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NUTRITION IN DEVELOPING COUNTRIES AND THE ROLE OF INTERNATIONAL AGENCIES: IN SEARCH OF A VISION Lincoln C. Chen INTRODUCTION Before I address the subject of the role of international agencies in helping to solve nutrition problems in developing countries, I would like to offer a few words about terminology. By the term "inter- national 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. My assigned topic does not lend itself to intellectual abstractions. Rather, I have chosen to deal with the subject in the role of an advocate, drawing broadly from my experience in Bangladesh and India. There is enormous diversity among agencies working in international nutrition. Muscat (1983) and Berg and Austin (1984) have recently reviewed the work of many of these agencies. Broadly speaking, these may be classi- fied as multilateral intergovernmental, bilateral governmental, and private. The United Nations family of technical and donor agencies are the most prominent of the multilateral intergovernmental agencies. Among these, I have counted at least 19 that undertake nutrition-related. The most significant United Nations agencies are the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF) Food and Agriculture Organization (FAO), United Nations University, United Nations Development Program, and World Food Programme. Some multilateral agencies deal primarily in financial resource transfer, including the World Bank (International Development Agency and International Bank for Reconstruction and Development), International Foundation for Agricultural Development, and one or two regional banks that are showing early interest. Not entirely insignificant (although disclaiming a nutritional mandate) is the International Monetary Fund (IMF), which has played a critical role in 63

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64 recent macroeconomic adjustments. Multilateral approaches have also been highly successful in nurturing research. 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 Inter- national Center for Diarrheal Disease Research in Bangladesh and the Institute of Nutrition of Central America and Panama in Guatemala have made useful research contributions. Bilateral agencies are equally diverse, involving the foreign assistance arms of many governments. At least 10 bilateral agencies fund nutrition programs. (Bilateral donors include the United States, United Kingdom, Canada, Australia, Denmark, Norway, Sweden, West Germany, Italy, Netherlands. and Japan.) TheY often work closely with or ^~ , and Japan.) _ J _ _ _ through their national technical organizations. In the United States, the U.S. Department of Agriculture, the National Institutes of Health, and the Centers for Disease Control have worked closely with the Agency for International Development; and the Committee on International Nutrition Programs of the National Research Council's Food and Nutrition Board has helped to consolidate the knowledge base of many nutrition issues in developing countries. Finally, several governments have created privately structured research funding agencies--the Swedish Agency for Research Cooperation with Developing Countries, Research Centre of Canada, Assistance Bureau. the International Development and the Australian Development The work ot these public agencies is joined by the private efforts of foundations, international voluntary agencies, and universities. The major private American foundations are Ford, Rockefeller, and Carnegie; several new foundations are emerging in Europe, Japan, and the United States. The most visible international voluntary agencies are CARE, Catholic Relief Services, and Oxfam. All public and private organizations work and interact with the research and training services of universities, particularly in the nutrition-related fields of public health, agriculture, economics, and management. The universities, in both developed and developing countries, are highly diverse and have various degrees of interest in international nutrition. IS

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65 The primary coordination mechanism for nutrition is the Administrative Committee on Coordination's Subcom- mittee on Nutrition of the United Nations. The Subcom- mittee on Nutrition is supported by an independent Advisory Group in Nutrition and has as constituent members almost all relevant multilateral and bilateral governmental agencies. The Subcommittee on Nutrition has performed some useful coordination and advocacy functions in recent years, including the commissioning of a series of state-of-the-art reviews. FUTURE CHALLENGES . The remainder of the 1980s and the l990s will surely present daunting nutritional challenges to the interna- tional community. That hunger and malnutrition will persist is certain; however, the magnitude, character, and trend over time are uncertain. These will be shaped by at least four basic forces: o International economics. 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 l990s (World Bank, 1985~. Many develop- ing 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, adverse prices for primary products, protectionism within developed countries, and reduction in conces- sional development assistance. The nutritional and welfare impact of the crisis is being exacerbated by pressure from organizations dominated by developed countries, such as the IMP and private banks, to undertake structural adjustments to achieve short-term balance-of-payment equilibrium (Jolly and Cornia, 1984) Such macroeconomic adjustment policies have invariably involved currency devaluation, inflationary pressures, unemployment, wage reductions, and cutbacks in government social services, including the withdrawal of food subsi- dies. These short-term adjustments are being pursued .

