. Six years later the same people had shed their taboo against fish with vast benefit to their health and nutrition.

Behind all this looms the unsolved problem of population pressure. Modern drugs are beginning to work wonders in the control of tropical parasites. Better feeding will lead to rapid population increases in Africa. What is to be the future of this population increase? Is it to become the kind of population pressure we already know in some parts of the world, where periodic famine is the only check to the multiplication of millions through the irresponsible spawning that is characteristic of grinding poverty? Or can the Dark Continent lead the world into a new dignity of development among backward people?