Human aging

GETTING YOUR CAT TO EAT THE FOOD

Human being
You can learn more about feeding whole prey -- which involves no grinding and instead serving a variety of whole, raw carcasses -- on several Yahoo egroups, including this one. So what do I consider ideal body fat standards for athletes? The availability of iron in foods varies greatly. In this sparkling talk from TEDGlobal , he asks us to embrace our randomness and start making better mistakes. Read it, study it, print it, and take it with you the next time you're talking to your vet about dental work for your cat.

An encyclopedia of philosophy articles written by professional philosophers.

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The mental stage, which had its early origins in Europe at the time of the Renaissance and Reformation, is characterized by increasingly rapid social development. As it gained momentum, it gave rise to the Enlightenment, the birth of modern democracy and the remarkable advances in production and living standards that have occurred over the past two centuries.

Duane Elgin and Coleen LeDrew describe this evolutionary progression in these terms. Each of these stages places emphasis on a different type of resource. During the physical stage, land is the most important resource. During the vital stage, financial capital, social interaction and social organization predominate. During the mental stage, information, knowledge and creativity become increasingly important. Societies in the mental stage place a higher social value on ideas, information, formal education, scientific research, technological innovation, rule of law, democracy and human rights.

Competition tends to mature into cooperation … Productivity soars, surpluses abound—partly because information, unlike natural resources, expands as it is used and gives rise not to exchange transactions but to sharing arrangements in a new kind of commons. Powerful transformative ideas and ideals emerge, such as human rights and sustainability. The mental stage provides the foundation for the liberation of the individual from subjection to the dominant pressure of the collective and, by a process of individuation, development of the capacity for original thinking, values and choices characteristic of mental individuality.

Giving is the characteristic principle of the mental stage. Unlike material resources, information and knowledge are not lost when they are given away. Knowledge multiplies by exchange. This is the principle behind the success of Internet-based businesses such as Facebook, Google and Yahoo, which attract visitors by giving away useful information or services and convert that traffic into profit. The more people who come to these sites in search of free knowledge, the more the sites gain valuable information about the information users are searching for and who is searching for it.

Information begets more information. Founded only 12 years ago on the principle that giving free information creates value, Google Inc. Knowledge begets more knowledge. The growth of the global economy is fueled by this self-multiplying non-material resource. No society strictly falls within any one stage. Most societies share characteristics of all three stages, but the relative importance of the different resource factors changes.

Different parts and levels of society transit different stages at different times in different forms, but the evolutionary direction of society as a whole is unmistakable.

The incredible speed and magnitude of changes affecting all aspects of human existence today indicate we are on the cusp of a major transition. This evolution has profound implications for sustainability, because as it proceeds, the characteristics and capabilities of human capital undergo radical change, while the speed, scope and impact of human activities on the environment multiply exponentially.

Various authors distinguish between strong and weak sustainability. Strong sustainability requires that both natural and human-made capital have to be maintained, while weak sustainability holds that utility of the sum of all capitals has to be maintained for future generations.

The concept of critical natural capital distinguishes that part of natural capital which performs irreplaceable environmental functions that cannot be substituted by other types of capital Critical natural capital is that part of natural capital that has to be maintained under any and all circumstances. Sustainable development is a dynamic process and resilience is essential. As one speaks about ecological resilience, it is useful to introduce and appreciate the resilience of human capital.

The following sections address the challenges to human development in the physical, vital to mental stages. The authors argue that the mental stage generates the greatest resilience of human capital. As society evolves, the challenge of sustainability changes. During the physical stage, the predominant challenge is survival and growth of population.

Shortages of food severely restrict the size of population. Before the advent of agriculture about 10, years ago, the entire population of humanity probably did not exceed 10 million. Then, over the next 8, years, it slowly grew to about million, primarily as a result of increasing availability of food. As trade, markets, money and other forms of social organization characteristic of the vital stage increased the productive capacities of society, population growth accelerated to reach one billion around , then soared past six billion over the past two centuries.

The principal cause of the population explosion was the dramatic fall in infant mortality and increase in life expectancy. Over the past six decades, infant mortality worldwide declined from per 1, to 47 per 1,, while life expectancy in developing countries rose from an average of These remarkable achievements were made possible by the dissemination of modern vaccines and antibiotics supported by rising food production as a result of the Green Revolution.

That is, advances in science and technology and improvements in social organization, both characteristic of the mental stage, dramatically increased the carrying capacity of the earth and human civilization.

Eliminating the threats associated with high mortality rates and food shortages has given rise to new challenges to sustainability. Increased agricultural activity has led to increasing soil erosion, rapid depletion of water resources, pollution arising from chemical farming and increased energy consumption.

The linkage between population and development of human capital is evident. Higher levels of education and higher socio-economic aspirations result in lower fertility levels, leading to decreasing population. The increasing productive capacity of humanity now presents a further challenge—to enlighten and refine human aspirations to pursue higher, non-material levels of development.

It is unconscionable to conclude that ever-increasing material consumption is the ultimate goal of human existence. Education is the principal means for overcoming this challenge. Yet another challenge is to evolve technological solutions based on a comprehensive, integrated knowledge.

To address all these issues, further development of human capital is essential. Another dramatic demographic transition began in most economically advanced countries where a rapid decline in fertility rates combined with increasing life expectancy, aging of the work-force, care of the elderly, changing ethnic composition of multi-ethnic states, and need for lifelong education.

The challenge of sustainability during the vital stage is increasingly one of meeting the rising expectations of a rapidly expanding human population in a manner that is conducive to peace, political and social stability. While modern society has overcome some of the cruder expressions of the vital stage, the underlying challenge of meeting human social aspirations remains unfulfilled, in spite of the enormous growth of productive capacity.

Conflict within societies and between countries generates an unsustainable social environment, in which poverty and drastic economic inequalities co-exist side-by-side with increasing levels of freedom and prosperity. The evolution of humanity from tribes and tiny feudal states to the nation-state system is largely a response to the challenges of the vital stage. Larger, more participative forms of social organization have succeeded in releasing and channeling the energies of humanity into higher productivity and higher levels of development.

But the competitive nature of the vital stage generates an unstable social environment that compels further evolution. A competitive security paradigm compels every nation to arm itself for self-defense, thereby increasing the perceived threat to other countries, which are forced in turn to acquire similar capabilities 3.

Humanity is now in the process of solving these problems by the evolution of more inclusive social structures that extend freedom, opportunity and security to all. Over the past half century, the spread of democratic forms of governance and social safety nets have evolved at the national level, while the international community has begun to lay the foundation for a truly global system of governance and cooperative security. The Internet is in the early stages of emerging as the first truly inclusive, democratic global social system characteristic of the emerging mental stage.

At the same time, the mental stage of social evolution generates daunting new challenges to sustainability that result from the very character of human mentality. Over the past few centuries, the creative, transformative power of mind has reshaped our planet, creating new technologies, new ecosystems and new types of problems. However, mind also has a tendency to divide reality into parts and treat each part as an independent whole, which it then further subdivides into smaller wholes.

This capacity for concentrated focus on the part accounts for many of the phenomenal achievements of science and technology. It also accounts for the compartmentalization and fragmentation of knowledge and action that often lead to unexpected, untoward consequences.

The problem of sustainability has now evolved to the stage where it endangers not only human life but threatens to undermine the natural capital on which human civilization is based. A solution to the problem necessitates further social evolution. The challenge is not merely to control or curtail human activity.

At its root it is about altering the way people perceive the world around them and think about solving problems. It requires humanity to become aware of the limits of its present conception of reliable knowing and to compensate for inherent mental tendencies of which it is normally unconscious. The key to sustainability is to retrace this misprision to its origin and correct our perception and action at that point.

This concurs with the view of Sri Aurobindo a century ago, who emphasized the need for further evolution to transcend the divisive aspects of the egoistic, mental consciousness.

Thus, a confluence of eastern and western thought is emerging that arrives from different starting points at a similar conclusion.

Though resources exist outside and independent of human beings, they are recognized as resources only by human beings. Knowledge is a resource that exists only within human beings.

Human capital, natural and human-made capital are interconnected. Similarly socio-economic and political conditions can have beneficial and destructive effects.

In addition there are sudden changes, black swans, labeled P for those having positive and D for those having destructive effects. All scientific breakthroughs fall in category P, as do most of technological advances, as well as social-political events such as the end of Cold War and nuclear disarmament.

War, any form of violence, injustice, large income inequalities, violation of human rights and terrorism destroy human capital.

These crises are interconnected and interdependent. Each one of these crises and the totality of all of them destroy human capital. All of them are represented by a function D. Nuclear war and climate change can lead to catastrophes or even to an end of civilization, and are also represented by D.

The interdependence among various forms of capital is represented by the last three terms in equation 1. Equation 1 is fairly complex. Sustainable development is development that meets the needs of the present generation without compromising the ability of the future generations to meet their needs That means that human capital increases over time, i.

Although adequate means for measurement of human capital are yet to be developed, there is ample evidence to demonstrate that the productivity of human capital has substantially increased over the last two centuries. This suggests that the first two terms in Equation 1 are positive and that positive black swans P more than outweighed the destructive ones D.

