Kwashiorkor is still not fully understood.

The work chosen as this month’s public health classic and reproduced on the following pages is one of the most widely cited papers on childhood malnutrition: in 1935, Cicely D. Williams introduced the West African name kwashiorkor into the scientific literature of nutritional diseases (1). Williams identified the condition as being associated with the social situation of the affected child in the family: kwashiorkor occurs in the “neglected” child, and thus the main aim of prevention and management should be to overcome this neglect. Most research on nutritional concepts has focused on biomedical aspects — pathogenesis, symptomatology, clinical course, and cell, tissue and organ failure — and appropriate medical care; research on social aspects is far less prominent, even though care for families with a child suffering from kwashiorkor has the potential to prevent and manage the disease effectively. Concentration on pathological and physiological factors and curative medical care takes only a short-term view, and the role of home visits and support has been recognized mainly in respect of preventing relapse. It is perhaps not easy for social paediatric practice to be accepted into scientific research. Seventy years later, Williams’s description of the condition is still valid. The 90% mortality reported in 1935 has declined — but by nowhere near as much as one could have expected. Kwashiorkor still has a high case-fatality rate in many places, and it is still true that most children die after initiation of treatment. This situation requires us to reassess continually our knowledge about the disease and our approach to its management. Williams described the typical development of the disease, the critical period being the second year of life when other foods are introduced and breastmilk is gradually replaced by a diet of foods suitable for intake and digestion by young children. Among the symptoms mentioned by Williams, peripheral oedema and skin lesions predominate. The clinical appearance of hypopigmentation, hyperpigmentation and desquamation was her main focus for the differential diagnosis, and this view is maintained to the present day. As Latham pointed out, “when ‘flaky paint’ dermatosis is seen in a malnourished child with oedema, it is pathognomonic of kwashiorkor” (2). A short account of kwashiorkor research would be incomplete without mentioning the work of Hendrickse and other