Progress report - project year 01
Project Title:
The Chakoria Food System Project for the Sustainable Prevention of Rickets and
Other Types of Malnutrition in Bangladesh
| Project Investigators: | ||
| PI: G.F. Combs, Jr., Ph.D. | Co-PI: C.A. Meisner, Ph.D. | Coordinator: Andrew M. Daly |
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| Cornell University, Ithaca, NY, USA | Dhaka, Bangladesh | Dhaka, Bangladesh |
| Investigators: | ||
| Md. Nazmul Hassan, Ph.D. | John M. Duxbury, Ph.D. | Ross M. Welch, Ph.D. |
| Institute of Food and Nutrition | Dept. Crop and Soil Sciences | US Plant, Soil and Nutrition Laboratory |
| Dhaka University, Dhaka, Bangladesh | Cornell University, Ithaca, NY, USA | Ithaca, NY, USA |
| Collaborators: | ||
| Shahidul Haque | Philip Fischer. M.D. | Dave Staab, M.D. |
| SARPV | Mayo Clinic | Memorial Christian Hospital |
| Dhaka, Bangladesh | Rochester, MN, USA | Malumghat, Bangladesh |
| Moustaq Chowdhery, Ph.D. | Luthful Kabir, M.D. | Jean-Paul Cimma, M.D. |
| BRAC | Institute of Mother and Child Health | Amis des Enfants du Monde |
| Dhaka, Bangladesh | Dhaka, Bangladesh | Vif, France |
| Julie Lauren, Ph.D. | ||
| Cornell University | ||
| Ithaca, NY | ||
| Consultant: | ||
| George Fuchs, M.D. | ||
| ICDDR,B | ||
| Dhaka, Bangladesh |
Background:
Rickets has emerged as a major source of disability in the Chakoria area of SE Bangladesh (Cox's Bazaar District). Based on our preliminary studies, the disease does not appear to involve vitamin D deficiency as a primary cause. Instead, our evidence suggests that low intakes of calcium (Ca) are likely to be a major cause of the disease. Its emergence within the last 15-20 yrs. suggests that other food/soil/water-borne factors may also be important in its etiology. Therefore, our theory of the disease is that primary (i.e., dietary) Ca deficiency is the pre-disposing cause and that this may be exacerbated by exposure to one or more precipitating factors. Such precipitating factors would include anything that would reduce exposure to dietary Ca (e.g., reduced production of such Ca-rich crops as brassicas and some grain legumes with the triple-cropping of rice; loss of access to dairy products) and/or reduce the metabolic utilization of ingested Ca (e.g., exposure to oxalates in leafy vegetables; expsoure to F, Sr, Al, Pb, Cd and/or Ba; deficient intakes of B; exposure to high levels of pseudo-estrogenic chorinated hydrocarbons). Such an etiology would very strongly suggest that the bone health of adults might also be affected in rickets-endemic communities. Although there are simply no data on the subject, one would expect that metabolic bone diseases other than rickets in children (which, after all, can be very dramatically evident in growing children) would also occur in these areas. In particular, one would expect high rates of post-menopausal osteoporosis in women and bone loss in older men (these conditions would be manifest as loss of stature, kyphosis [forward bending of the back] and relatively high rates of fractures particularly of the wrists, pelvis and vertebrae). Because the factors thought to be involved in the etiology of the rickets in Chakoria are all derived from food, the bone disease is properly seen as a manifestation of a deficient food system. Therefore, it is logical to look to that food system for means of preventing not only rickets, but also other metabolic bone diseases and nutritional deficiencies. In addition to efficacy, such approaches offer real chances of being sustainable if developed within the economic, social and biophysical contexts of food systems.
This project was developed with funds provided by the USAID Mission to Bangladesh; these were routed through the SM-CRSP.
Collaborations:
This project involves important collaboratorations with several other institutions, in particular the International Wheat and Maize Improvement Center (CIMMYT), the Bangladeshi NGO Social Assistance and Rehabilitation for the Physically Vulnerable (SARPV), Dhaka Univesity, the Bangladesh Rural Advancement Committee (BRAC) and the members of the Bangladesh Rickets Consortium(1).
We have arranged with CIMMYT to support the participation of the CIMMYT-Bangladesh office (i.e., Dr. Meisner and staff) in the project which handles all Soil Management-CRSP funding in this country under its Memorandum of Understanding with the Government of Bangladesh. The Dr. Meisner, an agronomist with CIMMYT's Natural Resources Group, has lived and worked in Bangladesh for 15 years. He, thus, brings important expert knowledge of local food systems to the project, as well as considerable experience in "whole family planning", a very successful means of fostering agricultural technological change within the culture. Our Project Coordinator, Mr. Daly, also enjoys the title of Adjunct Scientist in CIMMYT.