This attempt at quantitative discussion of human capital is impeded by the inadequacy of existing measures for human capital. The self-augmenting character of human capital is dramatically illustrated by the growth of per capita GDP in recent centuries. In spite of a fold rise in world population over the last years, per capita GDP has grown fold as shown in Figure 2. Since the advent of the Industrial Revolution, both population and per capita GDP have increased six-fold, signifying a fold rise in productive capacity in two centuries, challenging the very notion of scarcity and economic limits.

Research on sustainability focuses largely on the carrying capacity of the environment and the deleterious impact of human activity on it. This paper argues that the development and evolution ofhuman capital are the most critical determinants of sustainable development.

The evolution of human capital to a more mental stage impacts on sustainability in a variety of ways. It accelerates the process of technological innovations with the capacity to mitigate environmental damage.

It spurs the evolution to a less material-resource-intensive, service-based economy. Through an increasing emphasis on higher levels of education, it fosters the emergence of a more informed, socially conscious population capable of understanding and responding to the challenge of sustainability. Further, as Elgin and others argue, it creates conditions favorable to the evolution from a resource-intensive consumer culture to more sustainable cultures that give far greater importance to non-material needs and achievements.

Throughout history, humanity has suffered from shortages that imposed severe limits on its capacity for survival and enjoyment, justifying economics as a science of scarcity. Then, after millennia of slow, incremental progress, human history embarked on a radical and accelerating departure from previous trends. Technological, organizational and social innovation combined to generate unprecedented levels of economic growth and prosperity, which seemed to abolish the limits to growth.

But as human productive capacity increased, it began to confront more fundamental limits to the resource base and carrying capacity of the planet. Within a few short decades, society rearranges itself—its worldview, its basic values, its social and political structures, its arts, its key institutions. And the people born then cannot even imagine a world in which their grandparents lived and into which their own parents were born. We are currently living through such a transformation Fundamental differences between the industrial economy and the post-capitalist service economy have profound implications for both economy and ecology The emergence of the post-industrial service economy is in the process of altering the equations concerning resource consumption, forcing us to reexamine basic postulates regarding sustainable The emergence of the post-industrial service economy is in the process of altering the equations concerning resource consumption, forcing us to reexamine basic postulates regarding sustainable.

Decrease in Energy Intensity — Reproduced with permission from In recent decades, this trend has accelerated. The substitution of renewable energy sources combined with continued improvements in energy efficiency have dramatically increased fossil fuel energy intensity FFEI.

Figure 4 shows the substantial increase in FFEI fossil fuel consumption per unit of GDP measured in international dollars for 12 OECD countries from to , a period normally denoted as the beginning of the era of the post-industrial service economy. In spite of these gains, the scope for greater global energy efficiency is still considerable. The growing emphasis on education, health and welfare are major elements of the emerging economy, as well as central pillars in the development of human capital.

The continued evolution toward a service economy based more on human capital and less on material resources does not mean that the problem of sustainable energy supplies will be solved merely by a shift in the nature of economic activity. On the contrary, advances in technology, greater public awareness and commitment, changes in public policy and changes in culture are all essential.

The wholesale shift from manufacturing to services is more apparent in high income countries than in those at an earlier stage of economic development. It has long been assumed that full-scale industrialization is a necessary presage to the modern service economy and, therefore, that reduced energy intensity in the most economically advanced nations would have little impact on rising energy consumption in the developing world.

The remarkable progress of countries such as India in developing highly sophisticated IT and financial sectors suggests the possibility that emerging nations may be able to leapfrog from agrarian to post-industrial economies, avoiding at least some of the excessive energy demands of industrialization. The emphasis placed on raising levels of education and increasing research is one crucial determinant of this transition.

Although the service economy requires less energy and material resources consumption than industrial manufacturing economy to generate an equivalent unit of GDP, human energy demand will still continue to rise. The transition from the physical to vital to mental stages has a beneficial impact on energy intensity and other material resource consumption, producing more value with less material inputs as well as a greater awareness and capacity for conservation The sustainability of both human capital and the human environment necessitates a rapid, radical change of consciousness.

Thus, the evolution of human capital must be taken into account in any long-term projections and strategies regarding environmental sustainability. It matters most of all. The concept of human capital focuses on the productive and creative capabilities of human beings which can be harnessed to achieve higher and more sustainable levels of human welfare and well-being. In the prevailing economic system of market economies, employment is the principal means by which people express their productive capabilities to acquire the means for their survival and economic welfare.

Thus, access to remunerative employment opportunities is a crucial determinant of the productive utilization of human capital. Together with education, employment is a principal means for the development of human capital. The knowledge, skills and values acquired through work experience enhance the capabilities of people for constructive, organized activity that contribute to their own welfare and that of the society.

In addition, employment in modern society is also an important source of social identity, acceptance and respect, as well as a source of self-esteem and psychological fulfillment. Conventional wisdom tells that the combination of a population explosion, rapid technological advancement, urbanization and free trade over the past century must inevitably be leading toward a severe imbalance between the supply and demand of work, resulting in higher and higher levels of unemployment globally.

The actual facts tell a surprisingly different story, which compels us to re-examine basic assumptions about employment.

Growth of Global Population and Employment to Data from 38 Historically, humanity has done surprisingly well in generating employment opportunities to meet the needs of a rapidly expanding population. Over the past six decades, the world economy has generated nearly two billion jobs, nearly three times as many jobs as during the previous five centuries Global job creation has been taking place at record rates for the past six decades.

Figure 5 depicts growth in global population and employment since Global Employment and Employment-Population Growth — The remarkable expansion of employment opportunities since is itself the result of a more fundamental social transformation that has radically altered the nature of work and economy over the past two centuries and is now shaping the future of work. Employment as we know it today is a relatively recent concept, the result of a multidimensional transformation that began in Europe at the beginning of the 19th century.

Table 1 depicts important dimensions of that transformation. Individually and in combination these changes have had a profound impact on the nature of work. A near seven-fold increase in population has necessitated an enormous expansion in work opportunities in order to absorb new entrants to the work force.

At the same time work has migrated along with people from rural to urban areas. As agricultural productivity has risen, a declining percentage of the population is engaged in agriculture and entirely new fields of employment have been generated in industry and services concentrated in cities.

This was made possible by the mechanization of agriculture. Mechanization spurred the Industrial Revolution, as automation and computerization are now transforming manufacturing and many types of services. Over this period, and especially after , world trade has grown enormously, facilitating the movement of jobs to lower wage countries.

In combination these factors have radically transformed the nature of economy and employment. As job creation in Europe and North America shifted from agriculture to manufacturing during the latter half of the 19th and first half of the 20th century, since it has shifted even more dramatically from manufacturing to services in the most economically advanced nations and to a lesser extent even in developing countries. Worldwide Employment by Sector: The recent trend in growth of service sector employment is likely to continue indefinitely.

Contrary to common conception this trend does not represent a shift from higher skill manufacturing to low skilled, low-wage service jobs. In spite of the remarkable expansion of employment opportunities in recent decades, million people globally were classified as unemployed by the International Labor Organization ILO in Real unemployment rates in many countries are probably at least twice the official figures, since unemployment data in many countries is notably unreliable and does not take into account those who have given up seeking work.

These numbers also fail to take into account involuntary underemployment, which affects at least one billion workers globally. The problem of unemployment and underemployment is closely linked to the problem of poverty.

Unemployment relates to the productive utilization of human resources. Poverty relates to the economic welfare and well-being of human beings. Poverty itself is a relative, value-laden term, therefore measurement must always be somewhat arbitrary.

By all measures, there has been a substantial reduction in the percentage of the world living in poverty, much of it accounted for by dramatic improvements in China due to its huge population and high rates of economic growth. Poverty Levels over time. Asian Development Bank estimates that Asia alone is home to nearly million unemployed and underemployed Even in economically advanced nations, huge numbers of people—especially youth—are unable to find remunerative employment.

Randall Wray estimates that the actual level of unemployment and underemployment in the U. Similar conditions persist in most OECD countries. Today employment is the greatest challenge to the sustainability of human capital, and full employment is the only effective remedy. Figure 9 depicts growth of the working age population in G20 countries, including India and China, as projected by ILO in mid The working age population of these nations will increase by million during the period — India needs to create about million new employment opportunities in the coming decade just to absorb new entrants to the work force.

To put this number in perspective, a study by the International Commission on Peace and Food in estimated that India would need to generate million new employment opportunities during the s in order to achieve full employment and proposed a strategy to achieve it which was adopted as official government policy, though only partially implemented 3.

While official employment and unemployment figures in India and most developing countries are unreliable, evidence suggests that the Indian economy did in fact generate sufficient jobs to prevent a swelling of unemployment during that period.

Working age population in G20 countries, including India and China in mid The world is now in the early stages of another demographic revolution that is the result of a steep and steady decline in the birth rate and an increase in life-expectancy in the more economically-advanced countries. Figure 9 above also shows that the working age population will level off or decline in a number of G20 countries, reflecting a trend that is broadly applicable to Western Europe in general.

Figure 10 shows that life expectancy in Western Europe rose from 46 years in to 67 years in and then to Following the same trend, the fertility rate in these countries has fallen from 4. These trends will have enormous impact on the future of employment. By there will be million people over the age of 65 in the EU, up from 71 million in As the old age population grows, the working age population will shrink.