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66 with inadequate consideration of their impact among the poor and disadvantaged, who would likely shoulder the burden disproportionately. 0 Technological change. A host of modern technologies of consequence to nutrition are likely to Rome ~n-.ctr-~ in the remainder of this century. Recent experiences in agriculture and health suggest that the effects of technologic transformation can be mixed. The green revolution in agriculture has enabled substantial food production increases but these have been limited to well-endowed, resource-rich farms. National food self- sufficiency has been attained in some Asian countries. The employment and distributive effects of agricultural modernization have been mixed and have not made sufficient impact on poverty and malnutrition (See, 1982~. There is great excitement over the potential of medical technologies. Wide-scale dissemination and adoption of simple, cost-effective technologies, such as oral Dehydration for diarrhea and basic immunizations for common childhood infections, could dramatically promote child survival, including improved nutrition. However, technological campaigns focused on single problems without balance (e.g., birth spacing, behavioral and environmental improvements, and building capacity of a stable, effective service infrastructure) could lead to the paradox of improved child survival with increased malnutrition. Agricultural extension and health care organi- zations. The impact of these technologies ultimately will depend on the capacity of agricultural extension and health care systems in developing countries to ensure access to and use of new technologies. The organization of health care, for example, has demonstrated both passive acceptance of western models and indigenous creativity. 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. Highly creative indigenous organizational forms, 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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67 Through it all, two basic processes predominate. The first is the bureaucratization of health, i.e., the establishment of very large, state-funded, state-operated health systems dominated by technical-bureaucratic func- tionaries. In these systems, bureaucratic imperatives dominate, and a major task is to develop support and incentive structures to Promote health outputs that meet _~ , . The second, equally powerful, is the commercialization of health. Except in the objectives of the system some strictly socialist countries, there has been enor- mous growth of the private, fee-for-service systems-- doctors, pharmacies, and indigenous systems. But, as in rich countries, the commercially driven systems do not address health problems or venture into communities in which profit is low. Thus, a major challenge is how to shape both the bureaucratically dominated public sector and the profit-seeking private sector to optimize the health of all people, rich and poor alike. Domestic development. Another significant trend is rapid socioeconomic change in many developing coun- tries. The spread and penetration of private markets, rapid urbanization, and an emerging middle class in many developing countries are being accompanied by shifts in life style and dietary patterns (Latham, 1984~. Tradi- tional diets--often based on coarse, less-expensive cereals (sorghum and millets)--are being forsaken by middle-class consumers oriented toward more refined and expensive cereals (wheat and rice). The shift of land use from subsistence food production to cash crops, the increased penetration of markets into rural food exchange systems, and greater dependence on wage employment all will exert important nutritional effects. Many urban centers contain a growing pool of unskilled poor working in an informal economy. Among these disadvantaged groups, female-headed households are increasing, and there is the likelihood of a continuing decline in breast-feeding. Many developing countries will witness polarization between a growing middle class we an a, ecary affluence and the disadvantaged rural poor, whose productive land assets are ~ ~ balanced traditional diets, inadequate to generate 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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68 The worst-off region undoubtedly will be the low-income countries of sub-Saharan Africa. Coping simultaneously with rapid population growth (2.7%), 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. Agricultural production, because it depends on diverse environments, requires as yet undeveloped technologies and land management systems. Moreover, inappropriate price policies have operated as disin- centives to primary food producers. The health infrastructure is weak or nonexistent. These long-term problems are exacerbated by political instability and environmental-climatic disasters that generate large refugee movements. In the Near East and North Africa, the nutritional picture is decidedly more mixed and too varied for generalization. Several high-income oil-exporting countries have mayor nutr~ona~ problems, owing co weak social development--e."., in women's education, roles, and work. This social backwardness is compounded by the weakness of health services. The most successful developing countries in the last decade have been those of Southeast Asia with fast- growing economies. with economic vigor, These countries have been blessed the accumulation of strong human and tnst~tut~onat resources, good agricultural and health research and extension systems, favorable food production environments, and strong transport and physical infra- structure. Southeast Asia, however, continues to experience rapid urbanization, which leads to commercial- ization of the food economy with its attendant hazards, including the decline of breast-feeding. Furthermore, as much labor-intensive manufacturing has shifted to these countries, the formal and informal urban sector has grown correspondingly, drawing unskilled women into the work- force; and that has had major consequences for family nutrition. Malnutrition is much more intractable in South Asia, where three large countries--India, Pakistan, and Bangladesh--are burdened by mass absolute poverty. Impoverishment and landlessness in these primarily agrarian economies have not decreased. Aggregate food production has increased steadily and, if food were

