Educational Work among Rural Populations
An example of energetic educational work in the field of nutrition was provided by a Cooperative Extension Service in Agriculture and Home Economics in the United States of America. These types of agencies extended to most European countries in order to improve agriculture through instruction, technical help and advice to peasants and farmers. Their function was to apply the results of scientific research in agriculture and nutrition to the local problems of the farm and the rural community, particularly knowledge regarding home
- 15 Ibidem.
- 16 Ibidem.
economics, such as research into the vitamin and mineral content of foodstuffs, the effects of cooking on the nutritional value and the best methods for food preservation. In the USA, the Bureau of Home Economics carried out family budget enquiries and surveys on food consumption trends, devising adequate diets at minimum cost. In order to spread the benefits of such research, an Extension Service employed more than 60 extension nutritionists in 1934 in 45 States of the Union. These workers were all college graduates and a considerable number of them had taken advanced degrees and accumulated experience as high school or university teachers, hospital dieticians and county home demonstration agents.
Although rural communities were reached by ordinary publicity methods, the heads of the campaigns were the home demonstration agents, who achieved direct contact with the population through cooperatives and other local organisations, or through volunteer leaders chosen from rural communities. Malnutrition was attacked in a number of ways. For example, growing vegetables for home consumption was taught and encouraged, something especially important in the pellagra- affected areas. Methods of preserving meat, vegetables, fruit and other foods were taught, with the object of assisting the small farmer to eliminate waste and make full use of the potential wealth at his disposal. Education programmes also included food values, wise purchasing of foodstuffs, cooking, menu planning, food economy, dietary requirements, school lunches and so on. These activities were focused on preventing the lowering of health standards in critical years, and particularly on improving the diet of rural populations, taking into account that, contrary to popular belief, malnutrition was as common among the poorest people in the countryside as in the major cities. Therefore, educational work in nutrition among rural populations was considered a promising field, since the peasant community rarely made full use of the possibilities at their disposal for obtaining a varied, nutritious and attractive diet. Even in the absence of poverty, it was monotonous and badly cooked. “Cooking-classes in rural communities, at which some instruction in the principles of diet is given, have been organized in a number of European countries. Housewives, as a rule, are eager to attend such classes, to the great benefit of themselves and their families”.
In their report, Bumet and Aykroyd considered that useful dietary knowledge had several possible channels of distribution. It could be transmitted directly to individuals by means of infant and mother welfare dispensaries, nutrition clinics, visiting nurses and social workers, and disseminated through schools as part of health education programmes. It could also use the new methods offered by publicity and propaganda: pamphlets, lectures, exhibitions, cinema, radio, posters, daily press, journals and women’s magazines. However, nutrition experts warned of an increasing danger: educational materials about diet and nutrition could be parodied by commercial advertisements, resulting in the population finding it difficult to distinguish ingenious advertising from genuine health information.
During recent years, there has been, in many countries, a tightening-up of regulations designed to ensure that food preparations, advertised as being rich in this or that food factor, do, in fact, possess the quality stated: preparations alleged to contain vitamins, for example, may be subject to official approval and control on the basis of the standards and units established by the League of Nations. But there is, as yet, no machinery for controlling advertising which is false, no verbally, but by implication such advertising, for example, as attempts to give mothers the idea that, if they do not buy the article in question, their children’s health will suffer. Those engaged in teaching dietetics to the public find that the ingenuity of the modern advertisement adds greatly to their difficulties”.20
New regulations and strict control of advertising were crucial aspects demanded by health authorities. The results of education in nutrition were still hard to assess. During the economic crisis in the 1930s vigorous attempts were made in many European countries to disseminate dietary knowledge, but there was not enough perspective to estimate their effectiveness. However, the experts considered some indirect indicators as positive; the fact that infant and child mortality rates, as well as the death rate from tuberculosis, had not stopped falling, suggested that better nutrition could be involved and that educational campaigns had some influence. It was not only the poorer classes that required dietary education, but since it was the poor who suffered from malnutrition, much of the public health nutrition work was concerned with those social groups. One very valuable strategy, especially under critical circumstances, was spreading knowledge and possibilities of how an adequate diet might be obtained at very low cost. However, a wider goal was to attain the best diet, regarding both nutritive value and palatability, from the vast resources that the modern world can produce.