By the working age population in the EU will stand at million compared to million today. The EU would lose an average of one million workers a year Obviously, as health and life expectancy increase, there is no sound rationale for limiting the working age to 15—64 Data from 17 , Table 2 shows the U. For to , the projected increase in working age population declines dramatically to just over million.

Projected Change in Working Age Population — A UN study released in estimated that Europe would have to accept million new immigrants over the period — in order to maintain present levels of working and tax-paying population A World Bank Study estimated that 68 million immigrants will be needed to meet labor requirements during the period from — These estimates may be challenged, but there is no doubt that, unless major policy initiatives are taken, the net result will be a dramatic decline in the relative size of the working age population in Europe and a shortage of workers to fill the available jobs It has also spurred efforts to increase participation of women in the workforce.

Denmark, Finland, Norway and Sweden are the only nations that have a gender gap of less than 10 percentage points The UN study also estimated that Japan would need to admit , immigrants annually for the next 50 years in order to maintain the size of its working population at the level By , labor-force growth in the United States will be zero.

The US is forecast to have a shortage of 17 million working age people by China will be short 10 million workers. India is expected to have a surplus of 47 million workers in , but even this surplus may prove illusory The actual impact of demographic changes on working age population and employment over the next few decades may yet be influenced by technological developments, public policies regarding migration, and outsourcing, as well as unanticipated events, as the rise in unemployment in OECD countries as a consequence of the recent financial crisis demonstrates.

Nevertheless, the broad trends indicate a growing shortage of workers in the most economically advanced nations, which will act as a counter-weight to the increasing number of working age youth in developing countries.

Both historical trends and future projections support the view that full employment is an achievable goal. Economy is a social organization created by human beings to meet human needs and human welfare.

Society has become so structured and economy so specialized that today the vast majority of human beings are dependent on employment outside the home for their survival and welfare Government policies, laws and regulations permeate virtually every aspect of modern economic and social life, effectively determining what types of activity can and cannot be carried out and thereby directly or indirectly determining the number and type of employment opportunities available to the population.

Principles of justice necessitate that a government which controls economic activity must ensure conditions that support the basic economic rights of all its citizens. The responsibility of government to ensure employment was a basic premise of the New Deal in U. Articles 23 and 24 of the Universal Declaration of Human Rights affirm the right to work, free choice of employment, just and favorable working conditions and protection against unemployment.

These in turn served as the foundation for thedevelopment of two human rights treaties in the s concerned with civil, political rights, economic, cultural and social rights, which together are generally regarded as an International Bill of Human Rights. In its report to the UN in , ICPF argued that a firm commitment of governments to uphold this right is essential in order to generate the political will required to achieve full-employment: As government has assured the right to education—indeed, compels it—it can and must also ensure the right of every person to gainful employment.

Our very concept of the rights of the individual and the responsibilities of the society must undergo radical change. Although the goal of full employment was embraced by all the OECD countries after World War II, in the mids it was difficult to imagine any country coming forward to seriously implement measures to achieve it.

While classical economic theory commonly extols the value of moderate rates of unemployment as a counter to inflation, economists such as Wray argue that the costs of unemployment and the benefits of full employment are so high, that government-funded employment guarantee programs are financially feasible and economically justified.

Wray argues that similar programs can be effectively applied in other countries as a cost-effective strategy to generate full employment. In , India introduced the National Rural Employment Guarantee Scheme, designed to guarantee days of employment to the poorest families in 50 districts of the country.

In spite of the massive expenditure and enormous logistical challenges, the program was so successful that it was subsequently extended to the entire country and now provides days of employment for approximately 45 million workers annually. There is no inherent reason to believe that we cannot devise an economic system in which everyone that is willing to work and capable of productive activity is assured of an opportunity and means to do so.

As long as human wants go unmet and human resources remain underutilized, there is the possibility of refashioning our economic system to utilize human capital in a more effective, sustainable manner. Apart from this, humanity has an insatiable appetite for more education at all levels, improved health care, more and better attention to the needs of children and the aged, better community development, more research, new forms of entertainment, infrastructure improvements, etc.

It is not just advances in technology that work in this fashion. Achieving full employment is absolutely essential for the sustainability of human capital. Apart from the possibility of a global level natural calamity or nuclear war, unemployment looms as the single greatest threat to sustainable development of human capital.

Unlike most natural resources, human resources are perishable and rapidly deteriorate when left unutilized. Job-related knowledge and skills are lost or quickly become outdated. Socially, the long-term unemployed are looked down upon by employers and find it more difficult to find jobs.

Psychologically, they lose their self-confidence and self-respect. Employment is not only the principal means for harnessing human potential; it is also the principal means for nourishing, sustaining and developing human capital. High levels of unemployment are directly linked to poverty, social isolation, crime, regional deterioration, health issues, family breakdown, school dropouts, social, political and economic instability, violence, ethnic hostility, and even terrorism.

The cost of dealing with these social problems far outweighs the cost of public jobs programs designed to achieve full employment. Education is the primary means for the progressive development and sustainability of human capital.

More than 40 years ago, Nobel laureate economist Gary Becker highlighted the role of education and training in the development of human capital 6.

The complexity of modern life demands of the ordinary citizen a wide range of knowledge and skills. Education is the single most reliable indicator of family size, because it raises social aspirations and motivates people to direct their energies for qualitative increase in living standards and quality of life. Recent studies identify female education as the main driver for bringing down child mortality, helping to improve the health of all family members and leading to a value change towards lower fertility goals as well as enabling better access to family planning Education is also the key to sustainable growth and employment.

Throughout the world, higher levels of education are associated with higher levels of employment and higher income. In virtually every country of the world unemployment is significantly higher for those with the least education and lowest for those which have at least completed secondary education.

Although the correlation between education and income applies to all levels of education, tertiary education plays an increasingly important role in driving the emergence of the post-industrial service economy. Figures 13 and 14 depict the correlation between rising levels of tertiary enrollment and rising levels of per capita GDP over the past four decades for Korea and India, two countries with vastly different absolute levels of educational and economic development.

In both instances the growth rates for higher education are closely correlated with the growth rates for per capita income. Unemployment rates are closely connected with low levels of education. A study prior to the recent recession in the U. Recent demographic studies confirm that education at all levels is the key driver of economic growth in both high and low income countries This same difference exists with respect to unemployment levels for skilled and unskilled workers.

The differential gap between these two categories of people is 35 points in Belgium, Ireland, Italy, Finland and the U. Data from 74 , The problem of unemployment co-exists with a massive shortage of employable skills.

Studies in OECD and developing countries reveal that high levels of unemployment and a severe shortage of skilled workers commonly exist side-by-side.

Nor are skill shortages confined to the high tech industries. The skill shortage is also prevalent in basic manufacturing industries, such as the tool and die industry, that many companies are forced to invest in expensive, computer-based machines or outsource the work to overseas suppliers. Plumbers, electricians, masons, carpenters and other skilled craftsmen are also in short supply.

By recent count there is a shortage of at least , nurses in the U. By the year , a shortfall of , nurses and , doctors is projected 76 , The situation in most European countries is similar. A study conducted by International Data Corporation predicted a shortfall of networking skills to the extent of , personnel in Europe in Wall Street Journal reported that there were , unfilled jobs in Germany in , of which 40, were jobs for engineers and other skilled people The developing countries present a similar situation.

Though India produces more than , technical graduates annually, corporations are finding it difficult to recruit sufficient skilled personnel Here too, the skill shortage spans a wide spectrum of industries and types of jobs. A study by the Federated Indian Chambers of Commerce and Industry estimated a shortage of , MDs, one million nurses, and , engineers.

The study also found a severe shortage of top pharmaceutical scientists. Shortages also exist for middle-level and junior scientists, factory workers, machine operators, mechanics, carpenters, masons, painters and plumbers Figure 15 presents the results of global surveys conducted in by Manpower Inc.

Global Skills Shortage Skills Shortage by Country These skill shortages reflect the fact that the rate of social change brought globally far exceeds the rate of human resource development. All evidence points to an ever increasing rate of social change. Therefore, unless a concerted effort is made to consciously accelerate human capital formation, the gap will continue to increase. Left unaltered, this trend would be enough to account for rising levels of unemployment in the midst of unprecedented prosperity.

Sustainable development of human capital necessitates a radical overhaul of the current systems of education and vocational training. According to UNESCO estimates, global enrollment in universities rose from , in to around million in Raising global participation rates in higher education to the level prevalent in the U. For India to raise participation rates to the current U. Of course, the internet is being used to extend the reach of traditional colleges and universities.

Still less than half of all US degree-granting institutions offer fully online courses. Furthermore, these initiatives fail to take maximum advantage of the new technology. The potential now exists for creating a global virtual university capable of engaging the highest quality instructors and educational materials to deliver high quality education at a fraction of the cost of current systems.

At a time when major bookstore chains were trying to figure out how to leverage the power of the web as an adjunct and extension of their brick and mortar stores, Amazon started from scratch and built an entirely new, exclusively web-based system designed for optimal reach, lowest cost, ease of use and quality of service. In less than half a decade, this scrappy start-up grew to become the largest bookseller in the world.

A similar strategy can dramatically transform secondary and higher education worldwide. While the cost and expertise for producing high quality multi-media instructional materials may be prohibitive for private companies, a global consortium backed by national governments could elevate the quality of education globally to the highest levels now prevailing in the most advanced nations.

