Many complicating factors affect agricultural work, family health, and nutrition when one or more family members are HIV positive or have an active case of AIDS. In addition to those who are sick, others in the family and community are affected by the consequences of their illness. This broader community is commonly referred to as People Living With HIV/AIDS (PLWHA).
As we look for new insights and practical ways to provide agricultural and nutritional options for impoverished individuals with HIV/AIDS, we have tried to think through this question: How would the activities on the farm differ for PLWHA? Though this article does not include an exhaustive list, we paid special attention to the following areas.
Reduced family ability to work
Once a family member (usually a parent) progresses from just being positive for HIV to becoming ill with AIDS, the ability of that person to do agricultural work decreases steadily. This means that healthy family members must take on this extra work load. In many cases the spouse also is infected and will become ill.
If the healthy family members are unable to manage the extra work load, some farming activities will have to be done less adequately or cease altogether. The family may need to shift to another farming system that involves less work. One approach, for example, could be to grow perennial vegetables (see next article) as a component of kitchen gardens.
Knowledge of farming may not have been passed on to family
In cases where parents are diagnosed with HIV/AIDS, hopefully they will have enough years left and their children will be old enough that farming skills can be passed on to the children. When this is not the case, the farm may one day be managed by youth who have only partial understanding of the daily and seasonal agricultural activities that must be done.
Usually we at ECHO tell visitors who are preparing to work with small-holder farmers that they need to begin their assignment by learning from the farmers, because they all know how to survive. I’ve often said, “If someone took my passport and cash and put me on a two hectare farm in a difficult tropical setting I think I would survive. But the reason would be that I would quickly make friends with local farmers who have over the generations learned how to survive there. Once I learned what they know, after a few years, I would probably be able to help them improve agricultural practices.”
But agricultural development workers going to help orphaned children face a different situation. The orphans may not be starting with an adequate survival knowledge base. These young farmers may indeed need very basic training in things their parents knew well, and that their neighbors may still know. Sometimes neighboring farmers will help. But as some delegates to our workshops have pointed out, there is such a stigma to AIDS that sometimes very unkind things happen to the heirs of a farm.
This means that people doing agricultural and nutritional work with AIDS orphans may need to approach agricultural education at a more basic level than is normally part of agricultural development work.
Income is less than before
We have already considered that farm productivity and presumably income tend to drop as one or more family members have a diminishing ability to do farm work. There are other factors that may reduce family income as well.
The nutritional needs are higher for a person with AIDS than for a typical healthy individual. The AIDS patient needs the same amount of nutrients that a healthy individual requires, but more energy. We have read that once a person is infected with HIV, but before there are any symptoms, the daily energy needs to fight the virus and stay symptom-free increase by about 10%. As the disease begins to take its toll, the affected individual may no longer be able to stay healthy by eating only the inexpensive “belly filler” survival foods that are staples in the community. Now more expensive foods that contain a more balanced mix of important nutrients are needed. This will further reduce family income. A person with an active case of AIDS uses about 10-30% more energy daily to fight the disease and stay alive. A child with active AIDS who is at the stage of losing weight needs about twice as many calories than a healthy child.
Medical expenses put an extra strain on family income. To pay for the medical expenses the family may sell off some livestock, or food supplies, or even part of the land, further decreasing the family’s ability to access adequate income and nutrition.
Sometimes food needs to be considered on the same level as medicine
Anti-retroviral drugs to combat AIDS are very strong medicines and work best in well-nourished individuals. We have been told that when given to significantly malnourished patients, the drugs can cause serious harm and even death.
We have heard of instances where money has become available for the ARV drugs but not for improving nutrition. Think of food as medicine when planning a project to provide anti-retroviral treatments. The food must do much more than just cause the patient to feel full. It must supply all of the important nutrients. As we have noted, by this stage of the disease, the family income may be so low that such a nourishing diet is not possible. In that case, the program supplying money for the drugs needs to supply money for supplemental food as well. (A complicating factor is that the affected parent is likely to share whatever food supplements are provided with the rest of the family. It may be unworkable to expect the program to just provide food for one person.)
A Caution! Think carefully about directing any agricultural or nutritional initiatives in the community towards PLWHA specifically. Probably every option mentioned in this article can benefit other poor and possibly malnourished people. So promote such initiatives primarily in the larger sense of benefiting everyone who might attend, and only secondarily as a food or technique that is also helpful for AIDS patients. The stigma of HIV/AIDS is so strongly felt in some cultures that efforts to promote a new food or technique specifically for PLWHA may be fruitless.
ECHO recently heard of a community in East Africa where grain amaranth, a highly nutritious crop new to Africa, was promoted as being helpful for HIV/AIDS families. The person writing us said that people in the community stopped growing grain amaranth. Apparently they feared that people would think they were growing it because they secretly had someone in the family with AIDS.
Nutrient density of food and ability to swallow without pain
We already considered the importance of a diet that provides all essential nutrients in adequate amounts. In some situations we also need to consider the amount of nutrients per spoonful or cupful. This is referred to as the “nutrient density.” For example, people who are seriously ill or who are starving may lose their appetite. In these cases, you want every spoonful of food to be loaded with nutrients. When AIDS patients develop an infection of the alimentary tract so that it is painful to swallow, it is important that every spoonful they do eat contains as much energy and nutrients as possible.