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69 distributed equitably, would be sufficient to feed the populations. Food production, however, has come from resource-rich regions, and the gains in food production have not been translated into effective purchasing power to enable the poor to command adequate diets. Rural poverty and malnutrition in South Asia therefore has become disconnected from food production and agricultural modernization. I.atin American economies are more advanced than those of Asia or Africa. 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. However, the international economic EVOLUTION OF ladle FIEL1) How well will the international nutrition community respond to these challenges? The health of anv field is characterized by fresh ideas, ~ =, _ _ of new approaches to problems. International nutrition is no exception and has accomplished much in the last several decades (Berm and Austin, 1984~. An early 1 earning and the evolution _ biological phase contributed remarkable scientific advances in the understanding of the role of vitamins and minerals in human nutrition. In the 1960s, food produc- tion and the "protein gap" dominated the agenda. Food production was perceived to be the major problem, and protein inadequacy the key to the crisis. The approaches were thus often technical, such as the development of hi~h-Yieldina varieties of cereal grains, a_. ~ .= .~ ~ single-cell proteins, fish-protein concentrate, and amino acid fortification. By the early 1970s, recognition of the complexity of the determinants of malnutrition fueled support for a holistic approach that recognized the multiplicity of causation and recommended complementary interventions. This phase, called "integrated nutrition planning," ultimately foundered because, although conceptually

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70 valid, it was impractical and incompatible with the focused application of limited resources and the administrative alignment of organizations. the integration of nutrition Throughout the 1970s, ~ into several key development sectors (such as health and agriculture) took hold firmly. The "health for all by the year 2000," primary health care, and UNICEF GOBI-FFF* movements gave impetus to the dissemination of simple, cost-effective health and nutrition technologies (Nutrition in Primary Health Care, 1984~. Integration of nutrition into the agriculture and food sectors was slower, but productive. 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 copulations (Timmer, 1985~. To-- r-r By the end of the 1970s, concern over the protein gap had faded, and energy deficiency commanded center stage. It had become apparent that global food resources, if distributed equitably, would be sufficient to feed the world's people. Sociopolitical dimensions of the nutrition problem thus gained ground (Harries and Payne, 1984). The Political Perspective was reinforced by the dramatic nutritional strides made in some socialist countries. By the 1980s, however, the picture was decidedly more mixed. Some country assessments might have been overly optimistic (such as China); others, burdened by economic stagnation, were forsaking distributive objectives for market-oriented economic growth strategies (such as Sri Lanka); and still others across the political spectrum were showing remarkable rates of economic growth and nutritional improvement (such as Cuba, South Korea, Chile, and Costa Rica) (Scrimshaw, 1985~. . . . *GOBI-FFF is the abbreviation for the combination of growth monitoring, oral rehydration, breast-feeding, immunization, family-planning, food, and female education, which have been promulgated as inexpensive community-based strategies for primary health care.