There is considerable evidence to support the view that computer based learning can be more effective than traditional classroom learning, with learning and retention rates as much as twice as high. Multimedia computerized courses can use a mix of written, spoken and graphic materials along with video footage to impart lessons in a manner that cannot be done in a class room. Students can interact with the learning software and receive immediate feedback.

Students are able to learn at their own pace. Computer-based learning also reduces the need for experienced teachers. Courses can be designed according to the highest possible standards and quality, whereas instructors in classrooms vary enormously in their teaching capacities. Moreover, through internet-based, multi-media courses, the very best instructors in the world for each subject can be made accessible to students everywhere.

Computerized course materials can be more readily altered in response to changing requirements than printed textbooks. Uniform testing and evaluation can be done on-line.

Even if computer-based learning becomes far more prevalent, the need for teachers and professors will increase by an order of magnitude, since both the number of students and the number of years of education continues to grow.

Therefore, there is a need for more teachers and professors. Globally there is an urgent need to expand vocational training facilities and programs across a broad spectrum of industries in order to cope with the rapidly changing demands of the new economy. The need is especially great in the fastest growing developing countries, India and China. The more trained job seekers are, the more readily the market absorbs them.

Conversely, the less trained, the more difficult it becomes to get good jobs and the more expensive for employers to impart the required skill levels. Both the market value and the bargaining power of untrained job seekers are far lower. India has 4, industrial training institutes which impart vocational training to nearly , trainees in 43 engineering and 24 non-engineering trades. If all types of professions are included such as agriculture, medicine and law etc.

The country needs other short training courses that people can take at their own time and at lower costs. Moreover, those already in employment also need training courses to upgrade their skills in tune with developments in their professions. The deficiency in vocational training covers a very broad range, including basic mechanical skills required for repairing machines to skills required for book keeping, insurance, marketing and journalism etc.

Recognizing the need to radically expand and improve vocational training, India has recently formed a National Skills Development Corporation to impart skills training to million workers over the next 15 years. Existing arrangements for vocational training are far from adequate to meet the changing demands of the workplace in both OECD and developing countries. Compare Denmark, for example, where workers receive almost 1, hours of non-formal job-related training over the course of their career with Italy where they receive less than hours The huge size of the global labor force, the complex range of skills required and the high cost of training make it necessary to develop alternate training methods to increase the supply of skills to match the demand.

It is surprising to note that the most obvious solution to the general skills shortage has received very little attention until now—the use of computerized vocational training. It is surprising because computer-based training is already the prevalent means of providing instruction in a wide range of software and other computer-related skills.

In spite of the fact that flight simulators have been around for decades and recent advances in video game technology make it possible to replicate a wide range of life and work related situations, computer-based vocational training is rarely used for imparting other types of vocational skills.

Computerized simulation has been proven an effective training tool even for learning complex vocational skills such as flying an aircraft or handling sophisticated military equipment. This medium will lend itself to a very wide range of skills in such diverse fields as commerce, education, tourism, entertainment, media, language, health, environment and even agriculture.

Computerized vocational courses will have world-wide demand. Therefore the cost of developing the courseware can be amortized over a very large number of trainees, reducing the cost of training per worker substantially. Science and technology can provide powerful instruments for improving sustainability, but ultimately it is human choices expressed in individual and collective action that will determine the future of our race and life on earth.

Lured by profit or mandated by law, the introduction of new technologies can often be done quickly. But altering the pattern of human choices necessitates fundamental changes in the perceptions, understanding, values, attitudes and actions of countless individuals and myriad social organizations at the local, national and international levels.

Therefore, issues related to long-term sustainability must be addressed at the fundamental level of our collective human consciousness, which is the basis of culture. Culture represents the quintessence of human learning distilled from the experience of the collective, acquired subconsciously, stored in our racial memory and enshrined in our deepest values, attitudes and perspectives.

Changes in behavior can be imposed or occur in response to dramatic events, but cultural change normally occurs over long periods of time as changing circumstances, perceptions and understanding seep down into the fabric of our thought, emotion and relationships with the world around us. Education is the primary instrument society has evolved that is capable of consciously effectuating changes in culture. Biopolitics International Organization has proposed a new model of universal higher education designed to promote an environmentally conscious society and developed a model syllabus.

Of course, change in culture cannot be brought about merely by increasing the amount, expanding the range or altering the content of information and skills imparted to youth. It requires more fundamental changes at the level of individual and social character, which can only be effected by changes in the essential values enshrined in and communicated through our educational system.

What is the essential change in culture needed for the long—term sustainable development of human capital and life on earth? What type of educational system is capable of bringing about that change? Elgin argues that global consciousness and culture are already in the midst of a radical transformation, which is reflected in the emergence of a global consciousness as a result of the global communications revolution, greater ecological awareness and concern, a shift toward post-modern social values and a shift toward more sustainable ways of living Regardless of our answer to these questions, one thing is clear.

In order to be effective, the change in educational content and method will have to commence at the earliest possible age, for it is in childhood that the most essential values and attitudes are communicated and the basic structure of human character acquires form. Many new approaches to early childhood education have been developed and successfully applied on a pilot scale in the U. The best of them share some common characteristics that are central to the optimal development of human capital.

They are founded on a faith in the unlimited potential of the individual human being. They seek to create an environment of freedom in which that potential can naturally emerge.

One successful alternative model was developed by the American educationist Glenn Doman at the Institutes for the Achievement of Human Potential in Philadelphia. Doman has sold millions of books explaining methods for early childhood education that can be applied by parents teaching their children at home or by teachers in the classroom. At Primrose School in Pondicherry, South India, application of his methods in conjunction with computer-based, self-learning techniques has demonstrated that children before the age of six can learn to read two, three or even more languages, acquire a huge fund of general knowledge and develop the capacity for thinking and working independently out of native curiosity and for the sheer enjoyment of the learning process without homework, testing, or any competitive pressure on the students to learn.

Home schooling is another approach which can be very successful for education in families with educated parents, computers, internet and access to quality educational software. After the advent of the internet, home schooling has grown exponentially in the U.

Much more can be done to promote home schooling as an alternative pathway to value-based, family-centered learning. Education is the most effective means for constructively influencing human perceptions and behavior. Moreover, education, research, public policy and culture are interlinked. Learning fundamental concepts, vocational training, skills development, stimulating innovation and excellent teaching extended throughout our lifespan are imperative for the full sustainable development of human capital and the sustainability of our planet.

Development of science and technology combined with advances in social organization has created a global system capable of meeting the economic needs of the entire world population. But increasing productive capacity has not reduced or eliminated the gross inequalities of power and privilege that characterized earlier periods. Indeed, the disparities have in many cases increased.

The child should be given a thorough clinical examination, including careful examination for any infection and a special search for respiratory infection such as pneumonia or tuberculosis. Stool, urine and blood tests for haemoglobin and malaria parasites should be performed. The child should be weighed and measured.

Often hospital treatment is not possible. In that case the best possible medical treatment available at a health centre, dispensary or other medical facility is necessary. If the child is still being breastfed, breastfeeding should continue.

Treatment is often based on dried skimmed milk DSM powder. The child should receive ml of this mixture per kilogram of body weight per day, given in six feeds at approximately four-hour intervals. Each feed is made by adding five teaspoonfuls of DSM powder to ml of water. Attention to providing all micronutrients is important. The milk mixture should be fed to the child with a feeding cup or a spoon.

If cupor spoon-feeding is difficult - which is possible if the child does not have sufficient appetite and is unable to cooperate or if the child is seriously ill the same mixture is best given through an intragastric tube. The tube should be made of polyethylene; it should be about 50 cm long and should have an internal diameter of 1 mm.

It is passed through one nostril into the stomach. The protruding end should be secured to the cheek either with sticky tape or zinc oxide plaster. The tube can safely be left in position for five days. The milk mixture is best given as a continuous drip, as for a transfusion. Alternatively, the mixture can be administered intermittently using a large syringe and a needle that fits the tube. The milk mixture is then given in feeds at four-hour intervals.

Before and after each feed, 5 ml of warm, previously boiled water should be injected through the lumen of the tube to prevent blockage. There are better mixtures than plain DSM. They can all be administered in exactly the same way by spoon, feeding cup or intragastric tube. Most of these mixtures contain a vegetable oil e. The vegetable oil increases the energy content and energy density of the mixture and appears to be tolerated better than the fat of full cream milk.

Casein increases the cost of the mixture, but as it often serves to reduce the length of the hospital stay, the money is well spent.

A stock of the dry SCOM mixture can be stored for up to one month in a sealed tin. To make a feeding, the desired quantity of the mixture is placed in a measuring jug, and water is added to the correct level. Stirring or, better still, whisking will ensure an even mixture.

As with the plain DSM mixture, ml of liquid SCOM mixture should be given per kilogram of body weight per day; a 5-kg child should receive ml per day in six ml feeds, each made by adding five teaspoonfuls of SCOM mixture to ml of boiled water. A ml portion of made-up liquid feed provides about 28 kcal, 1 g protein and 12 mg potassium. Children with kwashiorkor or nutritional marasmus who have severe diarrhoea or diarrhoea with vomiting may be dehydrated.

Intravenous feeding is not necessary unless the vomiting is severe or the child refuses to take fluids orally. Rehydration should be achieved using standard oral rehydration solution ORS , as is described for the treatment of diarrhoea see Chapter For severely malnourished children, unusually dilute ORS often provides some therapeutic advantage.