In a world suffering from over-production of foodstuffs, emphasis should be placed on the optimum, rather than on the minimum... In education the public in nutrition, the simplicity of the principles involved should be emphasized: it should be made clear that it usually requires a little more knowledge, but no more effort and anxiety, to prepare and consume a well- balanced diet than a defective one.21
Public health administrations, seconded by private institutions, started different forms of intervention to improve diet and health conditions during the 1930s. Nutrition in childhood, food deficiency diseases and collective feeding were the main fields of action. From a nutritional perspective, the prenatal period is one of the most important in human life. The supervision of a woman’s diet during pregnancy was included among the duties of maternal and child welfare services. The diet of pregnant women required regulation in many respects, such as the vitamin D, calcium and iron content, essential factors for the prevention of rickets and anaemia. Most paediatricians agreed with the idea that breastfeeding was the ideal method of nourishing an infant, with particular advantages for poorer classes, which could not easily afford the better grades of fresh cow’s milk or dried milk preparations.
The principal aim of public health nutritional work was to raise dietary and health standards, which implied the elimination of food deficiency diseases. Dealing with malnutrition also meant an improvement in the rate of these diseases, although each could be regarded as representing a public health problem in itself, calling for special treatment and prevention measures. Several nutritional deficiency diseases became social problems and received a great deal of attention from the experts and authorities. Chlorosis, for instance, was a disease confined to the female sex, mostly affecting the working class (waitresses, shop assistants, domestic servants) and young women between 15 and 25 years old. Initially, the origin of the disease was ascribed to many causes, mostly to a psychological origin, but finally a diet deficient in iron was recognised as the fundamental cause, as a result of a diet composed of white bread, margarine, potatoes and tea. The disappearance of chlorosis in the space of a few years was attributed to the raising of living standards and the dissemination of knowledge about nutrition.
At the same time, nursing women suffering from hypochromic microcytic anaemia - as a result of blood loss during delivery and in the post-natal period, and to menorrhagia between pregnancies - consumed a diet low in iron. Many considered their condition of chronic ill-health and wretchedness as a natural state and accepted it with resignation. Nevertheless, this type of anaemia could immediately be treated by iron medication or by a rational improvement in diet. There appears to be at least one type of microcytic hyperchromic anaemia, which may justifiably be described as a disease due to dietary deficiency - pernicious anaemia of pregnancy. “Pernicious anaemia, as it occurs in Western civilisation, has been shown to be due to defective production of a specific enzyme, an ‘intrinsic factor’ in gastric juice, which interacts with an ‘extrinsic factor’ in food to produce the specific “antianaemic principle”. Treatment in this disease consisted of supplying either the “anti-anaemic principle” (by liver therapy) or giving gastric tissue products, which supply the intrinsic factor and enable the patient to manufacture the anti-anaemic principle for herself.22 This was the starting point of the discovery of the important physiological function of folic acid, particularly for pregnant women and especially for the normal development of the foetus.
Another major deficiency disease was rickets, associated with a deficit in vitamin D. The enrichment of artificial milk with vitamin D was widely extended in Europe during the 1930s and there was a tendency to promote fluid milk “as the most valuable anti-rachitic agent”, from a public health perspective. As a result of the practical application of scientific discoveries, severe rickets was greatly reduced in Europe and North America as a public health problem, although it was not fully solved.
Dental caries, pellagra and beriberi were also persistent problems associated with deficient nutrition, mostly notable in Western countries and among lower social groups. Collective feeding, public canteens or meals in common overseen by experts could avoid many of these problems. During the inter-war years there were primarily three kinds of collective feeding initiatives:
- a) Collective feeding in residential institutions, public or private, civil or religious, in armies and navies, in establishments such as hospitals, sanatoria, homes for the aged, asylums, prisons, and educational establishments.
- b) Meals given as a relief in times of unemployment and economic distress to the unemployed, or to impoverished students and artists, needy intellectual workers and others.
- c) Mass feeding organised by industry or the State in accordance with economic and physiological principles.