Nutrition Issues in Developing Countries for the 1980s and 1990s Proceedings of a Symposium (1986) / Chapter Skim
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I CRITICAL ISSUES IN INTERNATIONAL NUTRITION
I CRITICAL ISSUES IN INTERNATIONAL NUTRITION
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The focus should be the developing societies of the world, particularly the poverty-stricken families eking out an existence; the time, all the years up to the turn of the century; the objectives of the exercise, to perceive and identify major critical issues that impinge upon the deprived and impair their health and nutritional status. In choosing the time span up to the year 2000, the committee felt that it was a reasonable period for experienced scientists, endowed with exceptional wisdom, to "star gaze" and foresee how the nutritional problems and their determinants may evolve and what implications they may have for policies, programs, and research.
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We are aware that fiscal, monetary, and other economic policies, whose social consequences have not been carefully thought through, may have negative impacts among the poor, worsening their health and nutritional status. We are still struggling to understand the macroeconomics-nutrition connection.
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Despite the complexity of the problem, we have witnessed in the last 20 years an increasing number of successful programs that combine cost-effective health and nutrition interventions, improve food consumption, target mothers and children at greater risk of death and disease, and monitor and evaluate the different activities. These efforts have resulted in sustained and significant declines in infant and early childhood morbidity and mortality, malnutrition, and low birthweight and an increase in breast-feeding and better weaning practices.
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We hope their thoughts will be both illustrative and provocative and will contain suggestions to stir the imagination of those whose role is to investigate basic issues, as well as those whose role is to transform scientific evidence into realities of well-being. ~~ C Abraham Horwitz, Chairman Committee on International Nutrition Programs (from 1980 to 1986)
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In the Declaration of Alma-Ata in 1978, the same governments proclaimed that the key to achieving that target was primary health care. That is, essential health care should be made accessible at an affordable cost with methods that are practical, scientifically sound, and socially acceptable and that involve other sectors in addition to the health sector.
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Because periodic checks of the health and nutritional status of children and their mothers imply regular contact with health services, they also provide ideal opportunities for imparting health-improving and healthpreserving messages about appropriate nutrition. Such contact could expose those in need to a full range of preventive, diagnostic, therapeutic, and rehabilitative services -- whether at the first point of contact between individuals and the health system, where primary health care starts, or, after referral, through intermediate and central levels, where more complex problems can be dealt with.
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However, the main impact of agricultural policies and programs on nutrition and health occurs via the employment and income of laborers, who constitute most of the rural poor. Choices affecting employment in agriculture -- including pricing decisions, cultivation of food crops vs.
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To return to my earlier observation about the reorientation of the health system and the involvement of nonhealth sectors in achieving health for all: The major health policy declarations of the last decade, including the Declaration of Alma-Ata in 1978 and global and regional strategies and plans of action for health for all, have all stressed that health Is a social goal that has to be integrated into overall development strategies and that a wide range of actions must contribute to its achievement. Thus, WHO uses the comprehensive term "health system" to signify all the interrelated elements that contribute to health in homes, educational institutions, workplaces, public places, communities, and the physical and psychosocial environment.
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some kinds of cancer. The industrial countries face the deadly combination of faulty dietary habits and inappropriate life styles, including the uses of tobacco and too much alcohol and the lack of sufficient exercise or even genuine relaxation.
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Each event sets back a child's growth and development; if the interval between events is too short, a spiral leading to death all too often results. The primary health care approach to community health problems is particularly well suited to break this cycle of infection and malnutrition, because it can bring so many essential elements to bear simultaneously.
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And maternal and child health care, including family planning, has a mutually reinforcing effect on the health and nutritional status of mothers and children. THE LESSONS WE ARE LEARNING Eight years after the unanimous adoption of health for all as our main social target, can we say that our high expectations about primary health care's contribution to better nutrition are being justified?
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One reason is that it was able to prepare itself, thanks to a long-term commitment to the setting in place of a permanent, simplified, and highly effective primary health care infrastructure. The country has long had an operational food and nutrition "early-warning system," including some 500 small health posts that conduct regular surveys to monitor nutritional status.
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DR. NESHEIM: Some have argued that the solutions to the problems of malnutrition in the world were only to be achieved through economic development, and I think I understood from your discussion of a primary health care system that the interventions that can be undertaken in primary health care have a role to play in immediately alleviating problems of malnutrition.
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Even in countries where economic growth has been limited, it is still possible to have a useful discussion of the relationships of productivity and consumption.