Thus if standard ORS packets are used which are normally added to 1 litre of boiled water, in a serious case a packet might be added to 1. Even in tropical areas temperatures at night often drop markedly in hospital wards and elsewhere. The seriously malnourished child has difficulty maintaining his or her temperature and may easily develop a lower than normal body temperature, termed hypothermia.

Untreated hypothermia is a common cause of death in malnourished children. At home the child may have been kept warm sleeping in bed with the mother, or the windows of the house may have been kept closed.

In the hospital ward the child may sleep alone, and the staff may keep the windows open. He or she must be kept in warm clothes and must be kept covered with warm bedding, and there must be an effort to ensure that the room is adequately warm. Sometimes hot-water bottles in the bed are used. The child's temperature should be checked frequently. Although it is useful to establish standard procedures for treating kwashiorkor and nutritional marasmus in any hospital or other health unit, each case should nevertheless be treated on its own merits.

No two children have identical needs. Infections are so common in severely malnourished children that antibiotics are often routinely recommended. Benzyl-penicillin by intramuscular injection, 1 million units per day in divided doses for five days, is often used.

Ampicillin, mg in tablet form four times a day by mouth, or amoxycillin, mg three times a day by mouth, can also be given. Gentamycin and chloramphenicol are alternative options but are less often used. In areas where malaria is present an antimalarial is desirable, e. In severe cases and when vomiting is present, chloroquine should be given by injection.

If anaemia is very severe it should be treated by blood transfusion, which should be followed by ferrous sulphate mixture or tablets given three times daily. If a stool examination reveals the presence of hookworm, roundworm or other intestinal parasites, then an appropriate anthelmintic drug such as albendazole should be given after the general condition of the child has improved.

Severely malnourished children not infrequently have tuberculosis and should be examined for it. If the disease is found to be present, specific treatment is needed. On the above regime, a child with serious kwashiorkor would usually begin to lose oedema during the first three to seven days, with consequent loss in weight.

During this period, the diarrhoea should ease or cease, the child should become more cheerful and alert, and skin lesions should begin to clear.

When the diarrhoea has stopped, the oedema has disappeared and the appetite has returned, it is desirable to stop tube-feeding if this method has been used. A bottle and teat should not be used. If anaemia is still present, the child should now start a course of iron by mouth, and half a tablet mg of chloroquine should be given weekly.

Children with severe nutritional marasmus may consume very high amounts of energy, and weight gain may be quite rapid. However, the length of time needed in hospital or for full recovery may be longer than for children with kwashiorkor. In both conditions, as recovery continues, usually during the second week in hospital, the patient gains weight.

While feeding of milk is continued, a mixed diet should gradually be introduced, aimed at providing the energy, protein, minerals and vitamins needed by the child. If the disease is not to recur, it is important that the mother or guardian participate in the feeding at this stage. She must be told what the child is being fed and why.

Her cooperation with and follow-up of this regime is much more likely if the hospital diet of the child is based mainly on products that are used at home and that are likely to be available to the family. This is not feasible in every case in a large hospital, but the diet should at least be based on locally available foods. Thus in a maize-eating area, for example, the child would now receive maize gruel with DSM added.

For an older child, crushed groundnuts can be added twice a day, or, if preferred by custom, roasted groundnuts can be eaten. A few teaspoonfuls of ripe papaya, mango, orange or other fruit can be given. At one or two meals per day, a small portion of the green vegetable and the beans, fish or meat that the mother eats can be fed to the child, after having been well chopped.

If eggs are available and custom allows their consumption, an egg can be boiled or scrambled for the child; the mother can watch as it is prepared. Alternatively, a raw egg can be broken into some simmering gruel. Protein-rich foods of animal origin are often relatively expensive.

They are not essential; a good mixture of cereals, legumes and vegetables serves just as well. If suitable vitamin-containing foods are not available, then a vitamin mixture should be given, because the DSM and SCOM mixtures are not rich in vitamins. The above maize-based diet is just an example. If the diet of the area is based on rice or wheat, these can be used instead of maize.

If the staple food is plantain or cassava, then protein-rich supplements are important. After discharge, or if a moderate case of kwashiorkor has been treated at home and not in the hospital, the child should be followed if possible in the out-patient department or a clinic. It is much better if such cases can visit separately from other patients i. A relaxed atmosphere is desirable, and the medical attendant should have time to explain matters to the mother and to see that she understands what is expected of her.

It is useless just to hand over a bag of milk powder or other supplement, or simply to weigh the child but not provide simple guidance. Satisfactory weight gain is a good measure of progress. At each visit the child should be weighed. Weight is plotted on a chart to provide a picture for the health worker and the mother. Out-patient treatment should be based on the provision of a suitable dietary supplement, but in most cases it is best that this supplement be given as part of the diet.

The mother should be shown a teaspoon and told how many teaspoonfuls to give per day based on the child's weight. Many supplements, especially DSM, are best provided by adding them to the child's usual food such as cereal gruel rather than by making a separate preparation. The mother should be asked how many times a day she feeds the child.

If he or she is fed only at family mealtimes and the family eats only twice a day, then the mother should be told to feed the child two extra times. If facilities exist and it is feasible, the SCOM mixture can be used for out-patient treatment. It is best provided ready mixed in sealed polyethylene bags. Most deaths in children hospitalized for kwashiorkor or nutritional marasmus occur in the first three days after admission. Case fatality rates depend on many factors including the seriousness of the child's illness at the time of admission and the adequacy of the treatment given.

In some societies sick children are taken to hospital very late in the disease, when they are almost moribund. In this situation fatality rates are high. The cause and the severity of the disease determine the prognosis.

A child with severe marasmus and lungs grossly damaged by tuberculous infection obviously has poor prospects. The prospects of a child with mild marasmus and no other infection are better.

Response to treatment is likely to be slower with marasmus than with kwashiorkor. It is often difficult to know what to do when the child is cured, especially if the child is under one year of age. There may be no mother or she may be ill, or she may have insufficient or no breastmilk. Instruction and nutrition education are vital for the person who will be responsible for the child. If the child has been brought by the father, then some female relative should spend a few days in the hospital before the child is discharged.

She should be instructed in feeding with a spoon or cup and told not to feed the child from a bottle unless he or she is under three months of age.

The best procedure is usually to provide a thin gruel made from the local staple food plus two teaspoonfuls of DSM or some other protein-rich supplement and two teaspoonfuls of oil per kilogram of body weight per day.

Instruction regarding other items in the diet must be given if the child is over six months old. The mother or guardian should be advised to attend the hospital or clinic at weekly intervals if the family lives near enough within about 10 km or at monthly intervals if the distance is greater. Supplies of a suitable supplement to last for slightly longer than the interval between visits should be given at each visit.

The child can be put on other foods, as mentioned in the discussion of infant feeding in Chapter 6. It is essential that the diet provide adequate energy and protein. Usually kcal and 3 g of protein per kilogram of body weight per day are sufficient for long-term treatment. Thus a kg child should receive about kcal and 30 g of protein daily. It should be noted that a marasmic child during the early part of recovery may be capable of consuming and utilizing to kcal and 4 to 5 g of protein per kilogram of body weight per day.

There is little doubt that a disorder due mainly to energy deficiency does occur in adults; it is more common in communities suffering from chronic protein deficiency.

The patient is markedly underweight for his or her height unless grossly oedematous , the muscles are wasted, and subcutaneous fat is reduced. Mental changes are common: It is difficult to attract the patient's attention and equally hard to keep it. Appetite is reduced, and the patient is very weak.

Some degree of oedema is nearly always present, and this may mask the weight loss, wasting and lack of subcutaneous fat. Oedema is most common in the legs, and in male patients also in the scrotum, but any part of the body may be affected.

The face is often puffy. This condition has been termed "famine oedema" because it occurs where there is starvation resulting from famine or other causes. It was commonly reported in famines in Indonesia and Papua New Guinea.

Frequent, loose, offensive stools may be passed. The abdomen is often slightly distended, and on palpation the organs can be very easily felt through the thin abdominal wall. During palpation there is nearly always a gurgling noise from the abdomen, and peristaltic movements can often be detected with the fingertips.

It is not uncommon for adult kwashiorkor patients to regard their physical state as a consequence of abdominal upset. For this reason, strong purgatives, either proprietary or herbal, and peppery enemas are sometimes used by these patients before they reach hospital, which may greatly aggravate the condition. The hair frequently shows changes. The skin is often dry and scaly, and may have a crazy-pavement appearance, especially over the tibia.

Swelling of both parotid glands is frequent. On palpation the glands are found to be firm and rubbery. Anaemia is nearly always present and may be severe. The blood pressure is low. There is usually only a trace of albumin in the urine. Oedema may also be caused by severe anaemia. In adult PEM there is less dyspnoea than in anaemia and usually no cardiomegaly.

Other features such as hair changes and parotid swelling are common in adult PEM but not in anaemia. However, the two conditions are closely related. In contrast to adult kwashiorkor or famine oedema, which is not very prevalent, the adult equivalent of nutritional marasmus is very common.

