Helping Bangladesh battle an epidemic of rickets

What will it take to aid the young people affected, and prevent new cases from emerging?

BRATTLEBORO — More than half a million children in Bangladesh are suffering from a crippling form of malnutrition linked to a man-made environmental disaster.

In severe cases, their legs buckle at the knees or bow out because mineral-deficient soft bones cannot support their growing bodies when they stand up and walk. If uncorrected, children with rickets will be harmed for life.

Rickets is most commonly associated with vitamin D deficiencies mostly caused by insufficient sunlight exposure. But scientific studies in sunny Bangladesh found that children with rickets there are severely calcium deficient, as is the breast milk supplied by their mothers.

Rickets, first identified in Bangladesh in 1991, is now epidemic. More than half a million children are suffering with barely a murmur from development circles, the government, and the press. Shockingly little is being done to prevent even more children from being afflicted by this crippling disease.

The economy of Bangladesh has grown at a robust 6 percent and the gross domestic product now exceeds $100 billion annually.

The earnings from the export of garments and other goods total tens of billions of dollars each year. A major boost comes from nearly $20 billion sent home by people working abroad. And the country is effectively self-sufficient in rice, the staple food of the nation.

So why has this form of malnutrition emerged so recently?

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The rickets epidemic has occurred in conjunction with the loss of very small fish species that previously had been a cheap accessible food source for the poor. These fish, which are consumed bones and all, were until recently the only reliable source of calcium in the diets of most people in Bangladesh.

In 1991-92, I organized a study funded by the United States Agency for International Development (USAID) on “the Nutritional Consequence of Bio-Biodiversity of Fisheries in Bangladesh.”

Our field workers visited more than 500 rural households. They weighed and identified the fish species as they were being prepared for cooking.

Our research team found that families residing in various parts of the country consumed between 50 and 75 fish species during the course of the year.

Milk, meat, and eggs were rarely consumed. Rather, wild fish species provided most of the protein in their diet as well as nearly all the fats and minerals, including calcium, in the diet of pregnant women, lactating mothers, and children. Fishing was also a major part-time occupation for the majority of poor rural families.

Wild fish species provided readily bio-available sources of vitamins, fats, and calcium for most rural families. In these respects, they were far more nutritious than cultivated species.

A 1993 nutritional analysis found that small fish species were very rich sources of vitamins A, E, and K along with calcium, phosphorus, and essential fatty acids. In contrast, the study found that the cultivated species of native and exotic carps now available do not contribute these essential nutrients to the diet.

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For several decades, the World Bank and other agencies have invested hundreds of millions of dollars in large-scale flood-control projects, which led to the loss of these small fish.

The community voiced concerns about the impacts these projects would have on drainage, commerce, and fisheries, but these concerns were largely ignored. Project documents pejoratively termed the most widely consumed and nutritious types of fish affected by such projects as “miscellaneous“ and “non-economic species.”

Our study warned that “the blockage of water flows has dangerous repercussions for poor families who depend on the nutritional benefits obtained by the capture of diverse fish species in floodplains. Children, pregnant and nursing women are particularly vulnerable to nutritional losses caused by impeded fish migration.”

In much of Bangladesh, small fish have become increasingly scarce and are no longer abundantly available for netting close to home. In 1992, a bag of mixed small fish cost no more than a few takas. Today, because of scarcity, the price is at least 100 takas and often much more, a price well beyond the purchasing power of families at risk for rickets.

Project documents prepared by consultants after the completion of large-scale flood control embankments commented on the catastrophic impacts they have had on production of natural fisheries.

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To offset these losses, millions of dollars were invested for the production of native and exotic carps and for their release in open waters. These types of fish, while economically valuable, are micronutrient-deficient. The bones are not eaten and, as a result, they do not contribute calcium to one's diet.

The epidemic of rickets is growing, and the absence of committed interventions will only get worse.

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Social Assistance and Rehabilitation of the Physically Vulnerable, a non-governmental organization, has been active in preventing and treating rickets since its executive director, Shahidul Haque, discovered and first reported on the devastating presence of leg deformities among children and youths in 1991.

Other organizations have provided some support, but much, much more is required.

Vulnerable families need to be identified and educated on low-cost ways of adding calcium to their diets. Many children require surgery and braces to help their legs return to functioning normally.

The Center for Natural Resources Studies (CNRS) has shown how community involvement in the ecological restoration of floodplains can regenerate natural fisheries, leading to improved diets for vulnerable families. These very small fish, which for countless generations protected Bangladeshi children from rickets, must once again be abundant and affordable.

The epidemic is at a tipping point, and without these measures, we will see another one million cases in 10 years.

A national plan for the eradication of rickets in Bangladesh is urgently required. The government, NGOs, the World Bank and donor agencies need to wake up to the scale and causes of the rickets epidemic in Bangladesh. The crippling scourge of rickets must be eradicated once and for all.

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