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71 CRISIS The past can inform and guide the future, but cannot ensure it. International nutrition is in an "identity crisis." In my opinion, the crisis stems from three factors. First, the malnutrition problem is vast and tenacious. Progress in combating it has been slow. Second, the identity crisis has organizational origins. The United Nations has specialized agencies-- and thus constituencies--for agriculture, food, health, children, population, education, culture, trade, finance, environment. labor. refugees--but none for nutrition. Nutrition in WHO has been accorded low visibility and organizational status (Muscat, 1983~. In FAO, although nutrition has divisional status, it is considered a minor subject. Malnutrition among children is high on UNICEF's agenda, but the nutritional components of the GOBI-FFF campaign have fared less well than health technologies. Nutrition funding constitutes only about 1% of United Nations Development Program and World Bank commitments (World Bank, 1984). involves many actors, nutrition has been subsumed organizationally under other rubrics. Because the problem is complex and . . ~ . ~ ~ Nutrition suffers from the adage: "Everybody's business is nobody's business." The third source of the crisis is intellectual. Nutrition does not command the excitement of the research frontiers in the "new biology," nor does it compete in global significance with international economic rela- tions. In many academic centers, nutritional interests have declined, owing in part to funding cutbacks. After 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. Controversy surrounds the food intake necessary to satisfy minimal require- ments. Some have even argued that there is no such thing as a "safe allowance." There is also debate over the use of physical growth as a measure of malnutrition. With the knowledge base fundamentally so unstable, the nutrition community appears to be rudderless and to have little to offer in furthering understanding or problem- solving.

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72 LESSONS LEARNED The search for a future vision should begin with a reaffirmation of the lessons learned by the nutrition community over the last several decades. These lessons could form the first step toward an honest appraisal of needs and opportunities leading to an articulation of a future vision. What are these lessons around which broad-based consensus can be mobilized? PROBLEM CLUSTER The character of the malnutrition problem in developing countries is clear. The primary deficiencies are those of protein and energy, vitamin A, iron, and iodine. Malnutrition is not a single problem, but rather a cluster, or a system, of related problems. The cluster is highly heterogeneous in developing countries and displays enormous diversity. Definitional ambiguities notwithstanding, the numbers affected by protein-energy malnutrition are very large indeed (350 - 1,200 million). More modest, but nevertheless significant, are iron-deficiency anemia (350 million), vitamin A blindness (6 million), and iodine-deficiency goiter (150 million) (Latham, 1984~. These deficiencies, particularly protein-energy deficiency, are inextricably linked to poverty (Jolly and Cornia, 1984; Reutlinger and Selowsky, 1976; Sen, 1982~. Like poverty, malnutrition is a tenacious problem deeply influenced by income, employ- ment, productive assets, wages and prices, human behavior, and health. The long-term solution to protein-energy malnutrition is thus linked to the eradication of poverty. 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. Multidimensional complexity, however can overwhelm feasibility and practicality (Berg and

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73 Austin, 1984~. Thus, the multidimensional nature of malnutrition should be observed in introducing nutrition as a dependent variable into a range of sectoral activities. Such integration, however, should be undertaken only if diffusion and ambiguity are minimized. Effective program translation must build on political, organizational, and disciplinary realities. The solution to malnutrition does not have a single answer; the nutrition community should avoid false promises or unrealistic expectations. POLITICAL ECONOMY Malnutrition does not recognize political boundaries. It is primarily a product of the process of social exploitation and discrimination. A necessary condition for the elimination of protein-energy malnu- trition is improvement in the distribution of effective demand for food (Harries and Payne, 1984~. Such distribution of food entitlements have been achieved across the political spectrum. Radical political solutions, although intellectually satisfying, are not sufficient in themselves, even if necessary in some political settings. INTERVENTIONS Experience over the last 2 decades has conclusively demonstrated that malnutrition can be dramatically reduced, if not eliminated. In a variety of countries across the political spectrum, the problem has been solved--in Chile, Cuba, China, Costa Rica, South Korea, Sri Lanka, and a few countries of the Caribbean. These positive experiences and their lessons need to be analyzed and widely disseminated. Among the common characteristics are political and resource commitments to equitable forms of development, including investments in nutrition services. There are also enormous opportunities for integrating nutrition into primary health care and food policy analysis. Primary health care is a feasible, cost- effective vehicle for the delivery of basic nutritional services (Nutrition in Primary Health Care, 1984~. The nutritional components of primary health care are well

