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INTRODUCTION This year, Programs has been entrusted by the Food and Nutrition Board with the responsibility of organizing the annual symposium that the board sponsors. True to its purposes, which turn around the word "international," the committee chose more than a subject, an intellectual exercise in perceiving the future almost already upon us. 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. Not everybody is impressed with the year 2000 as being a magic date, when everything will be brighter and every- one will be healthy and better off. What we all should hope--and strive for--is that the twenty-first should be a more humanitarian century with greater concern for human development and well-being. For many, this century, whose end we foresee, has been the most cruel one in the history of mankind. Man-made crimes in the name of all sorts of reasons and unreasons have been varied and abundant--despite the marvels brought about by science and the arts, the other face of this century, which has enlightened our lives. Hunger and malnutrition in the developing countries are on the increase, even on the basis of the limited information we have. This trend may well continue for the rest of this century. Poverty, population growth, overcrowding, unemployment, lack of food availability and of purchasing power, and behavioral patterns act synergistically to induce malnutrition and high morbidity and mortality. In absolute numbers, malnutrition is for many the most important social problem in the developing world. It is also so because it can affect human beings the Committee on International Nutrition 1

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2 in all stages of life, from conception to senescence. In a number of them, it impairs intellectual development, school performance, and labor productivity and produces a pessimistic outlook on life. With reference to specific nutritional deficiencies, it is unforgivable that still no fewer than 250,000 children become blind every year for lack of vitamin A and that at least 3% of those living in the highlands become cretins. We have well-tested, highly cost- effective technologies to control both problems. Still, we have not applied them systematically. By its very nature, malnutrition is a complex problem for which there is no panacea. It results from environmental stresses on human beings poorly endowed genetically and metabolically. And these stresses are related to economic, social, biological, and agricultural determinants. We know most of them and how they act to induce malnutrition, but we do not know all their synergisms and antagonisms and their pathways in nature. This remains a large area of basic and applied research that could have significant program implications. 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. The on-going economic recession, particularly in the debt-ridden developing countries, is for us of great concern. We feel that the therapies recommended may be aggravating the patient's condition. Austerity measures, even with the best intentions, may be hurting badly those in the lower strata of the income scale. In certain countries, we can infer from the information available that this is already happening and that the numbers are increasing. For this reason, we are convinced of the need of economic adjustment policies "with a human face," to use the felicitous expression of Richard Jolly. This will require in every country a careful analysis, looking for measures that, at least, will palliate the impact of the on-going recession on the poor. It should be done by the government and international agencies concerned and by a mix of experienced professionals, not exclusively economists.

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3 We all believe that food production per se, although fundamental, does not solve the problem of hunger and malnutrition, at least in the short run. Frequently, food consumption and utilization are interfered with by a web of economic, environmental, social, and behavioral determinants that must be identified and controlled. Some of them are country-specific. We understand the concepts of "food entitlements' and "food security' and their significance, but they seem difficult to implement. 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 activi- ties. These efforts have resulted in sustained and significant declines in infant and early childhood mor- bidity and mortality, malnutrition, and low birthwei~ht ~- and an increase in breast-feedin~ and better weanin~ ~ O practices. What is more important, these outcomes have occurred in countries with a severe recession but with adequate health and nutrition policies, supported and financed by the government and effectively implemented. In some of them, the situation is considered to be "a paradox of economic backwardness "despite] health development." For many, this is a prescription for the short term that can be successful, while economic development and sound agricultural and social policies create the conditions in the long term to prevent acute ill health and malnutrition. Science has contributed during this century fundamental discoveries of nutrients and nutritional processes in animals and hu~Tan Thin. _ _ ~ We do not apply in the developing world everything that is known and has been proved effective, and we should. At the same time, we expect that pending issues will be unraveled, both conceptually and technically, so as to enlarge the scope of possibilities for controlling malnutrition through adequate policies and programs. J V - ~ ~ ~ V We find ourselves at a crucial period. Malnutrition is on the increase as a result of man-made decisions and actions. We have more knowledge than we are using to reduce the deleterious effects of the problem. Further- more, hunger and malnutrition do not have the political

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4 support that is required for sustained government decisions and appropriate investments in order to apply well-tested technologies and search for new ones. How is malnutrition going to evolve up to the end of the century? How will its major determinants influence present trends in developing countries? Are the pre- scriptions needed to reduce the magnitude and conse- quences of this problem different from the ones in use? What is the role of the international organizations-- multilateral and bilateral? These and related questions were posed to the distinguished scientists that are with us today. We hope their thoughts will be both illustra- tive 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. Cat . ... ~ Abraham Horwitz. _ _ _, rman Committee on International Nutrition Programs (from 1980 to 1986) Food and Nutrition Board