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Our mistake is in believing that the advanced industrial countries, socialist or capitalist in their developed form, are a guide and model for the poor countries, whose economic development and social development are less advanced. It is an error that arises from the failure of the older industrial countries to understand their own history or to appreciate the sources and well-springs of their own development and modern well-being.
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There is another, more recent and more important error. Much of the advice flowing from the older industrial countries reflects the modern ideologic attitudes toward economic development.
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In reality, agriculture has its own design, given not by ideology, but by the practical accommodation to ~ : _ stances. We make a grave and foolish mistake when we carry over to agriculture the ideological concepts and debate relevant to the mature industrial world and in doing so delay or abort the very development we seek.
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From the case for the cultivator-operated farm unit there comes, in any discussion of an agricultural system, the question of land reform. Land reform is widely celebrated in principle in our own day, but it is wonderfully resisted in practice.
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The independent proprietor, however, must be intellectually competent, so there is a compelling need in agricultural development for a good educational system. The mature industrial countries especially have gravely misunderstood their own history.
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We must surely agree that the industrial countries should be persuaded not to sell such weaponry to the new and poor agricultural lands and that these lands should renew their determination not to buy such weaponry. Nothing is less consistent with the agricultural stage of development than a complex and costly military apparatus.
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This is a standard, indeed universals practice in the industrial countries and has rendered major service in some countries, such as India. One must react with unease to the numerous efforts in the new countries to keep food inexpensive through public action.
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1985. Agricultural Price Policies.
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MR. BUTZ: In your summary, you regretted the export from socialist countries of the organizational structures of their agricultural economies and also the export from capitalist countries of technological approaches to development.
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This close relation between food production and poverty means that it is necessary to understand the dynamics of food production growth if one is to understand changes in nutritional status. To set the more general framework for analyzing these issues, a review of recent trends in population, food production, and trade in the Third World is needed, together with an examination of the prospects for food production and consumption in various areas of the Third World.
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, only slightly faster than the average annual population growth of 2.5%. Thus, on a per capita basis, food production in the Third World as a whole increased by only 0.1% per year.
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For sub-Sahara Africa, the increase was from 1.5 to 8.5 million tons. In the Third World, two principal forces tend to fuel a steady rise in food consumption: population growth and TABLE 1 Growth in Population and in Production and Consumption of Major Food Crops in the Developing Worlda Average Annual Average Annual Growth Rate in Growth Rate in Average Annual Production of Consumption of Growth Rate Major brood Major Food Country in Population, Crops, Crops,b Group 1961-1980.
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bPercent increase in demand for each 1% increase in per capita income. CSum of population growth rate and the product of per capita income growth rate and income elasticity.
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They therefore depend heavily on food imports to meet their food needs. According to Table 3, between the periods 1961-1965 and 1973-1977, net food imports by the Third World increased by a factor of 4.3, from 5.3 to 23 million tons per year.
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Projections are based on differences between extrapolations of 1961-1977 country trends in production and aggregate projections of demand for food, animal feed, and other uses; projections of demand for animal feed were assumed to follow country growth rates of meat consumption, i.e., no change in feeding efficiency. A basis for this assumption is being pursued at International Food Policy Research Institute, but results are not yet available.
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, ~ , Third World as a whole is projected to grow at 1.0% a year between 1980 and 2000. This impressive aggregate figure covers widely different rates of food production growth in various regions.
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dIncludes 105 Asian, African, Middle Eastern, and Latin American countries. People's Republic of China included.
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The slowdown in world trade and the overcharge of debit make it difficult for the nascent potentials for increased productivity from research successes to assert themselves. Second, for the least developed countries, this base period was one of rapid growth in foreign aid, which sustained food consumption in otherwise retrogressing economies.
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Each of these characteristics has important implications for the pattern and pace of food production growth, and each constitutes a sharp contradiction of a capital-intensive strategy of development. Emphasis on consumer goods is central to an agricultural strategy, because agriculture is basically an industry that provides consumer goods.
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An agricultural strategy of development, which stresses the increased production of agricultural and labor-intensive goods, helps to supply goods for export.
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In many developing countries, calorie-protein deficiencies might well exist in the presence of plentiful food. Thus, efforts to increase total food output should be coupled to attempts to determine how they will affect the nutritional status of various types of consumers.
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Under these circumstances, most developing countries would be well-advised to Pursue an agricultural strategy of development. agriculture is often an ~ r ~ 7 - - ~ sufficient, condition for solving the problems of hunger and malnutrition in the developing world by not only increasing the total amount of food available to malnourished groups, but also helping to increase their ability to purchase food.