SARPV is a Bangladeshi NGO committed to improving opportunities for the physically challenged in Bangladesh, a group that is too often forgotten in development efforts. In fact, it was the call by SARPV's executive Director, Mr. Shahidul Haque, that originally brought us (Drs. Combs and Meisner) to recognize that rickets was a significant public health problem in Chakoria. SARPV has been active in Chakoria since 1991 and has a system of Village Development Workers (VDWs) and, more recently, has established a system of Agricultural Workers (AWs). We have been genuinely impressed as SARPVs selfless commitment to the people of Chakoria and have found working with its director and staff to be rewarding and effective. We have provided SARPV with modest support for developing their property near Chakoria as an Agro-Food Resource Center and for supporting community-based medical care in Chakoria. In these efforts our approach is to allow our efforts to be perceived locally as those of SARPVs which, after all, will remain active locally long after this project of concluded. With that in mind, we are mindful of improving SARPV competence partricularly in the areas of agriculture, horticulture, nutrition and health.
Project Goals and Objectives:
The ultimate goal of the project is to increase the intakes and utilization of Ca by infants and children in Chakaria, Bangladesh, in sustainable ways that also improve their status with respect to other limiting micronutrients (2) many of which (i.e., the essential minerals) must be obtained ultimately from soils. The project seeks to develop multiple opportunities within the Chakorian food system to increase the Ca intake/utilization of children from the estimated present value of 130 mg/cap/day to at least 300 mg/cap/day. Emphasis is being placed on steps that also increase the supplies of essential minerals and vitamins, which the Chakoria food system presently does not provide in sufficient amounts to support child health and development. Our original plan was to accomplish this goal by address five specific objectives:
WORK PLAN (revised): Chakaria Food System Project
| Objective | Activity | Responsible Individuals | Collaborators | Orig. Completion | Rev'd Completion | Outputs |
| 1 Characterize Food System | 1A collect area data | Hassan, Daly, Combs, Meisner | Haque | 6.30.99 | 6.30.00 | area soil/water/farm practices data set |
| 1B collect village data | Hassan, Daly, Combs, Meisner | Haque | 6.30.99 | 6.30.00 | village practices data set | |
| 1C collect HH data | Hassan, Daly, Combs, Meisner | Haque | 6.30.99 | 6.30.00 | HH food security/health data set | |
| 1D collect individual | Hassan, Daly, Combs, Mesiner | Haque | 6.30.99 | 6.30.00 | baseline rickets/ malnutrition prevalence data set | |
| 2 Analyze Food System | 2A prelim. analysis | Combs, Hassan | 12.01.99 | rickets risk factors , round I data | ||
| 2B develop & evaluate model | Combs,Hassan,Daly, Duxbury,Meisner,Welch | 1.1.00 | 6.30.00 | Food System Model; intervention opportunities | ||
| 3 Elucidate Rickets | 3A map MCH cases | Daly | Staab | 6.1.99 | map of MCH rickets cases | |
| Prevalence & Etiology | 3B pilot rickets survey | Daly, Combs | Chowdhery | 12.1.99 | thana-level estimates of rickets prevalence, Cox=s Bazaar Dist. | |
| 4 Evaluate/Develop Home Gardens | 4A conduct home/village meetings | Daly, Meisner, Hassan, Haque | Haque | 6.30.99 | 1.30.00 | constraints/opportunities/needs |
| 4B sample soil, water | Meisner, Daly, Duxbury, Welch | 6.30.99 | 1.30.00 | baseline data for home garden program | ||
| 4C estimate nutrient outputs in crops | Combs, Duxbury, Welch | 1.1.00 | 1.1.00 | home gardens nutrient models | ||
| 5 Introduce New | 5A develop SARPV farm | Daly, Meisner, Duxbury | Haque | 6.30.99 | contin'g | functioning farm for testing & demon. |
| Techniques/Strategies | 5B evaluate new techniques & strategies | Daly, Meisner, Duxbury | Haque | contin'g | contin'g | candidate interventions for farmers and home gardeners |
| 5C introduce new techniques & strategies | Daly, Meisner, Duxbury, Hassan | Haque | contin'g | contin'g | interventions for farmers and home gardeners | |
| 6. Support of Rickets Consortium | 6A provide secretariat | Combs, Meisner, Daly | Haque, Kyaw-Myint | contin'g | contin'g | annual meeting; press conference; newsletter |
Modifications of Original proposal:
During the first project year (PY01), we modified the project plan in three ways:
1. We added a specific aim (#3) to address what we feel to be the pressing need to understand the extent and etiology of rickets in Bangladesh. These needs are considered by the members of the Bangladesh Rickets Consortium to be key to addressing the problem of rickets in this country.
2. We adjusted our time-lines for the completion of the Chakoria Food System Survey. This was necessitated by the date (nearly 6 months into PY01) at which funds were finally delivered to Cornell, and after we decided that the best way to conduct such a study would be to collect data in multiple (4) rounds of surveys each of which would be timed to yield information relating to known periods of food shortage/abundance during the year.