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74 recognized: breast-feeding, growth monitoring, oral Dehydration, immunization, nutrition education, food and micronutrient supplementation, and treatment and reha- bilitation of the severely malnourished. Indeed, the wide dissemination of several key health technologies (such as oral Dehydration and measles immunization) could generate enormous nutritional benefits. Similarly, nutrition can be improved through consumpti.on-oriented macroeconomic policies in the food and agricultural sectors (Timmer, 1985~. Food policy analysis affecting prices and marketing provides greater specificity to and thus increases the power of broader socioeconomic development policies. Particularly responsive to intervention are micro- nutrient (iron, vitamin A, and iodine) deficiencies. These are also linked to poverty, but they-are highly responsive to targeted technical intervention. Iron and iodine fortification of salt, vitamin A fortification of sugar, and the mass distribution of vitamin A supplements are feasible and highly cost-effective. KNOWLEDGE GAPS Despite much research and experience, major knowledge gaps remain. The field today lacks strong, sustained human and institutional capacity to address major policy and operational issues. How are international economic adjustments and malnutrition linked? 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? How can these public systems be improved through better matching of individual incentives with overall program objectives? How should limited nutri- tional resources be targeted to prevent severe, moder- ate, and mild cases? Is nutrition behavior rational from the health vantage point, and what is the role of nutrition education? These questions need to be answered according to specific people, times, and places. The problems and solutions are likely to differ between regions. Thus, filling these knowledge gaps requires investments in building human and institutional capacities in developing countries.

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75 IN SEARCH OF A VISION Today, more than ever before, the international nutrition community needs to think anew about how it will address the fundamental challenge of malnutrition. It should consider program clarity and effectiveness, mobilization of resources, and international agency actions--all parts of an articulated vision for the future. PROGRAM CLARITY AND EFFECTIVENESS In the past, the nutrition field has been overwhelmed and bogged down in extraordinary complexity (Berg and Austin, 1984~. Yet it has been demonstrated that simple, practical, and cost-effective actions can make a difference. These actions need to be articulated and disseminated with clarity, conviction, and confidence. Relevant here are the recent initiatives in health technology promulgated by UNICEF and WHO. Mass programs based on dissemination of oral Dehydration and immuni- zation have gained enormous public, congressional, and international agency support. Cost-effective actions along several fronts are feasible. Elimination of iron, vitamin A, and iodine deficiency globally is feasible technically and finan- cially. The nutritional components of primary health care are well recognized and can be implemented. 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. In all such endeavors, we need to set priorities and simplify the inherently complex nature of malnutrition to develop feasible organizational structures for effective operations at the field level. r RESOURCES Most of the resources necessary for combating malnutrition must come from within the developing

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76 countries themselves. Given the current international economic climate, however, developing countries require more financial resource transfers under confessional terms. Development assistance continues to represent a major share of flexible, investable resources for problem-solving. A major question, therefore, is how to increase concessional assistance, particularly that directed at alleviation of poverty and malnutrition. The Task Force on Concessional Assistance of the Development Committee (an interministerial committee of 18 World Bank and IMP member governments of developed and developing countries) 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. The task force failed to find any evidence of the "aid fatigue" syndrome. With few exceptions, the public in developed countries is not hostile to foreign assistance, and the alleviation of poverty and hunger commands much stronger support than other development investments. In a 1982 poll commis- sioned by the Chicago Council on Foreign Relations, 60% of the respondents said that they viewed 'combating world hunger" as a "very important" objective of the United States (Eberstadt, 1981~. Only 5% felt that it was "not important." Combating world hunger was far ahead of "protecting American business abroad," "ensuring our Allies' security," or even "matching Soviet military strength." The-task force noted that the volume and allocation of foreign assistance depend on a dynamic process between the general public, the legislature, the executive branch, and special-interest groups. Within the range of public support, there is far more scope than heretofore appreciated for creative leadership by the executive or legislative arms of government in response to public initiative. Nor does political conservatism in developed coun- tries explain the situation. Conservative politics might have dampened the growth of concessional assist- ance, might have shifted the pendulum away from the "basic needs" approach to development, and certainly has