Porridges are usually familiar, well-liked foods that are affordable to the poor. They are made by boiling ground seeds or roots that contain a large amount of starch. For example, when corn or cassava meal or rolled oats are boiled, the hot water inserts itself into the starch crystals causing them to expand and become soft—and thus much easier to eat. If not enough water is used, the porridge will be sticky, thick and hard to swallow. The thick porridge can be diluted with more water or milk, but then the nutrient density is reduced, too.
An easy way to make porridge with an extra high nutrient density that is much easier to swallow is to use the malting process that is discussed in detail in EDN issue 102 (January 2009). Make porridge with the minimum amount of water, then add about ¼ teaspoonful of brewer’s malt and stir. Within a minute or so the thick, sticky porridge will become much thinner, and (in some cases) even runny. Because the volume did not change, the resulting porridge has the same nutrient density. But now it will be much easier to swallow. An added advantage is that much of the starch and protein are pre-digested by the enzymes in the malt. In some cases, essential minerals are made available that would otherwise be excreted. The same process can be a great help if a toddler has to be weaned early, while he/she still has difficulty swallowing thick porridge.
An especially nutrient-dense porridge can be made from popped or ground seeds of “grain” amaranth. It is also reported to be especially easy to swallow for AIDS patients with throat infections. Amaranth grown for its edible leaves is widely known in many countries, but there are species of amaranth that produce large seed heads filled with hundreds of small seeds. The seeds are considerably more nutritious than corn, wheat or rice. In East Africa, amaranth scientist Dr. Davidson Mwangi has shown that select varieties of ground amaranth made into porridge and fermented (commonly done with other porridges in the area as well) are reported to be especially smooth and easy to swallow. In addition, the nutritional level is exceptional, with high amounts of protein and of the amino acid lysine (that is almost lacking in maize).
Read more about grain amaranth, its increasing popularity in East Africa, and the use just described, in EDN issues 91 and 92. ECHO also has a Technical Note (#2) about amaranth that incorporates much of the information from the EDN articles.
Learn two important lessons from the goat and the deer—diversify food options!
Lesson I. Browsers can pay less attention to exact nutritional analysis of each component of their diet.
Goats and deer are browsers. This means that they eat a modest amount of one kind of plant, then go looking for something else to eat. In contrast, grazers (such as cattle and sheep) find something they enjoy and contentedly eat more and more and more of that one thing.
The diet of the browser contains a sampling of all the edible plants they enjoy. By the end of the day they have likely eaten a modest amount of every vitamin, mineral, oil, carbohydrate or essential amino acid that they need for good health. The grazer has eaten only what was in the one or two kinds of plant they ate that day.
People will be rewarded by intentionally being browsers. By eating a wide variety of foods, we will be more likely to take in a sufficient daily amount of all that we need for good health. In contrast, cultures that, for example, eat mainly rice or tortillas or bread made from one kind of grain (and perhaps some legumes, if they can afford them) are much more likely to experience deficiencies in one or more nutrients. Cultures that enjoy a wide variety of vegetables, including cooked leaves, are blessed for that reason.
A common question when I give tours of the plantings at ECHO is, “What is the nutrient content of that plant?” That is interesting information to know, though in many cases the plant has never been completely analyzed. But I think we tend to make nutrition more complex than it needs to be. An otherwise healthy person with a diverse diet probably has no nutrient deficiency. (An exception would be if plants cannot take up an essential mineral because that mineral is not present in the soil. A good example is goiter caused by iodine deficiency in locations where there is little or no iodine in the soil. In such cases the mineral must be brought in from outside the community.)
It becomes important to know more precise figures about nutrient content when we need to treat a specific deficiency. For example, if illnesses are showing up because of a certain vitamin deficiency (perhaps because there is little diversity in the diet or disease prevents adequate uptake), then it would be helpful to identify edible plants high in that nutrient that are acceptable to individuals who lack it.
This is why one of ECHO’s core ministries is to make people aware of the incredible diversity of food plants that have been placed here by our Creator, and to make trial seed packets available to increase the local diversity of food options. Ninety-five percent of the food eaten by man comes from only 30 species of plants. Only one of those, the 29th most important, comes from the continental United States where I live! That plant is the sunflower. Almost everything I eat originated in another part of the earth. (You may ask, “What about corn/maize?” Maize was introduced from Mexico and Central America to what is now the United States by American Indians.)
Lesson II. Browsers are less likely to react to toxic substances.
Animal nutritionist Dr. Peter VanSoest, my advisor when doing post-doctoral research one summer at Cornell University, taught me the second lesson from the goat and the deer. He pointed out that the liver is capable of detoxifying modest amounts of almost anything. But its capacity to detoxify a particular toxin can easily be exceeded. Then health problems arise.
A decreased ability to handle a particular toxin can result when people adopt a “fad diet” and eat something in extreme. A good example of that was mentioned in EDN 90. People in Taiwan went on a diet plan in which a main food was raw juice extracted from leaves of a popular vegetable in SE Asia (and at ECHO) called katuk, Sauropus androgynous. Thousands of people have eaten this popular vegetable for centuries with no report of harm. But many people on this diet in Taiwan (EDN 59) ate far, far more than their liver could detoxify and they ended up with serious, incurable lung disease.
PLWHA face a number of unique challenges. An awareness of some of the issues can be helpful when planning ways to help. We would welcome feedback regarding issues that we have mentioned, as well as ideas and insights not mentioned here.
Price, M.L. 2010. Agricultural and Nutritional Options for Impoverished People Living with HIV/AIDS. ECHO Development Notes no. 107