3. We added specific aim (#6) the support of the Bangladesh Rickets Consortium (which we co-founded) to this project.
PROGRESS, PY01
OBJECTIVE 1: Characterization of the Chakorian Food System
Under the leadership of Prof. Hassan, we initiated a sophisticated study of the Chakoria food system. This was designed as a household-level case-control study; its primary purpose will be to identify those factors associated with having a rachitic child. Such risk factors will be important in our other efforts to elucidate the etiology of the disease as well as to guide our development of preventive measures. We expect to use the risk factors identified in this study in larger, more targeted surveys in other areas (of Bangladesh and elsewhere). The household surveys were also designed to yield quantitative information about all household activities relating to food (production, acquisition and utilization) as well as general health, demographic and economic data.
This work involved the hiring and training of a 10-person team of data enumerators. In this we were particularly fortunate in being able to recruit a team most of whom were experienced in these interviewing methodologies and many of whom, in fact, had studied with Prof. Hassan. The team was deployed, with the help of the local SARPV staff in finding suitable living quarters, in Chakoria where they conducted in-depth interviews (one with the men of the house concerning farming and economic issues; another with the women of the house concerning household food acquisition and utilization and health) with a total of 480 households in six villages (three in areas of high rickets prevalence and three in low-rickets areas). This represented a total of 187 households having at least one child affected by rickets and 293 unaffected households.
The fourth (and last) round of survey data collection will be completed in February, 2000. At the time of this writing, data from round I have been encoded into SPSS and data for rounds II and III were being entered. The investigators, under the leadership of Drs. Combs and Hassan, have developed a plan for the preliminary analysis of the early round data, this will be used in developing communication materials for Chakoria residents and will be presented at the third annual meeting of the Bangladesh Rickets Consortium which we plan to sponsor in the late spring of 2000.
Between rounds of this survey, the survey team was also used to conduct a food system survey in Dinajpur and Rangpur using the same survey instrument and methodologies. Although the Dinajpur-Rangpur data will not be used in the formal analysis of household-level risk factors for rickets, these data will give us a picture of the food system of a rice-wheat area to compare with that of a predominantly rice area. This approach also enabled us to keep a good survey team employed on a full-time basis.
| Food System Surveys: Distribution of Households (HHs)by Study Location | |||||
| survey | location | village | rickets HHs | non-rickets HHs | total HHs in village |
| Rickets Case-Control Study | Chakoria,Nathpara | Nathpara | 25 | 26 | 76 |
| Chakoria, Pekua | Andhakhali | 31 | 47 | 119 | |
| Chakoria, Paschim Bara Bheola | Ammardera | 50 | 61 | 203 | |
| Chakoria Khutakhali | S. Khutakhali | 24 | 51 | 142 | |
| Chakoria Boraitali | Maizpara | 20 | 55 | 144 | |
| Chakoria, Binamara | Fasiakhali | 37 | 53 | 282 | |
| Rice-Wheat Food System Study | Rangpur | Haldibari | 55 | 249 | |
| Dinajpur | Jagdol | 76 | 341 | ||
| Schedules: Food System Surveys | ||
| dates | Chakoria Case-Control Study | Rice-Wheat Food System Study |
| March 14-23, 1999 | round I | |
| April, 13-May 20, 1999 | round I ("lean" period) | |
| July 17-26, 1999 | round II | |
| July 28-Sept. 12, 1999 | round II (food "peak" period) | |
| Oct.-Nov., 1999 | round III ("leanest" period) | |
| Dec. 1999-Jan. 2000 | round IV (greatest food "peak" period | |
OBJECTIVE 2: Analysis of Chakoria Food System
This work will employ the data sets produced by the household-level case-control survey in Chakoria and will be conducted in PY02.
OBJECTIVE 3: Determination of Rickets Prevalence
We have collaborated with three other groups to learn more about the actual prevalence of rickets in Bangladesh. Our conclusion is that the disease is not isolated to Chakoria.
Institute of Mother and Child Health (IMCH). Before the initiation of this project, we assisted (as the leaders of the Bangladesh Rickets Consortium) Dr. Kabir and colleagues at the IMCH in the planning of a study of rickets prevalence in Chakoria Thana. They published their results in1998 as a non-peer reviewed monograph and presented them at the second meeting of the Rickets Consortium which we sponsored as part of this project in January, 1999. Briefly, their results, from a random sampling of 30 children in each of 30 villages, indicated that as many as 30% of children in Chakoria may be affected to varying degrees. They found that 9% of children had clear physical signs of rickets with 11% of that number showing active rickets (i.e., with elevated alkaline phosphatase activities). But they also found that a disturbingly high (22%) number of asymptomatic children also showed elevated serum alkaline phosphatase activities, indicating that for every child crippled by the disease there were another two that were on the verge of getting it. Their results showed that in some villages rickets affected as many as 4 in every 10 households.
Memorial Christian Hospital (MCH). The MCH, located in Malumghat, Chakoria Thana, is an acute care center that is used as a referral hospital for obstetrics, neonatal care, general and orthopedic surgery. It has been serving the area since 1966. In addition to clinical care, MCH also offers educational programs on health care and paramedical courses for village doctors. Patients come to MCH with a variety of complaints. These have included cases that have been diagnosed as rickets. Thus, MCH has a reputation for treating children with leg deformities. Dr. Staab of their medical staff acknowledges that rickets is not well understood in the community.