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77 singled out some activities (e.g., population) for critical review. Interest in addressing global hunger and malnutrition, however, commands wide support across the political spectrum (Eberstadt, 1981, 1985~. In fact many consider hunger and malnutrition as legitimate claimants for subsidized concessional transfers, as opposed to other development investments under pressure to obtain capital from private commercial sources. How, then, do we explain the sense of dwindling support for international assistance, including nutrition programs? In part, the problem results from the increas- ing isolation of the international nutrition community from its public and special-interest constituencies. International agencies have both developinz-country and developed-country constituencies. _ But many agencies have become increasingly isolated trom one public and parallel interest groups in both developing and developed countries, such as voluntary agencies, religious bodies, universities, and business. Many agencies have also become disconnected from the acute food crisis, which commands much public attention and support. The out- pouring of public support for addressing the sub-Saharan famine underscores this phenomenon, and international agencies need to find ways of linking attention-capturing short-term disasters to longer-term nutritional efforts. INTERNATIONAL AGENCIES International agencies face a dual challenge. On the one side, the mobilization of political and financial support from advanced countries requires a clear articu- lation of nutritional needs and practical, feasible, flexible actions. On the developing-country side, the agencies need to play a facilitating role to enable developing countries to apply knowledge and resources to their problems in a flexible and locally adaptive manner The role of international agencies in this linkage process can be enlarged first through an honest assess- ment of their strengths and weaknesses. The World Bank . recently reviewed its nutrition lending program and concluded that the bank appears to be particularly strong in project development, sectoral analysis, and the planning and management of large-scale projects (World Bank, 1984~. It explicitly recognizes organizational

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78 weaknesses in undertaking innovative pilot demon- strations, support of nongovernmental initiatives, food aid, and acute emergencies. Similar internal assessments by other agencies would be useful. Although most reports dealing with the United Nations call for more "coordi- nation" (Muscat, 1983), the problems of coordination in' the United Nations system are endemic, not peculiar to nutrition. Coordination should be promoted, but the need is not for more coordination, but rather for leadership. Any of the key international agencies could, if it wished, exert such leadership. 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: . 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. The center could also disseminate and analyze experiences that have demonstrated effectiveness in meeting nutritional problems. A nutrition project development facility is needed to train professionals in the design and management of nutrition projects. If properly used, international resources that are already available could be applied at increased levels to the investment in nutrition with far greater effectiveness. Intellectual resources need nurturing in both developing and developed countries. Building capacities in developing countries for food policy analysis and health and nutrition policy and management would strengthen the underpinning of the field as a whole. Universities are particularly relevant in this regard. The special program approach has been highly successful in promoting public attention, the participation of the scientific-technical community, organizational visibility, and financial' resources. A special nutrition program launched by international agencies should be considered.

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79 Finally, an international funding consortium should be considered to provide sustained, systematic support for international nutrition research (Mitra, 1982~. In agriculture, the Consultative Group on International Agricultural Research has been highly successful, and a similar consortium for international health and nutrition has been discussed, but has yet to crystallize. Bureaucratic and territorial instincts should be set aside in preference to the pooling of resources to support a global and long-term attack on malnutrition. CONCLUSION Program clarity and effectiveness, resource mobilization, and specific actions by international agencies would all be components of a vision--with moral force--to underscore an international commitment to the elimination of malnutrition. The World Food Conference in 1974 concluded with the mandate that within a decade "no child should go to bed hungry." Today, more children than ever are hungry. At the threshold of the twenty- first century, we will look back on the twentieth century as one marked by remarkable advances in science and technology. Modern science has brought unprecedented affluence (and hazards) to much of humankind, including the capacity to produce sufficient food for all the world's people. Can the promise be fulfilled? REFERENCES Berg, A., and J. Austin. 1984. Nutrition policies and programmes: a decade of redirection. Food Policy 9:304-312. Development Committee, Task Force on Concessional Flows. 1985. Report of the Task Force on Concessional Flows. Development Committee. Pamphlet 7. Washington D.C.: The Joint Ministerial Commission of the Boards of Governors of the World Bank and the International Monetary Fund on the Transfer of Real Resources to Developing Countries.