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Research Report 11. Washington, D.C.: International Food Policy Research Institute.
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1982. Food Consumption Parameters for Brazil and Their Application to Food Policy.
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Prepared for Agricultural Policy Workshop, Santiago, Dominican Republic, April 1-3, 1985. Washington, D.C.: International Food Policy Research Institute.
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This requires that national agricultural research systems be developed. The stronger the national agricultural research system, the greater the speed with which basic science can be borrowed and strategic science can be adapted from other countries National systems of this kind require higher education, and the process can be accelerated by assistance with institutional development.
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The purchasing power of the majority of the rural people in Asia and Africa cannot be raised unless their productivity -- which is primarily agricultural -- is increased. Increasing nutritional status will require improving incomes of the lowest socioeconomic groups and increasing their production.
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C Waterlow There will be no nutritional science, and hence no useful discussion of priorities, unless there is a continuing flow of young people into the study of the subject.
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In the United States and United Kingdom, nutritional science has gained much of its strength from animal husbandry, as is obvious if we look at the institutions in these countries and the traditional nutritional journals. I do not think it would be unfair to say that perhaps the greater part of scientific output in nutrition is irrelevant to Third World problems.
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The difficulty, of course, is that nutritional status is a continuous variable, so it is artificial to draw a line between those who should and those who should not be called severely malnourished. Nevertheless, in real life
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I shall now discuss three examples of gaps in our knowledge on the effects of energy and protein deficiency that I think should have a high priority for nutritional science in the next decade. Protein takes second place to energy, because, as is widely accepted, an intake that provides enough energy will usually supply enough protein.
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People tend to have low weight if they are heavy smokers, alcoholics, or in some way ill. In contrast, the average BMI of healthy people in Third World countries is typically about 19 (Eveleth and Tanner, 1977)
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and others, that stunting in the Third World is determined mainly by environmental, and not by genetic, factors. Two opposing views about its significance have been put forth.
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, and that it can be prevented with specific nutritional measures. Whether such prevention
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They also had very low food intakes. Many groups of people seem to subsist quite well on energy intakes much lower than their estimated requirements, even when allowance is made for their low body weight.
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Exercise physiologists believe that the capacity to be either a sprinter or a marathon runner is determined by genes, not by training. Perhaps Third World people have undergone a genetic selection of fiber types that allows work to be done in the most economical way.
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milk. There is also evidence, from somewhat older children, that nutritional status has little effect on the incidence of infections, but much influence on the duration and severity of infections (Tomkins, in press)
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But such measures take a long time, so we need an emer gency strategy. · I am not saying that the kind of operational research being done under the auspices of the Subcommittee on Nutrition of the United Nations Administrative Committee on Coordination with the leadership of Dr.
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FAO/WHO/UNU (Food and Agricultural Organization/World Health Organization/United Nations University.
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1963. Journeys Toward Progress: Studies of Economic Policy Making in Latin America.
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1983. Anthropometric assessment of young children's nutritional status as an indicator of subsequent risk of dying.
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If we focus on the causes of small body size, rather than on small body size itself, we obtain a different perspective on whether stunting merits concern. Focusing on small body size alone is misleading.
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In the light of Dr. Mellor's comments on the numbers of malnourished people in the world today, are the current nutrition assessment tools and derived indicators sensitive, specific, and adequate to detect the extent of malnutrition, and are the types of data being reported or the methods of reporting accurate?
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How much of that was not confounded by the low birth weight of these babies? This makes us wonder how early is early enough for intervention, such as changes in maternal nutrition during pregnancy.
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UNIDENTIFIED SPEAKER: I would like to return to nutritional science. As you said, we are in a state of transition in nutritional science.
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DR. WATERLOW: Thank you for your comment about nutritional science in general.
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By the term "international nutrition," I mean the major problem of contemporary humankind: the deprivation of essential nutrients in a world of plenty among disadvantaged peoples, mostly in low-income countries. Our focus is directly on the nutrition-health-food consumption triad which complements broader concerns related to food production, income generation, and socioeconomic development.
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In food and agriculture, the Consultative Group on International Agricultural Research consortium supports 11 international research centers, including the fine work of the International Food Policy Research Institute. In the health-nutrition field, the International Center for Diarrheal Disease Research in Bangladesh and the Institute of Nutrition of Central America and Panama in Guatemala have made useful research contributions.