As part of the Bangladesh Rickets Consortium, we asked MCH to review their medical records for any information they may contain about the recent history of rickets in the area. They accomplished such a review through the efforts of a visiting American medical intern in 1998 who spent four months going through their hand-written records. This effort, revealed a total of 441 patients that were diagnosed with rickets or rickets-like symptoms (e.g., varus/valgus deformities of the knees, swollen wrists and joints, bent forearms and difficulty walking) since 1991. We reviewed this information, which they shared with us; our evaluation is as follows:
Age-Distribution of Cases. During the initial hospital visit, parents or patients were asked when they first noticed the signs of the disease. A wide range of responses was noted (1-30 yrs.); however, most cases were reported as having begun between one and three years of age (see graph). MCH clinicians have told us that they have treated rachitic children as young as six months.
Trends in Prevalence. The records showed that from 1991-97, the number of rachitic cases at MCH increased by 124% (i.e., 20% per year) (Graph 2 ). In the 17-month period from January 1, 1997 to May 7, 1998, 113 rickets cases were seen as outpatients.
| Residential Distribution of MCH Rickets Cases, 1991-1998 | |||
| District | Thana | Cases | District Total |
| Bandarban | Lama | 2 | 4 |
| Naingkha Chhari | 2 | ||
| Chittagong | Satkania | 30 | 67 |
| Lohagora | 19 | ||
| Hathazari | 6 | ||
| Patia | 6 | ||
| Double Muring | 2 | ||
| Fatikchhari | 2 | ||
| Anwara | 2 | ||
| Cox's Bazaar | Chakoria | 104 | 243 |
| Cox's Bazaar Sadar | 93 | ||
| Ramu | 21 | ||
| Teknaf | 9 | ||
| Moheshkali | 8 | ||
| Ukhia | 5 | ||
| Kutubdia | 3 | ||
| Feni | Feni Sadar | 4 | 4 |
| Khagrachhari | Khagrachhari Sadar | 1 | 4 |
Geographic
Distribution of Cases. While the MCH records show that 25% of the
verified rickets cases came to MCH from Chakoria Thana and the neighboring
thana of Cox's Bazaar Sadar, they also show that almost an equal number
(21%) came from thanas in Chittagong District to the north and that some
cases came from as far away as Feni and Comilla District--more than 200
km away. While we are aware of the potential for biases in this sort of
data: mis-classification bias (i.e., the closest post office was used as
the residential location identifier) and ascertainment bias (persons may
be less likely to come to MCH if they live far away, have little money,
are not comfortable with Christians, etc.). Nevertheless, we feel that these
data establish that rickets is not restricted to Chakoria. While it is clear
that rickets is under-diagnosed in Chakoria, these data suggest that the
disease is also under-diagnosed elsewhere in Bangladesh.
Bangladesh Rural Advancement Committee (BRAC). With the strong suspicion that rickets may be widely under-diagnosed in Bangladesh, we approached Dr. Ahbed of BRAC with the proposal that their research unit help us develop an instrument that could be useful for the rapid, community-based assessment of rickets prevalence. Our idea was to develop a way of ultimately preparing a "rickets map" of the country to determine how widespread/focused is the prevalence of the disease - either of which outcomes would be informative as to it etiology. We were very pleased that BRAC was eager to collaborate on such an effort and that Dr. Moustaq Chowdhery, a very experienced researcher was identified to lead the effort. Working with Dr. Chowdhery's group, we developed and pilot tested simple survey instrument appropriate for use by non-medical personnel, i.e.,an instrument that can be used by community workers to survey their community and note down relevant information about probable rickets cases. The instrument, which consisted of a 1-page poster showing photographs of the major leg signs of rickets, was employed in a survey designed to yield statistically valid thana-level estimates of the prevalence of rickets leg signs prevalence in Cox's Bazaar District.
The survey involved 28 villages selected randomly from each of 4 unions from each of the 7 thanas of the district. Two teams surveyed these households: one comprised of non-medical personnel, which used the instrument to canvass thoroughly for rickets cases between 1-20 yrs. of age; one comprised of medical doctors, which followed the non-medical team and examined all cases identified by the first team. This check was designed to quantify the error in having non-medical personnel diagnose rickets based only on lower limb deformities. The study was conducted in June-July, 1999.
Dr. Chowdhery is in the process of conducting the final analysis of data from the BRAC survey of Cox's Bazar District. Preliminary results suggest that rachitic leg deformities occur throughout the district and are by no means limited to Chakoria thana. The thana-avarge prevalence of rachitic leg signs varied from 0.6 to 1.8% of children; it should be understood that these significantly underestimate the true prevalence or rachitic bone deformities which are also seen particularly in the wrists, chest and head. Based upon the IMCH data, we can expect the BRAC estimates to represent nearly half of the actual cases that can be diagnosed by a trained clinician. Therefore, these data indicate that as much as 4% of the child population of Cox's Bazaar District have rickets and that the disease is not tightly clustered.