There are five major causes. Any older child or adult whose diet is grossly deficient in energy will develop signs almost exactly like those of nutritional marasmus, and if the condition progresses it may often be fatal. In the case of famines, the condition may be termed starvation see Chapter Famines and severe food shortages resulting from war, civil disturbance or natural disasters such as droughts, floods and earthquakes may result in nutritional marasmus in children and a similar condition in adults, who suffer from weight loss, wasting, diarrhoea, infectious diseases, etc.

The second major cause of severe wasting or severe PEM in adults is infections, especially chronic, untreated or untreatable infections. The most common of these now is acquired immunodeficiency syndrome AIDS resulting from infection with the human immunodeficiency virus HIV.

As the disease progresses there is marked weight loss and severe wasting. Advanced tuberculosis and many other long-term chronic infections also lead to wasting and weight loss.

A number of malabsorption conditions cause PEM in adults and children. These diseases, of which some are hereditary, result in the inability of the body to digest or absorb certain foods or nutrients.

Examples are cystic fibrosis, coeliac disease and adult sprue. Another cause of wasting in people of any age is malignancy or cancer of any organ once it progresses to a stage not treatable by surgical excision. Cachexia is a feature of many advanced cancers. A group of eating disorders cause weight loss leading to the equivalent of PEM. The most widely described is anorexia nervosa, which occurs much more commonly in females than males, in adolescents or younger adults rather than older persons and in affluent rather than poor societies.

Other psychological conditions may also result in poor food intake and lead to PEM. Treatment of adult PEM includes therapy related to the underlying cause of the condition and therapy related to feeding and rehabilitation, when the cause makes that feasible. Thus infections such as tuberculosis or chronic amoebiasis require specific therapy which when effective will eliminate the cause of the weight loss and wasting.

In contrast, curative treatment is not applicable in advanced AIDS or cancer. Dietary treatment for adult PEM should be based on principles similar to those described for the treatment of severe PEM in children, including those recovering from kwashiorkor or marasmus. Emergency feeding and the rehabilitation of famine victims described in Chapter 24 have relevance to adult PEM. It is much more difficult than controlling, for example, iodine deficiency disorders IDD and vitamin A deficiency, because the underlying and basic causes, as described above, are often numerous and complex, and because there is no single, universal, cheap, sustainable strategy that can be applied everywhere to reduce the prevalence or severity of PEM.

Part V of this book includes various strategies to reduce the prevalence of PEM. Appropriate nutrition policies and programmes are suggested, and separate chapters deal with, for example, improving food security, protection and promotion of good health, and appropriate care practices to ensure good nutrition. These chapters provide guidance on how to deal with the three underlying causes of malnutrition, namely inadequate food, health and care, which in Chapter 1 were included in the conceptual framework for malnutrition.

Other chapters in Part V discuss solutions to particular aspects of the problem, including improving the quality and safety of foods, promoting appropriate diets and healthy lifestyles, procuring food in different ways and incorporating nutrition objectives into development policies and programmes. Throughout Part V there is an emphasis on improving the quality of life of people, especially by reducing poverty, improving diets and promoting good health. Improving the energy intakes of those at risk of PEM is vital.

In the late s and s it was thought that most PEM was caused mainly by inadequate intake of protein. A great deal of emphasis was placed on protein-rich foods as a major solution to the huge problem of malnutrition in the world. This inappropriate strategy diverted attention from the first need, which is adequate food intake by children.

There is now much less emphasis on high-protein weaning foods and on nutrition education efforts to ensure greater consumption of meat, fish and eggs, which are economically out of the reach of many families who have children with PEM.

Protein is an essential nutrient, but PEM is more often associated with deficient food intake than with deficient protein intake. In general, when commonly consumed cereal-based diets meet energy needs, they usually also meet protein needs, especially if the diet also provides modest amounts of legumes and vegetables. Primary attention needs to be given to increasing total food intake and reducing infection.

Sensible efforts are needed to protect and promote breastfeeding and sound weaning; to increase the consumption by young children of cereals, legumes and other locally produced weaning foods; to prevent and control infection and parasitic disease; to increase meal frequency for children; and, where appropriate, to encourage higher consumption of oil, fat and other items that reduce bulk and increase the energy density of foods fed to children at risk.

These measures are likely to have more impact if accompanied by growth monitoring, immunization, oral rehydration therapy for diarrhoea, early treatment of common diseases, regular deworming and attention to the underlying causes of PEM such as poverty and inequity.

Some of these measures can be implemented as part of primary health care. Nutritional anaemias are extremely prevalent worldwide. Unlike protein-energy malnutrition PEM , vitamin A deficiency and iodine deficiency disorders IDD , these anaemias occur frequently in both developing and industrialized countries. The most common cause of anaemia is a deficiency of iron, although not necessarily a dietary deficiency of total iron intake.

Deficiencies of folates or folic acid , vitamin B 12 and protein may also cause anaemia. Ascorbic acid, vitamin E, copper and pyridoxine are also needed for production of red blood cells erythrocytes.

Vitamin A deficiency is also associated with anaemia. Anaemias can be classified in numerous ways, some based on the cause of the disease and others based on the appearance of the red blood cells. These classifications are fully discussed in medical textbooks. Some anaemias do not have causes related to nutrition but are caused, for example, by congenital abnormalities or inherited characteristics; such anaemias, which include sickle cell disease, aplastic anaemias, thalassaemias and severe haemorrhage, are not covered here.

Based on the characteristics of the blood cells or other features, anaemias may be classified as microcytic having small red blood cells , macrocytic having large red blood cells , haemolytic having many ruptured red blood cells or hypochromic having pale-coloured cells with less haemoglobin.

Macrocytic anaemias are often caused by folate or vitamin B 12 deficiencies. In anaemia the blood has less haemoglobin than normal. Haemoglobin is the pigment in red cells that gives blood its red colour. It is made of protein with iron linked to it. Haemoglobin carries oxygen in the blood to all parts of the body.

In anaemia either the amount of haemoglobin in each red cell is low hypochromic anaemia or there is a reduction in the total number of red cells in the body. The life of each red blood cell is about four months, and the red bone marrow is constantly manufacturing new cells for replacement. This process requires adequate amounts of nutrients, especially iron, other minerals, protein and vitamins, all of which originate in the food consumed.

Iron deficiency is the most prevalent important nutritional problem of humans. It threatens over 60 percent of women and children in most non-industrialized countries, and more than half of these have overt anaemia. In most industrialized countries in North America, Europe and Asia, 12 to 18 percent of women are anaemic.

Although deficiency diseases are usually considered mainly as consequences of a lack of the nutrient in the diet, iron deficiency anaemia occurs frequently in people whose diets contain quantities of iron close to the recommended allowances. However, some forms of iron are absorbed better than others; certain items in the diet enhance or detract from iron absorption; and iron can be lost because of many conditions, an important one in many tropical countries being hookworm infection, which is very common.

Nutritional anaemias have until recently been relatively neglected and not infrequently remain undiagnosed. There are many reasons for the lack of attention, but the most important are probably that the symptoms and signs are much less obvious than in severe PEM, IDD or xerophthalmia, and that although anaemias do contribute to mortality rates they do not often do so in a dramatic way, and death is usually ascribed to another more conspicuous cause such as childbirth. However, research now indicates that iron deficiency has very important implications, including poorer learning ability and behavioural abnormalities in children, lower ability to work hard and poor appetite and growth.

To maintain good iron nutritional status each individual needs to have an adequate quantity of iron in the diet. The iron has to be in a form that permits a sufficient amount of it to be absorbed from the intestines. The absorption of iron may be enhanced or inhibited by other dietary substances. Human beings have the ability both to store and to conserve iron, and it must also be transported properly within the body. The average male adult has 4 to 5 g of iron in his body, most of it in haemoglobin, a little in myoglobin and in enzymes and around 1 g in storage iron, mainly ferritin in the cells, especially in the liver and bone marrow.

Losses of iron from the body must not deplete the supply to less than that needed for manufacture of new red blood cells. To produce new cells the body needs adequate quantities and quality of protein, minerals and vitamins in the diet. Protein is needed both for the framework of the red blood cells and for the manufacture of the haemoglobin to go with it.

Iron is essential for the manufacture of haemoglobin, and if a sufficient amount is not available, the cells produced will be smaller and each cell will contain less haemoglobin than normal. Copper and cobalt are other minerals necessary in small amounts. Folates and vitamin B 12 are also necessary for the normal manufacture of red blood cells.

If either is deficient, large abnormal red blood cells without adequate haemoglobin are produced. Ascorbic acid vitamin C also has a role in blood formation. Providing vitamin A during pregnancy has been shown to improve haemoglobin levels. Of the dietary deficiency causes of nutritional anaemias, iron deficiency is clearly by far the most important.

Good dietary sources of iron include foods of animal origin such as liver, red meat and blood products, all containing haem iron, and vegetable sources such as some pulses, dark green leafy vegetables and millet, all containing non-haem iron. However, the total quantity of iron in the diet is not the only factor that influences the likelihood of developing anaemia. The type of iron in the diet, the individual's requirements for iron, iron losses and other factors often are the determining factors.

Iron absorption is influenced by many factors. In general, humans absorb only about 10 percent of the iron in the food they consume.

The adult male loses only about 0. On an average monthly basis, the adult pre-menopausal woman loses about twice as much iron as a man.

Similarly, iron is lost during childbirth and lactation. Additional dietary iron is needed by pregnant women and growing children. The availability of iron in foods varies greatly.