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For most developing countries, particularly in sub-Saharan Africa and Latin America, the most optimistic economic scenarios project slow, stagnant, or even negative economic growth well into the 1990s (World Bank, 1985~. Many developing countries -- already handicapped by the vestiges of colonialism, including underdevelopment of physical assets, institutional infrastructure, and human resources -- face a hostile international economic environment marked by heavy international indebtedness.
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The western model of hospital care, medical professionalism, curative-biased technologies, and fee-for-service private systems all have been transplanted successfully to the developing world. H; Kohl v ~r~Ativc~ incl; t:rF~nr ~reran; Anti rinds fr~rm.c ___~___J ~ ~ ~ ^A~ ~ However, have also evolved, such as the Chinese barefoot doctors, low-cost and simplified delivery systems for illiterate populations, and the use of mass media and social marketing for dissemination of health technologies.
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Many developing countries will witness polarization between a growing middle class with dietary affluence and the disadvantaged rural poor, whose productive land assets are inadequate to generate balanced traditional diets, or the urban poor, who lack the stable wage employment that would permit them to purchase adequate diets in the marketplace.
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, decreasing per capita food production (where 70% of the labor force depends on agriculture) , and stagnant overall economic growth, these countries face awesome nutritional prospects.
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However, the international economic crisis has profoundly affected virtually all Latin American countries, precipitating severe economic adjustments that undoubtedly will have profound effects on the poor (Jolly and Cornia, 1984~. Because most of the population depends on market economies in urban centers, the employment and wage effects of economic policy adjustments can be expected to affect the welfare of disadvantaged subgroups of the population directly.
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Earlier agricultural research to improve the protein content of cereals through genetic breeding was disappointing and perhaps misdirected. By the late 1970s, however, sophisticated methods for food policy analysis provided intellectually powerful tools to consider the impact of food price policies and marketing systems on food consumption in disadvantaged populations (Timmer, 1985~.
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decades of good work, the nutrition community can no longer agree even on the magnitude of the global problem (Food and Agriculture Organization, 1977; Reutlinger and Selowsky, 1976~. Estimates of the world's malnourished range from 350 to 1,200 million.
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Extensive program experience, however, has demonstrated that nutritional advances can be made within existing economic constraints and that nutrition programs indeed are important components of efforts to alleviate poverty (Berg and Austin, 1984~. MULTIPLE DETERMINANTS The causes of malnutrition are multiple, and approaches toward its solution must be flexible and locally adaptive.
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There are also enormous opportunities for integrating nutrition into primary health care and food policy analysis. Primary health care is a feasible, costeffective vehicle for the delivery of basic nutritional ~ ~4 ^-~- 19841.
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How can these policies adapt to short-term fiscal austerity while protecting nutritional status in the disadvantaged? What are the cost structures and impact of nutrition delivery systems?
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Nutri tion is a critical component of recent international initiatives in the mass dissemination of oral Dehydration therapy and basic immunizations. We are increasing our capacity to apply the tools of food policy analysis to ensure that access of the poor to food is considered within food production, price, and marketing strategies.
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recently concluded that foreign assistance is likely to grow at 2% per year in real terms for the remainder of the 1980s -- a decline from the 4% during the 1970s (Development Committee, Task Force on Concessional Flows, 1985~. The explanations for this decline in the growth rate of foreign development assistance are complex.
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How, then, do we explain the sense of dwindling support for international assistance, including nutrition programs? In part, the problem results from the increasing isolation of the international nutrition community from its public and special-interest constituencies.
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Coordination becomes problematic only if there is much activity, and occasionally conflict within a system. Progress will depend on strong people and insti tutions, particularly within developing countries -- an obvious fact that has been insufficiently recognized in nutrition Among the actions that should be considered are the following: e An information dissemination and documentation center could play an advocacy role and could link the nutritional concerns of the public, universities, and voluntary agencies with international agencies.
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9:304-312. Food Policy Development Committee, Task Force on Concessional Flows.
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Nutrition in Primary Health Care: Summary of An International Conference, co-sponsored by the Ministry of Health, Arab Republic of Egypt and the International Nutrition Planners Forum, Cairo, January 16-19, 1984. Boston: Oelgeschlager, Gunn & Hain Publishers, Inc.
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DR. CHEN: If one looks at international nutrition and developing communities, one sees that too much activity has been taken over by government and government agencies, and this has acted as a funnel for communication between developed and developing countries and among developing countries.
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DR. ALLEYNE: I listened with interest to your comments about the multiplicity of international agencies and their different agendas and proposals.
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