| thana | leg signs, % | est'd rickets prevalence§, % | est'd. cases |
| Moheshkhali | 0.6 | 1.3 | 1860 |
| Chakoria | 0.7 | 1.5 | 5175 |
| Ukhiya | 0.8 | 1.7 | 1320 |
| Ramu | 0.9 | 1.9 | 1960 |
| Cox's Bazaar Sadu | 1.1 | 2.3 | 3485 |
| Teknaf | 1.3 | 2.7 | 2675 |
| Kulubda | 1.8 | 3.8 | 2170 |
| total: | 19,185 | ||
We have been planning a clinical
intervention trial to determine whether supplemental dietary calcium can
reduce rickets risk in Chakoria and also whether the supplementation of
other limiting micronutrients (i.e., vitamins and minerals) is necessary
for calcium-supplementation to be effective. Our partner in this effort
has been Drs. Bruce Daggey and Adrianne Bendich, Smith-Kline Beacham, Ltd.
(SKB). SKB has agreed to provide the dietary supplements for this study;
these will consist of modifications of one of their products(3)
which will be produced for this use in their manufacturing plant
in Hyderabad, India. SKB has spent the last 4 months working to develop
the treatment "a" placebo product that is both low in calcium
and has organoleptic properties identical to the other products.
OBJECTIVE 4: Evaluate/Develop Home Gardens
We included in our Household-Level Case-Control (Food System) survey a substantial number of questions relating directly to homestead food production including home gardening. These data will give us a good picture of these activities in Chakoria and how they contribute to household food economies.
We also joined (June, 1999) in the AVRDC-USAID Bangladesh Project. This program is of great benefit to our project, as it is helping to facilitate collaborative working relationships in the community with our key collaborator, the Bangladeshi NGO, SARPV (a Rickets Consortium member). SARPV, which has worked in the Chakoria Thana since 1991, already has a well developed village outreach program covering a good portion of the Thana(4). As part of AVRDC's effort to transfer technological advances in horticulture to rural farmers, that agency has agreed to support SARPV in conducting demonstrative homestead gardening plots and adaptive trials in SARPV's target area. Our plan is to headquarter these activities in the Agro-Food Center and to provide the initial leadership and impetus in developing sustainable competence within SARPV in the harticultural field. The objectives of our program will be:
a) to evaluate suitability of recommended varieties/technologies in the area; and
b) to promote vegetable cultivation and consumption to supplement nutrition.
As an AVRDC collaborator, it will be our responsibility to coordinate and monitor program activities; supply the seeds and program guidance and technical support, and reimburse expenditures. In addition, SARPV will be responsible for implement program/activities as per guidelines/suggestions of AVRDC, collecting certain data and provide feedback to AVRDC; present results at a number of workshops; provide technical and financial reports including participating farmer information; and manage the project execution according to the above objectives. This program will involve families which have agreed to establish Demonstrative Gardens as well as others which have agreed to participate in Homestead Gardening. More vegetable varieties are grown in the demonstration gardens and farmers are using hormone applications and poly tunnels. SARPV is currently working with 86 households on demonstration gardens and with about 300 participating farmers who have planted homestead gardens. This program is of great benefit to our project, as it is helping to facilitate collaborative working relationships in the community between SARPVs Agricultural Workers and VDWs. The program fits in well with the framework for the planned community food-based intervention program.
To date, two large training sessions have been conducted at the Agro-Food Resource Center. AVRDC and the Center Manager conducted one homestead gardening session involving 20 farmers. The second training, focused on vegetable and fruit cultivation, was organized and conducted by the Local Thana Agricultural Officer and the Center Manager with 30 participants (men and woman) from the community.
OBJECTIVE 5: Development of SARPV Agro-Food Nutrition Resource Center
Our efforts, therefore, have included steps explicitly designed to enhance the abilities of our partner SARPV to deal with issues it appreciates but which are still new to its experience, namely, agriculture, food and health. Our rationale is that SARPV is not only a committed local and effective entity; but that it will be in Chakoria long after the conclusion of our project. Thus, we see any lasting contributions that we can make can best be made through SARPV. Therefore, our strategy in much of this work has been to present our activities with a SARPV "face". In PY01, these activities involved the initial development of the SARPV Agro-Food Nutrition Research Center and the initiation of a community-based health program.
Agro-Food Nutrition Resource Center
Background. In 1998, SARPV made available to this project a 7-acre plot located on the edge of the Hill Tract area (Banderban) not far from Chakoria(5). Our shared vision for this site is to develop it as a center for practical experimentation, demonstration and outreach activities relating to the production of key foods that can improve the health and reduce the risk of malnutrition of people in this area. To this end, we hired a manager and staff of 6 agricultural workers (formally, SARPV employees) and gave them the immediate task of developing the Center, with our technical and (modest) financial support. As work has progressed, the team, in association with SARPV VDWs has established a presence in the neighboring communities where they have been promoting vegetable and fruit cultivation. Our goal for the Center is to develop the facility into an agricultural food nutrition resource center which will serve as:
The core value of our development concept for this site has been to use, as much as possible, approaches within reach of the local community.