In general, haem iron from foods of animal origin meat, poultry and fish is well absorbed, but the non-haem iron in vegetable products, including cereals such as wheat, maize and rice, is poorly absorbed. These differences may be modified when a mixture of foods is consumed. It is well known that phytates and phosphates, which are present in cereal grains, inhibit iron absorption. On the other hand, protein and ascorbic acid vitamin C enhance iron absorption.

Recent research has shown that ascorbic acid mixed with table salt and added to cereals increases the absorption of intrinsic iron in the cereals two- to fourfold. The consumption of vitamin C-rich foods such as fresh fruits and vegetables with a meal may therefore promote iron absorption.

Egg yolk impairs the absorption of iron, even though eggs are one of the better sources of dietary iron. Tea consumed with a meal may reduce the iron absorbed from the meal. The normal child at birth has a high haemoglobin level usually at least 18 g per ml , but during the first few weeks many cells are haemolysed.

The iron liberated is not lost but is stored in the body, especially in the liver and spleen. As milk is a poor source of iron, this reserve store is used during the early months of life to help increase the volume of blood, which is necessary as the baby grows. Premature infants have fewer red blood cells at birth than full-term infants, so they are much more prone to anaemia. In addition, iron deficiency in the mother may affect the infant's vital iron store and render the infant more vulnerable to anaemia.

A baby's store of iron plus the small quantity of iron supplied in breastmilk suffice for perhaps six months, but then other iron-containing foods are needed in the diet.

Although it is desirable that breastfeeding should continue well beyond six months, it is also necessary that other foods containing iron be introduced into the diet at this time. Although most solid diets, both for children and adults, provide the recommended allowances for iron, the iron may be poorly absorbed. Many people have increased needs because of blood loss from hookworm or bilharzia infections, menstruation, childbirth or wounds.

Women have increased needs during pregnancy, when iron is needed for the foetus, and during lactation, for the iron in breastmilk. It is stressed that iron from vegetable products, including cereal grains, is less well absorbed than that from most animal products. Anaemia is common in premature infants; in young children over six months of age on a purely milk diet; in persons infected with certain parasites; and in those who get only marginal quantities of iron, mainly from vegetable foods.

It is more common in women, especially pregnant and lactating women, than in men. In most of the world, both North and South, the greatest attention to iron deficiency anaemia is directed at women during pregnancy, when they have increased needs for iron and often become anaemic. Pregnant women form the one group of the healthy population who are advised to take a medicinal dietary supplement, usually iron and folic acid.

Pregnant and lactating women are a group at especially high risk of developing anaemia. It is only in recent years that the prevalence and importance of iron deficiency apart from anaemia has been widely discussed. Clearly, however, if the causes of iron deficiency are not removed, corrected or alleviated then the deficiency will lead to anaemia, and gradually the anaemia will become more serious.

Increasing evidence suggests that iron deficiency as manifested by low body iron stores, even in the absence of overt anaemia, is associated with poorer learning and decreased cognitive development. International agencies now claim that iron deficiency anaemia is the most common nutritional disorder in the world, affecting over 1 million people.

In females of child-bearing age in poor countries prevalence rates range from 64 percent in South Asia to 23 percent in South America, with an overall mean of 42 percent Table Prevalence rates are usually considerably higher in pregnant women, with an overall mean of 51 percent.

Thus half the pregnant women in these regions, whose inhabitants represent 75 percent of the world's population, have anaemia. Unlike reported figures for PEM and vitamin A deficiency, which are declining, estimates suggest that anaemia prevalence rates are increasing. In most of the developing regions, and particularly among persons with anaemia or at risk of iron deficiency, much of the iron consumed is non-haem iron from staple foods rice, wheat, maize, root crops or tubers.

In many countries the proportion of dietary iron coming from legumes and vegetables has declined, and rather small quantities of meat, fish and other good sources of haem iron are consumed. In some of the regions with the highest prevalence of anaemia the poor are not improving their dietary intake of iron, and in some areas the per caput supply of dietary iron may even be decreasing year by year.

In many parts of the world where iron deficiency anaemia is prevalent it is due as much to iron losses as to poor iron intakes. Whenever blood is lost from the body, iron is also lost. Thus iron is lost in menstruation and childbirth and also when pathological conditions are present such as bleeding peptic ulcers, wounds and a variety of abnormalities involving blood loss from the intestinal or urinary tract, the skin or various mucous membrane surfaces. Undoubtedly one of the most prevalent and important causes of blood loss is hookworms, which can be present in very large numbers.

The worms suck blood and also damage the intestinal wall, causing blood leakage. Some million people in the world are infested with hookworms. Other intestinal parasites such as Trichuris trichiura may also contribute to anaemia. Schistosomes or bilharzias, which are of several kinds, also cause blood loss either into the genito-urinary tract in the case of Schistosoma haematobium or into the gut. Malaria, another very important parasitic infection, causes destruction of red blood cells that are parasitized, which can lead to what is termed haemolytic anaemia rather than to iron deficiency anaemia.

In programmes to reduce anaemia actions may be needed to control parasitic infections and to reduce blood loss resulting from disease as well as to improve dietary intakes of iron.

Anaemia resulting from folate deficiency is less prevalent than that from iron deficiency or iron loss. It occurs when folate intakes are low and when red cells are haemolysed or destroyed in conditions like malaria. The anaemia of both folate and vitamin B 12 is macrocytic, with larger than normal red blood cells. Folic acid or folates are present in many foods including foods of animal origin e.

Iiver and fish and of vegetable origin e. Vitamin B 12 is present only in foods of animal origin. In most countries vitamin B 12 deficiency is uncommon. Haemoglobin in the red blood cells is necessary to carry oxygen, and many of the symptoms and signs of anaemia result from the reduced capacity of the blood to transport oxygen. The symptoms and signs are: These symptoms and signs are not confined to iron deficiency anaemia but are similar in most forms of anaemia.

Most occur also in some other illnesses and thus are not specific to anaemia. Because none of the symptoms seem severe, dramatic or life threatening, at least in the early stages of anaemia, the disorder tends to be neglected.

An experienced health worker can sometimes make a preliminary diagnosis by examining the tongue, the conjunctiva of the lower eyelid and the nailbed, which may all appear paler than normal in anaemia. The examiner can compare the redness or pinkness below the nail of the patient with the colour beneath his or her own nails.

Enlargement of the heart may result and can be detected in advanced severe anaemia. Oedema usually occurs first in the feet and at the ankles. There may also be an increased pulse rate or tachycardia. Occasionally the nails become relatively concave rather than convex and become brittle. This condition is termed koilonychia. Anaemia is also reported to lead both to abnormalities of the mouth such as glossitis and to pica abnormal consumption of earth, clay or other substances.

What is surprising is that many persons with very low haemoglobin levels, especially women in developing countries, appear to function normally. With chronic anaemia they have adapted to low haemoglobin levels. They may indeed do reduced work, have fatigue and walk more slowly, but they still give the appearance of performing their normal duties even though severely anaemic.

Severe anaemia can progress to heart failure and death. Anaemia, as well as producing the symptoms and signs discussed above, also leads to a reduced ability to do heavy work for long periods; to slower learning and more difficulty in concentration by children in school or elsewhere; and to poorer psychological development. A very important aspect of anaemia in women is that it markedly increases the risk of death of the mother during or after childbirth. The woman may bleed severely, and she has low haemoglobin reserves.

There is also an increased risk for her infant. The diagnosis of anaemia requires a laboratory test. In this respect it differs from the serious manifestations of PEM, vitamin A deficiency and IDD; kwashiorkor, nutritional marasmus, advanced xerophthalmia, goitre and cretinism can all be diagnosed with some degree of certainty by skilled clinical observation. Consequently, whereas few district hospitals and practically no health centres have laboratories set up to test, for example, levels of serum vitamin A or urinary iodine, most are able to do haemoglobin or haematocrit determinations.

These tests require quite cheap apparatus and can be performed by a trained technician, nurse or other health worker. Determinations of haemoglobin or haematocrit levels are the most widely used in the diagnosis of anaemia. It is now realized that although these tests provide information on the absence, presence or severity of anaemia, they do not provide information on the iron stores of the individual. In terms of nutritional assessment to guide nutrition planning and interventions, or for research, it may be important to know more about the iron status of an individual than can be gained from haemoglobin and haematocrit determinations.

Many methods are used to measure haemoglobin levels. These range from simple colorimetric tests to more advanced tests which require a proper laboratory. Some new portable colorimeters can be used in the field; they are simple to use and provide reasonably accurate measurements.

In the laboratory of even a moderate-sized hospital the so-called cyanmethaemoglobin method is frequently used; it is accurate and can be used to test blood collected by finger prick in the field.

The different methods and their advantages are discussed in various books, of which some are included in the Bibliography. Haematocrit level or packed cell volume PCV , i. Blood also obtained from a finger prick is placed in a capillary tube and centrifuged, usually at 3 rpm.

The centrifuge can be electric run if necessary from a vehicle battery or hand operated. A thin blood film examined under the microscope can be used to judge if the red blood cells are smaller microcytic or larger macrocytic than normal normo cytic.

In iron deficiency they are microcytic and in folate or vitamin B 12 deficiency they are macrocytic. Pale cells are termed hypochromic.