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80 Eberstadt, N. 1981. 72~1~:40-49. Hunger and ideology. Commentary Eberstadt, N. 1985. The perversion of foreign aid. Commentary 79~6~:19-33. Food and Agriculture Organization. 1977. The fourth FAO world food survey. FAO Food and Nutr. Rept. Ser. No. 10, FAO Statistics Ser. No. 11. Harriss, B., and P. Payne. 1984. Rejoinder: magic bullets and the nutrition agenda. Food Policy 9:313-316. Jolly, R., and G. A. Cornia, Eds. 1984. The Impact of World Recession on Children. New York: Pergamon Press. Latham, M. C. 1984. Strategies for the control of malnutrition and the influence of the nutritional sciences. Food and Nutrition: The FAO World Review of Food Policy and Nutrition 10~1~:5-31. Mitra, A. 1982. Changing roles of UN and bilateral agencies in the field of nutrition with particular reference to India. Unpublished paper. Muscat, R. J. 1983. Responding to the changing nutritional conditions of the 1980's: roles for the international agencies. A report to the Advisory Group on Nutrition, Sub-Committee on Nutrition, UN Administrative Committee on Coordination. Presented at the 9th session of the UN ACC/SCN, Copenhagen, March 7-11, 1983. 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, Januarv 16-19 1984. Boston: Oelgeschlager, Gunn & ~ _ , _ Hain Publishers, Inc. Reutlinger, S., and M. Selowsky. 1976. Malnutrition and Poverty: Magnitude and Policy Options. Baltimore: Johns Hopkins University Press.

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81 Scrimshaw, N. S. 1985. Realistic approaches to world hunger: policy considerations. Food Nutr. Bull. 7~1~:10-14. Sen, A. 1984. Food battles: Conflicts in the access to food. Food Nutr. 10~1~:81-104. Timmer, C. P. 1985. Realistic approaches to world ~ hunger: how can they be sustained? Food Nutr. Bull. 7~1~1-4. World Bank. 1985. World Development Report 1985. New York: Oxford University Press for the World Bank. World Bank, Population, Health and Nutrition Department. 1984. World Bank Nutrition Review. Washington, D.C.: World Bank. DISCUSSION OF DR. CHEN'S PAPER DR. McGUIRE: Many people have concluded that the hunger problem is due to political factors and govern- ments themselves, including the U.S. government and its foreign aid policies. In many ways, these policies do not reflect the kinds of poll results you cited. How do you think individuals in developed countries can help individuals in developing countries, given that working through governments or international organizations is often ineffective? Because the World Bank and other United Nations organizations all work through govern- ments, the individual initiative is stifled. 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 communi- cation between developed and developing countries and among developing countries. More participation by the public is needed, including a variety of different sectors and including voluntary agencies and universities. It is a shame that the natural spirit of collegiality and professionalism among universities is not being adequately promoted. In a -

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82 broader historical perspective, we should recognize that many developing countries are going through a postcolon- ial period. Governments in developing countries often do not feel confident in their own rule, and that accounts for turmoil. Many government activities strengthen government's hand, and I think there is a need for sym-- pathy and understanding. But international agencies and government bodies need to promote more independent, nongovernmental interactions as well. DR. GASSER: Would you care to comment on the role of multinational businesses in the development process, especially as it relates to nutrition? DR. CHEN: I have spent 12 of the last 15 years in Bangladesh and India. The role of multinational businesses in both countries is very small, compared with that in other countries, particularly in Southeast Asia, Latin America, and probably parts of Africa. Multina- tional businesses seem to play a very important role, some of it adverse. However, I was asked to talk about the international agencies in particular. DR. ALLEYNE: I listened with interest to your comments about the multiplicity of international agencies and their different agendas and proposals. One of the things that often concerns us is the capacity of developing countries to cope with these so-called international agencies. You did not address mechanisms for strengthening the national capacity to bring order out of the chaos that many international agencies bring. DR. CHEN: I agree with your comment. I think I addressed the need to develop capacities within developing countries. One of the most important roles of advanced education in developed countries is not necessarily the accumulation of knowledge but the con- fidence acquired by those who have been exposed to advanced societies and who then take roles in develop- ing countries so that they can cope with the outside interests in their countries. This is important, because the interactions are multiple and confidence in dealing with them is much needed. There might be a role here for the institutions of developed countries.