Site Development. The site has a variable topography with steep sloping land (ca. 3 acres), top flat land (ca. 1 acre) and bottom flat land (ca. 3 acres) with a natural stream on the northern boundary. This water source, while not disappearing completely during the dry season, is unreliable for year round irrigation. All of the sloping lands were covered with a thick natural growth of local wild species. The previous owner used the bottom land for rice cultivation, but found the top flat land unusable during most of the year because of water constraints. We commissioned detailed topographic and hydrologic surveys of the site, and base, grid, and contour maps were prepared showing the physical features of the land. We also conducted soil analyses (pH and mineral contents), and installed a macadam road (500 m) to link the property with the main (paved) road nearby. Before we began work on the land, we prepared a log of all plants growing on the property, with those having food, timber or other useful value (e.g., mango, amla, jackfruit and sal trees) allotted space and special attention; other wild plants were cut back.
Our staff, which lives on the site, has constructed "village"-style (i.e., mud brick, thatched roof) living quarters, latrine and goat shed; they are presently constructing a 3-room building to serve as an office, storeroom and living quarters for the site manager.
The water needs of the site are not easily being met. We installed a low-cost, shallow tube well (with hand pump) near one of the main growing areas. While this is currently sufficient for the irrigation of one 1- acre plot, that task is labor-intensive and very time-consuming. We are also using a natural spring as a source of water; but that source practically dries up during the dry season. Drinking and household water for the staff is now carried uphill from that well or from a neighbor's well some distance away.
Our hydrological consultants proposed for the site a drinking/irrigation water system that would call for the installation of a second, deep (400 m) tube well located at a mid-level elevation with two header tanks and a buried-pipe irrigation system for the low bottom land, and an overhead tank and distribution system for the top flat land. With a submersible pump, this system would supply an estimated flow of 14 liters/sec. Our colleague, Dr. Michael Walter(6), found this proposal to be well designed and certainly adequate for our immediate and anticipated future needs. Therefore, we designated $14,000 of our funds to establish the basic portion of this irrigation system. While the full system will cost an additional $11,500, it appears likely at this point the those funds may be available to SARPV from the Canadian Development Agency.
Our efforts were greatly assisted by the contribution of funds from CIMMYT-Bangladesh for the purchase of a Chinese-made two-wheeled tractor. This has benefited our efforts in three ways: i. by allowing the SARPV agricultural workers to compete with local growers by being able to till the land without the risks associated with maintaining bullocks for that purpose; ii. by enhancing access for workers with physical disabilities; and iii. by offering a source of rental income to the farming operation.
Horticulture. Because neither the Center manager nor most of the workers are from local area, we decided to allow them to take some time and use their own initiative to learn about the local cropping cycle and micro-climate. Therefore, for most of this first year, the Center's staff was given a fair degree of freedom to cultivate all vegetables that they considered suitable to the area, with a push toward marketing surplus production. During this time, we compiled a vegetable cropping calendar from several local sources including the Asian Vegetable Research and Development Center (AVRDC), the local Thana Agricultural Department, and other NGOs and INGOs working on gardening programs in the district (Helen Keller International, Bangla-German Sampriti, BRAC and CARE) with which we have networked.
We believe that the key to successful and economically rewarding homestead gardens will be the dependable production during the rainy season when raising vegetables is most difficult. Therefore, during the rainy season we have planted water-tolerant crops (e.g., kang-kong, amaranthus, taro, which can be fair sources of calcium) on our bottom land while on better drained land we have planted cash crops (e.g., turmeric, ginger) and on the upper flat land we have planted micronutrient-rich crops (e.g., tomatoes, cucurbits, yard-long bean, red amaranth, turmeric, ginger, okra) in raised beds. In addition, we have planted several fruit trees (mango, olive, carambola [star fruit], guava) on the sloping land and around the staff quarters.
Forestry. We have planted 115 neem and 50 mahogany around the entire perimeter of the property. A tree nursery of fodder, agroforestry, and fruit trees has been established on the upper flat land.
Livestock. We are interested in dairy goats as a means of producing calcium-rich foods with relatively low capital investment We recently acquired several locally bred goats to see how the farm staff handles them. After the monsoon, we will introduce some other breeds (e.g., Anglo-Nubian and Barbari are available from the Southern Baptist Mission) and commence a herd improvement program.
Composting. Several composting bins have been constructed, filled with vegetation and organic matter, and placed near to the main vegetable growing areas and the staff quarters/homestead. We have conducted regular discussion sessions with the Center staff to demonstrate and emphasize the importance of composting techniques and the use of composted organic matter.
Problems. Wild elephants are a serious problem in the area. They regularly disrupt and destroy plantings, equipment, fences and irrigation lines. We have tried several methods of control without much success. We are now refraining from planting certain fruit and vegetable species preferred by elephants (e.g., jack fruit, banana, pigeon pea); instead, we are considering the planting of these species off the property in an effort to attract them away from the Center.
In the late fall, one of our agricultural workers was murdered in a robbery attempt not far from the Center.