Cut-off points taken from the World Health Organization WHO suggestions for the diagnosis of anaemia based on haemoglobin and haematocrit determinations are given in Table Certain other laboratory tests are useful in judging iron nutritional status rather than for diagnosing anaemia or its severity.

In recent years it has been increasingly recognized that iron status is important because mild or moderate iron deficiency, prior to the development of anaemia, may adversely influence human behaviour, psychological development and temperature control. A person whose diet is low in iron or who is losing iron goes through a period when body iron stores which are mainly in the liver are gradually depleted before he or she develops anaemia as judged by low haemoglobin or haematocrit levels see Figure 7.

Anaemia is the end stage after iron stores have been depleted. To monitor iron stores it is useful to determine serum ferritin levels, because they are the first to decline. This is not a simple or cheap test to do, and few small or medium-sized hospitals in developing countries have the ability to do it, but teaching hospitals and nutrition research laboratories sometimes can. Unfortunately serum ferritin levels are influenced by infections, which are common in developing countries.

Other determinations that may be done to evaluate iron status and which are described in textbooks include free erythrocyte protoporphyrin FEP and transferrin saturation TS Figure 7.

Suggested criteria for diagnosis of anaemia using haemoglobin Hb and haematocrit PCV determinations. Changes in body iron compartments and laboratory parameters of iron status during development of iron deficiency due to a continuous negative iron balance.

The treatment of anaemia depends on the cause. Iron deficiency anaemia is relatively easy and very cheap to treat. There are many different iron preparations on the market; ferrous sulphate is among the cheapest and most effective. The recommended dose of ferrous sulphate is usually mg providing 60 mg of elemental iron twice daily between meals for adults.

Iron tends to make the stools black. Because side-effects can occur, particularly involving the intestinal tract, sometimes people do not take their iron tablets regularly. Slow-release iron capsules have become available and seem to be associated with fewer side-effects. Most capsules contain ferrous sulphate in small pellets, so the iron is slowly released.

Only one capsule or dose needs to be taken each day, but the capsules cost much more than ferrous sulphate tablets. Therefore it is unlikely that slow-release preparations will replace standard ferrous sulphate tablets for use in clinics in developing countries. New research conducted in China suggests that ferrous sulphate is as effective when given once every week as when given once a day.

If further trials confirm this observation, the finding will alter both the treatment of anaemia and the efforts to prevent it using medicinal iron supplements in prenatal clinics. In Indonesia, where vitamin A deficiency is a problem, it has been shown recently that giving vitamin A as well as iron improves the haemoglobin levels of pregnant women more than iron tablets alone.

In all cases the underlying cause of the anaemia should be sought and treated if possible. Iron dextran is the injectable preparation most commonly used. Intravenous injection is preferable. The standing rule is to give a very small test dose initially and to wait for five minutes for any sign of an anaphylactic reaction.

If there is no reaction, then mg can be given from a syringe over a period of five to ten minutes. These injections may be given at intervals over a few days.

Alternatively, a total dose infusion can be provided at one time. This procedure must be employed only by doctors experienced in the technique and in calculating dosage levels. It is common during pregnancy to provide folate as well as iron, or combined with iron, as part of the treatment of or prophylaxis against anaemia. For prevention, where anaemia is prevalent, doses of mg of iron and 5 mg of folate daily are recommended.

For treatment of established anaemia, doses of mg of iron and 10 mg of folate are suggested. Successful treatment usually leads to a response in haemoglobin levels within four weeks. Persons with iron deficiency anaemia on very poor diets should be advised to consume more fresh fruits and vegetables at mealtimes. These foods contain vitamin C, which enhances the absorption of non-haem iron in cereals, root crops and legumes. They also contain folic acid and an array of other vitamins and minerals.

If it is feasible and in line with the anaemic patient's budget and culinary habits, he or she could also be advised to consume, even in small quantities, more foods rich in haem iron such as meat, especially liver or kidney.

Creating awareness of the nutritional needs of different family members and helping household decision-makers to understand how these needs can best be met from available resources are important steps in preventing iron deficiency. Iodine deficiency is responsible not only for very widespread endemic goitre and cretinism, but also for retarded physical growth and intellectual development and a variety of other conditions. These conditions together are now termed iodine deficiency disorders IDD.

They are particularly important because: In fact, as H. Labouisse wrote in when he was Executive Director of the United Nations Children's Fund UNICEF , "Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for this reason" quoted in Hetzel, Nonetheless this crime persists. Endemic goitre and severe cretinism are the exposed part of the IDD iceberg. These are abnormalities that are visible to the populations where they are prevalent, and they can be diagnosed relatively easily by health professionals without the use of laboratory or other tests.

The submerged and larger part of the iceberg includes smaller, less visible enlargements of the thyroid gland and an array of other abnormalities. In many areas of Latin America, Asia and Africa iodine deficiency is a cause of mental retardation and of children's failure to develop psychologically to their full potential.

It is also associated with higher rates of foetus loss including spontaneous abortions and stillbirths , deaf-mutism, certain birth defects and neurological abnormalities. For several decades the main measure used to control IDD has been the iodization of salt, and when properly conducted and monitored it has proved extremely effective in many countries. It is also relatively cheap. Several international meetings, including the International Conference on Nutrition held in Rome in , called for the virtual elimination of IDD by the year This goal is achievable, provided the effort receives international support and real national commitment in each of the many countries where the disorders remain prevalent.

The most important cause of endemic goitre and cretinism is dietary deficiency of iodine. The amount of iodine present in the soil varies from place to place and this influences the quantity of iodine present in the foods grown in different places and in the water. Iodine is leached out of the soil and flows into streams and rivers which often end in the ocean. Many areas where endemic goitre is or has been highly prevalent are plateau or mountain areas or inland plains far from the sea.

A less important cause of IDD is the consumption of certain foods which are said to be goitrogenic or to contain goitrogens. Goitrogens are "antinutrients" which adversely influence proper absorption and utilization of iodine or exhibit antithyroid activity.

Foods from the genus Brassica such as cabbage, kale and rape and mustard seeds contain goitrogens, as do certain root crops such as cassava and turnips. Unlike goitrogenic vegetables, cassava is a staple food in some areas, and in certain parts of Africa, for example Zaire, cassava consumption has been implicated as an important cause of goitre. Areas of the world where iodine deficiency is prevalent.

Any enlargement of the thyroid gland is called a goitre. The thyroid is an endocrine gland centrally situated in the lower front part of the neck.

It consists of two lobes joined by an isthmus. In an adult each lobe of the normal thyroid gland is about the size of a large kidney bean.

In areas of the world or communities where only sporadic goitre occurs or where health workers see only an occasional patient with an enlarged thyroid gland, the cause is not likely to be related to the individual's diet. Sporadic goitre may for example be due to a thyroid tumour or thyroid cancer. However, if goitre is common or endemic in a community or district, then the cause is usually nutritional.

Endemic goitre is almost certainly caused by iodine deficiency, and where goitre is endemic other iodine deficiency disorders can also be expected to be prevalent. Where goitre is endemic, often large numbers of people have an enlargement of the thyroid gland, and some have enormous unsightly swellings of the neck.

The condition is usually somewhat more prevalent in females, especially at puberty and during pregnancy, than in males. The enlarged gland may be smooth colloid goitre or lumpy adenomatous or nodular goitre. The iodine content of foods varies widely, but the amount of iodine present in common staple foods such as cereals or root crops depends more on the iodine content of the soil where the crop is grown than on the food itself.

Because the amount of iodine in foods such as rice, maize, wheat or legumes depends on where they are grown, food composition tables cannot provide good figures for their iodine content. Foods from the ocean, including shellfish, fish and plant products such as seaweed, are generally rich in iodine.

In many populations, particularly in the industrialized countries of the North and among affluent groups almost everywhere, diets do not depend mainly on locally grown foods. As a result many of the foods purchased and consumed may contribute substantially to iodine intakes.

For example, persons living in the Rocky Mountains of North America, where goitre used to be endemic, now do not rely much on locally produced foods; they may consume bread made from wheat grown in the North American central plains, rice from Thailand, vegetables from Mexico or California, seafood from the Atlantic coast and so on. Similarly, affluent segments of society in La Paz, Bolivia consume many foods not grown in the altiplano, and these imported foods will have adequate quantities of iodine.

In contrast, the poor in the Bolivian highlands eat mainly locally grown foods and do develop goitre. Many countries of Asia, Africa and Latin America have major iodine deficiency problems, although some countries have made great progress in reducing the prevalence of IDD. China and India, with their vast populations, still have a high prevalence of IDD. In the Americas, endemic goitre has been largely controlled in the United States and Canada, but many Andean countries including Bolivia, Colombia, Ecuador and Peru still have relatively high endemic goitre and cretinism rates.

During a survey conducted by the author in the s in the Ukinga Highlands of Tanzania, 75 percent of the people examined had goitre. This was the highest prevalence yet reported in Africa. Prevalence rates of over 60 percent have been reported from communities in many African, Asian and Latin American countries. Generally goitre prevalence rates of 5 to But even with rates of 10 to 15 percent the need for action is important.

Where prevalence rates are moderate, urgent action is needed. Where rates are severe, early action is critical see Table Enlargement of the thyroid gland is the most frequently described and most obvious clinical manifestation of iodine deficiency.

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