Editorials

Antioxidants for children with kwashiorkor

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7500.1095 (Published 12 May 2005) Cite this as: BMJ 2005;330:1095

There is nothing mysterious about kwashiorkor

There is no mystery [1, 2] about "kwashiorkor", which is a word from
a Ghanaian tribe, my very own Krobo/Dangme/Ga megatribe [3, 4]. Indeed, it
was when I was a toddler that the remarkable white woman based at the
Princess Marie Louise Hospital in Accra (before the Gold Coast became
Ghana) first described the condition which was brought to her attention by
my fellow tribes folk [5,6].

Imagine my utter astonishment when, coming over to England to read
Medicine in London University, I heard Lecturer after Lecturer state with
unwarranted confidence that "kwashiorkor means red hair in an African
language". The word means no such thing in my tribe. Kwashiorkor, as I
once pointed out to a British Professor of Paediatrics in this very
medical journal "is, primarily, a sibling positional word, which requires
careful explanation to the non-native" [3]. It is a reflection of the
'birth position' of the sufferer, before it is a pathology [4], a fact
emphasized by Dr Cicely Willams whose descriptions of the condition have
not been bettered by anyone [5, 6, 7, 8].

Apart from being a Krobo tribesman, I have a further reason for
claiming that I know more about Kwashiorkor than all the non-Ghanaian
experts that have written volumes about the syndrome (Cicely Williams
excepted). And I say that for this reason: In my tribe, it was said of me
(the second child) the day my younger brother was born while I was not yet
completely weaned - "afor ese kwasiorkor" [3] which, literally means "it
has been born after him kwasiorkor", stressing my positional risk of being
sandwiched between my elder brother, Agbetey, who was just 13 months older
than me, and the just arrived sibling who was also just 17 months my
junior. See http://www.konotey-ahulu.com/images/generation.jpg for the
first 3 children of my parents Rev & Mrs Konotey-Ahulu in Generation
VII, and note how closely spaced we were.

The whole tribe expected me to develop kwashiorkor because of the
birth of my brother. "The reason I escaped the syndrome first described by
Dr Cicely Williams [3, 4] was simply because my educated parents took the
same steps that Professor Marsden described from Brazil [9]: I was fed
with beans, eggs, milk, minced meat, and Ovaltine" [3]. Less fortunate
relatives of my age in my tribe, whose parents also had 3 children in less
than 3 years, "and of whom it was also said 'afor ese kwasiorkor' went on
to develop kwashiorkor because they could only afford to be fed with maize
products such as akasa and k enky" [3].

I went on to make the point that: "The sibling positional word became
almost invariably associated with the syndrome Cicely Williams was
investigating, and although the term kwashiorkor was occasionally attached
to a child who never went on to get the disease " (just as in my own
case), whenever the the syndrome kwashiorkor was seen in a child there
was, more likely than not, very close proximity to a younger sibling" [3].
Exceptions, of course, occurred, "when children were orphaned" (as would
be the case in Malawi ravaged with AIDS), regardless of sibling
positioning, or multiple births. Indeed, I described such children (with
photographs) on my AIDS tour of African countries [Ref 10 - See Figure
6.14, page 124]. I also described in a man who was mistaken for suffering
from HIV-AIDS [Ref 10, photographs on pages 80-82] what has been called
the Adult Kwashiorkor syndrome "in which diarrhoea, pitting oedema,
hepatomegaly, dermatopathy, mental apathy, and hair changes result from
protein energy malnutrition as, for example, in the creatorrhoea and
steatorrhoea of severe alcoholic chronic pancreatitis". This syndrome was
completely reversible in the man described [10] when his alcoholism [he
was on one litre and half of gin a day] was treated, diabetes reversed,
pancreatin supplied, and protein supplements given [See remarkable change
in just 6 months - Ref 10]. Should we have spent research funds finding
out how much antioxidants this man's diet contained?

I had the enormous privilege of meeting up with 93-year old Dame
Cicely Williams in Oxford in 1986 when we were photographed together[See
The Lancet, Ref 4 for what she looked like at 93!]. I thanked her
profusely for all that she did in my tribe in those colonial days wihout
electron microscopes and sophisticated analysers. We both were greatly
baffled why many of today's experts (especially those who have little
experience of a tropical sojourn)find it difficult to accept that
"Kwashiorkor is the result of a social pathology before it is the outcome
of a biochemical pathology" [4]. Clinical epidemiology ie answering the
questions Who? Which? Where? When? Why? What? and How? is far and away the
best tool to investigate a tropical phenomenon such as kwashiorkor, and
Cicely Williams gets my Full Marks for employing that tool with hardly any
funds for medical research.

I repeat what I said a decade or so ago in The Lancet: "Those of us
who grew up in the kwashiorkor belt and who have also had the benefit of
an excellent medical education cannot but caution our ministries of health
and social welfare about the danger of missing the social pathology wood
for the trees of free radicals and leukotrienes".

Nothing to declare, except that Kwashiorkor is my tribal language.

References

1 Fuchs GJ. Antioxidants for children with kwashiorkor. Brit Med J
2005; 330: 1095-1096.

2 Ciliberto H, Ciliberto M, Briend A, Ashorn P, Bier D, Manary M.
Antioxidant supplementation for the prevention of kwashiorkor in Malawian
children: randomised, double blind, placebo controlled trial. Brit Med J
2005; 330: 1109-1111.

3 Konotey-Ahulu FID. Kwashiorkor. Brit Med J 1991; 302: 180-181.

4 Konotey-Ahulu FID. Issues in kwashiorkor. Lancet 1994; 343: 548.

5 Williams CD. A nutritional disease of childhood associated with a
maize diet. Arch Dis Child 1933; 8: 423-8.

6 Williams CD. Kwashiorkor - a nutritional disease of children
associated with a maize diet. Lancet 1935; 2: 1151-52.

7 Williams CD. Kwashiorkor. JAMA 1953; 1280-85.

8 Williams CD. Social Medicine in Developing Countries (Millroy
Lecture, Royal College of Physicians). Lancet 1958; 863-66.

9 Marsden PD. Kwashiorkor. Brit Med J 1990; 301: 1036-37.

10 Konotey-Ahulu FID. What Is AIDS? T-A'D Co. Watford 1996.

Competing interests:
None declared

Competing interests: No competing interests

14 May 2005
Felix D Konotey-Ahulu
Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast,, Ghana
Dept of Internal Medicine & Tropical Medicine, Cromwell Hospital, London SW5 0TU
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