Community-Based Health Program
With modest support from this project, SARPV has been able to improve this outreach work, particular as it relates to malnutrition including rickets. This has included the hiring of a full-time physician (Dr. Tapan, formally a SARPV employee) with responsibilities for community based general medical care. We arranged for Dr. Tapan to spend a day a week for 3 months working with Dr. Dave Staab and colleagues at the MCH for the purpose of enhancing his diagnostic skills, particularly as they concern rickets and other metabolic bone diseases, and of educating him as to current approaches to treating these diseases. We have provided Dr. Tapan with modest material support in the form of a few basic diagnostic tools and some current medical texts, and have worked with him to develop a patient record system (something that is quite atypical in local medical practice). We see Dr. Tapan serving an important role in the community both in facilitating the general awareness of diet-health interrelationships, and in the triage/treatment/referral (to MCH) and follow-up of rickets patients.
OBJECTIVE 6: Support of Bangladesh Rickets Consortium
We have undertaken the role of secretariat of the Bangladesh Rickets Consortium. This is an informal group, which we first called together in 1997, composed of several agencies, NGOs, universities and individuals which share the goal of seeking to eliminate rickets as a public health problem in Bangladesh and elsewhere. Its mission statement is as follows:
"Rickets is prevalent in Chakoria and possibly elsewhere in Bangladesh. Its etiology involves dietary deficiency of calcium, perhaps as the major factor, but the disease occurs in a population of children that is not well nourished in general and suffers from a significant morbidity burden.
We believe that the ultimate resolution of this problem will require a better understanding of the disease and the food system where it occurs. To this end, we see the need for:
We further believe that there is now sufficient evidence to warrant an intervention trial to determine whether calcium supplementation can prevent the disease in young children in Chakoria. Such an effort should be undertaken according to sound scientific and ethical standards. In addition, simultaneous efforts should be made to render effective intervention outcomes sustainable within the local socal, economic and environmental context."(7)
Membership in the Consortium is open; current membership includes:
Consortium Secretariat. We have served as the secretariat and central linkage for the various members of the Consortium. This has involved a great deal of ongoing correspondence with the non-resident members by e-mail, planning meetings and personal visits (by Dr. Combs), as well as the regular direct interactions with resident (i.e., Bangladesh) members (by Mr. Daly and Dr. Meisner). We have also created a website upon which we will be mounting information related to rickets and to the Consortium activities.
2nd Consortium Meeting and Press Conference. In collaboration with UNICEF, we organized and supported the 2nd meeting of the Consortium on Jan. 30, 1999. This full-day meeting was held at the UNICEF headquarters in Dhaka with a half-day technical follow-up held at the Cornell-CIMMYT office (Uttara). The first session consisted of a series of six informational updates relating to emerging information about rickets in Chakoria and elsewhere, and the development of a consensus statement concerning what we need to learn in order to prevent the disease on a sustainable basis. These discussions resulted in general agreement on the following points:
It was also agreed that efforts of Consortium members should address the following key questions:
At the conclusion of the meeting, we held a press conference that was very well attended (some 20 reporters) and went on for more than 90 minutes.
PLANS FOR PY02
OBJECTIVE 1 Characterization of Chakoria Food System
We (Hasaan and Daly) will complete both the Household-Level Case-Control (Food System) Survey and the Rice-Wheat Area Food System Survey and will convert all results into electronic format (SPSS files).
OBJECTIVE 2 Analysis of Chakoria Food System
We (Combs and Hassan) will conduct a preliminary analyis based on the 1st and 2nd round data from the Household-Level Case-Control (Food System) Survey. The purposes of this analysis will be:
When the complete data set has been entered into electronic format, we will conduct a series of data integrity tests (i.e., 5% direct comparisons with original format data) after which we will conduct two types of analyses:
When these analyses have been conducted, we will convene one or more workshops (with project investigators and other members of the Bangladesh Rickets Consortium) to discuss these results in terms of their implications to the etiology of riokets in Chakaria and to the development of effective programs to improve nutritional status and health in this area.
We recognize that our data set may also be useful to address questions of other researchers. After we have completed our analyses, we intend to collaborate with any such researchers who can add scholarly value to our data and/or analyses.
OBJECTIVE 3 Determination of Rickets Prevalence and Etiology
We will meet with our collaborators (Dr. Chowdhery and colleagues) at BRAC to review in detail the results of the rapid, community-based survey or rickets prevalence in Cox's Bazaar District. On the basis of these results we will decide whether we feel it is appropriate to call for a nation-wide study of rickets prevalence using this kind of approach If so, we will continue to work with BRAC and UNICEF(8) to implement such a "National Rickets Map Project".
We also are keenly aware that our hypothesis for the etiology of rickets in Bangladesh, i.e., that it is caused predominantly by dietary deficiencies of calcium, remains untested. Because the success of our food systems-based efforts will depend on our having the correct target, we will also undertake to test this hypothesis in two ways.
a) a low-calcium supplement providing some food energy and protein
b) the same product supplemented with calcium carbonate to provide 200 mg Ca/serving
c) the same product supplemented with calcium carbonate and multi-vitamins-trace elements.
We expect to enroll a total of 200-300 healthy, asymptomatic children 1-3 yrs into the trial, randomizing them by family to the respective treatments. The intervention will be followed with regular home visits by the study physician, with blood samples collected at randomization and at 6, 12 and 18 months thereafter, and radiographs taken at randomiz-ation and at 18 months. The primary endpoints of the study will be changes in alkaline phosphatase activity (used as a proxy of pre-clinical rickets), with a panel of other biochemical measurements (serum 25-hydroxy-cholecalciferol, 1,25-dihydroxy-cholecalciferol, PTH, P and Ca) also made to enhance the inferential value of findings.
OBJECTIVE 4 Evaluate/Develop Home Gardens
We will continue to participate in the AVRDC-USAID project. As part of this effort we will continue to use the SARPV Agro-Food Nutrition Research Center as a place to experiment and demonstrate with new crops and crop management techniques, to convene outreach sessions, etc. We expect that our analyses of the Household-Level Case-Control (Food System) Survey data, we will gain a better picture of what crops are most successful in homestead gardening situations and how those crops contribute (or might) to household food and nutrient use. We will also conduct a series of village meetings (organized and lead by SARPV AWs) with interested families to discuss the their home gardening experiences as a means of learning the barriers particularly to the derivation of substantial nutrition from such homestead activities. We see the SARPV VDWs and AWs as important community workers in this work The VDWs (many of whom are women) currently serve a total of 350 home gardens and AWs serving some 90 demonstration gardens; we/SARPV hope to increase that total to ca. 800 within the next year. Therefore, we will be seeking to support these workers several ways by providing them class/discussion-format instruction in diet/nutrition/health, and gardening.
OBJECTIVE 5 Development of SARPV Agro-Food Nutrition Resource Center
We will continue to use the SARPV Agro-Food Nutrition Resource Center as a place to experiment and demonstrate with new crops and crop management techniques, to convene outreach sessions, etc. This will include studies to determine;
We will also integrate the production of dairy goats and small fish within the farming system of the Center.
In order to accomplish this we will further develop the water supply to the Center, probably by implementing the abbreviated system described above.
OBJECTIVE 6 SUPPORT BANGLADESH RICKETS CONSORTIUM
We will continue to serve as secretariat and otherwise play a leading role in the Consortium. In PY02 this will involve convening the 3nd General Meeting of the Consortium (probably in late January - early February, 2000) at which our colleagues at BRAC would present the results of the community-based rapid rickets assessment survey of Cox's Bazaar District and we (Hassan and Combs) would present the preliminary results from the Household-Level Case-Control (Food System) Survey in Chakoria. We have talked already with a number of other investigators(11) with rickets projects in other parts of the world with the plan to include in the 3rd Consortium meeting a day of scientific presentations dealing with rickets as a global issue. This would involve bringing some 20 international scientists to Dhaka for such a meeting. On the basis of very positive preliminary discussions, we expect to be able to leverage project funds with substantial corporate support for this purpose. We will also initiate a Consortium Newsletter, which we will edit and produce both electronically and in hard copy.
1. In addition to Cornell University, CIMMYT, SARPV and Dhaka University, the Consortium includes the United Nations Childrens' Fund (UNICEF), the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), the Institute for Mother and Child Health (IMCH), the Memorial Christian Hospital (MCH), Amis des Enfants du Monde, the Mayo Clinic, Mr. Joshua Tsujimoto, the Grameen Trust, the Bangladesh Agricultural Research Institute (BARI) and the United States Agency for International Development (USAID).
2. These include micronutrients for which Chakarian children are known to be at high risk to deficiency (Fe, riboflavin, vit. A, and Zn) or which affect the utilization of Ca (P) or Fe (vit. C).
3. Tradename: Horlick's
4. Currently, this includes a network of Village Development Workers (VDWs), i.e., young men and women working with their home communities in development efforts that increase living standards, decrease health hazards and decrease the general dependency of disabled people including rachitic children and their families. As a result of our collaboration, SARPV has also developed a system of local Agricultural Workers (Aws). Both VDWs and AWs are supported in the field by a SARPV Program Manager and Field Monitors.
5. The Center is located between Chakoria and Lama thanas. SARPV acquired this land with funds provided by the French NGO Amis des Enfants du Monde which made the request that our project assist SARPV in developing it to the service of rickets prevention.
6. Professor of Agricultural and Biological Engineering, Cornell University, Ithaca, NY
7. This statement was drafted and signed by 17 participants in a Planning Meeting held in Chakoria, Oct. 7-9, 1997.
8. UNICEF has already committed funds for the production of the survey instrument for such a national study.
9. We have determined that Smith, Kline, Beecham, Inc. can make for the purpose of this study two versions of their product: one with a substantial amount (500 mg) of Ca and another (the placebo) that contains only ca. 50 mg Ca. Each contains other vitamins and essential elements.
10. Tradename: Horlick's
11. Dr. John Pettifor (University of Witwatersrand, Bertsham, Rep. S. Africa, who has worldwide clinical experience with rickets including in his country ), Dr. Phil Fischer (Mayo Clinic, Rochester, MN, who has a rickets project in Nigeria) and Dr. David Fraser (University of Sydney, Sydney, Australia who has a rickets project in Mongolia)