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II INVITED COMMENTS
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INVITED COMMENTS
ABRAHAM HOROWITZ
If the ideas discussed here are not translated into
policies and programs, they will fall into a vacuum and
be replaced by other ideas, which will be worse or pe-r-
haps better. As I consider the papers presented here and
think about what has been said in the discussions, I
believe we need to consider how all this can be trans-
lated into clear-cut policies and programs. This will be
difficult, especially in view of the obstacles that some
governments present with regard to the problem of malnu-
trition, but we must pursue it and we must look also at
the fundamental role of international agencies.
Both governments and international agencies have a
key role in nutrition policies and programs. Recognizing
the weaknesses of governments, we must help them to
identify the major issues, to recognize available and
potential resources, and to bring the resources together
into clear-cut objectives and programs. Governments also
have a role in coordinating international efforts, rather
than in being coordinated by them.
To begin to give some thought to the implications of
what has been said here, we will first hear comments from
several panelists.
SOL CHAFKIN
,
In a Latin American country, I once asked the leader
of an important labor union, "What is the objective of
the union?" He said, "Mass, mass, mass." In a sense,
this has characterized demands by both the health and
nutrition communities for more of this, more of that, and
more of the other thing. Health and nutrition problems
have been perceived as solvable "if only we could get
more." It is going to be necessary to redeploy,
redeploy, redeploy the available resources to achieve a
particular objective. This is not necessarily because of
today's political configurations; I think it is going to
be the wave of the future beyond the year 2000.
In the issues identified thus far, there was some
star-gazing, although perhaps not as much as I would have
liked. With two or three exceptions, the issues are the
same as those I remember from the 1970s. At the World
85
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Food Conference in 1974, many of the same issues were
highlighted; however, the two or three issues that were
not are highly significant.
_ _ In economic development,
especially as practiced by national governments and
international agencies, it used to be that, when all else
failed, you started a bank, and if the bank failed, you'
started another bank. A parallel in nutrition has
emerged since the 1970s: if all else fails, you start a
project, and if the project fails, you start four more.
This is very important and wise, because you have to do
something to create constituencies. If you are lucky,
perhaps the fourth of the four projects will work. In
this way. it is possible to move forward. Another
- -I 7 ~
significant factor is the invention, by the leadership of
WHO, UNICEF, and others, of GOBI-FFF. It is a striking
invention and a striking demonstration that strong
leadership can cause specific problems to receive
specific attention. Something different in both nature
and degree has happened as a result of initiatives that
were not present, as I recall, in the 1970s.
The second difference between the issues in the 1980s
and 1990s and those in the 1970s is that in the 1980s, as
Dr. Waterlow has noted, the concept of standard nutri-
tional requirements has been challenged. I have taken
that challenge seriously, because in essence it says,
"markedly low food energy intakes seem to allow normal
activity" and people can lead healthy lives. The
implication is profound. If we have seen this, and we do
not have evidence of impairments, we might not have
looked hard enough. However, if there are no impair-
ments, then there is an interesting status quo and a
great opportunity for benign neglect. The argument
implies that, if you can do normal activities with low
caloric intake, then the nutrition problem is diminished.
The prevalence of malnutrition in developing countries is
anywhere from 5% (probably less than 10%) of, say,
340 million or 1 billion, and it is important and must be
dealt with.
The key problem that I see with this is that our
interpretation of "normal" in this kind of situation is
status quo--that is, you are where you are. If, however,
you are interested in development, in what Dr. Mahler
called socially and economically productive lives, you
are certainly not there. I suggest that the development
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process, in the smallest units of society--the household
or community, for instance--requires abnormal activity,
and that abnormal activity can represent an expenditure
of energy that changes the markedly low food energy
intakes.
It might be necessary to prime the energy pump to
accomplish all those difficult, time-consuming, painful
tasks that communities have to experience to organize-
themselves, such as negotiating with Dr. Mahler or his
lieutenants or the local government or digging the well.
Presumably, these tasks will be undertaken after spending
a great deal of time digging in very rough soil and
carrying very large loads. At the end of the day,
typical development schemes call for recipients to attend
a community meeting to organize a project.
The third significant difference that I observed is
also in Dr. Mahler's field, primary health care. I view
primary health care as a mechanism for organizing a
community. We are, I hope, long past the romanticiz-
ing of the words "community participation," which
Dr. Waterlow noted as one of the fashionable rallying
cries that appear from time to time. Initiatives or
opportunities for development are needed for communities
to act on those opportunities. Otherwise, they will have
to invent those opportunities. The communities repre-
sent, as Dr. Mahler said, a pool of energy. The pool
might be small and ingenuity might exceed energy; but,
without this energy, we are going to be stuck with
bureaucracies of the kind that people are uncomfortable
with. Community organization must be incorporated; it
must have a juridical personaliev to take on Projects,
borrow money, and be sued.
The significance of the idea
of the primary health care center is that it is a way of
organizing a community; it is not the only way, but it is
one way to start the process. Primary health care will
not solve all the problems of development, but it will
demonstrate, as I have witnessed in the United States,
how a health approach or a nutrition approach can be the
most effective way of organizing a community. It is an
issue that you can get your arms around and do something
about. Those are the three significant advances that I
heard reflected in this morning's discussions.
I also noted Dr. Waterlow's passing remark that we
had better have some kind of an emergency strategy.
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Dr. Chen also referred to a chasm between events that
lead to emergency actions--such as hunger, famine, and
disaster--and the activities of the international
agencies. This suggests to me that perhaps an emergency
strategy can be developed that runs for 5 or 10 years and
takes advantage of public support to Despond to a -
crisis. The most astute of the nongovernmental agencies
are beginning to try to convince their contributors to
stay with Africa after the crisis of famine is over, but
there is a need for a better articulation of what an
emergency is. The Ethiopian famine emergency can be com-
pared with what happens every day in a disaster household
to a child who is at risk all the time and whose mother
is at risk all the time and unable to function
effectively.
There is a need for a safety net or food security or
some other kind of protection that uses existing food
resources, whether from overseas food aid or from local
products. There are precedents for localized food
reserves, but a strategy is needed to foresee and plan
for emergencies of various sizes over the next 10 years
that require the kind of support we are talking about.
I am suspicious of health ministries, despite
Dr. Mahler's changes and fresh ways to redefine prob-
lems. I urge those who worry about food to watch their
programs as they enter into collaboration with health
. . .
ministries.
Finally, in examining the severe malnutrition problem
that Dr. Waterlow mentioned, I have a suspicion that many
of the severely malnourished are in what might be called
disaster households. The mother is in trouble; she could
be abandoned, sick, unemployed, too young--regardless,
more than food or health care is needed. It is often a
matter of a broad range of social services, of which I am
also suspicious. This same problem can be seen in some
places in Harlem in the United States, as well as in
Latin America or India. If the food distribution center
or the health center were next door, the mother would not
take the sick child there, because she is simply unable
to function.
.
-
RICHARD JOLLY
I want to emphasize opportunities for action, because
I think many people here are in a good position to think
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creatively about nutrition
ties in with Dr. Chafkin's
interventions. First (this
comments regarding differences
in nutritional realities as they exist today), there is a
major difference between the malnutrition we are talking
about today and the malnutrition we talked about in the
1970s and even before. Historians in the next century or
perhaps even in the l990s will have to describe at least
the early part of the 1980s, and quite possibly the rest
of the 1980s, as a period in which malnutrition
systematically increased in most countries, whereas there
was a good deal of economic progress in the 1950s, 1960s,
and 1970s. Although there were fluctuations, with
periods in which malnutrition increased in some countries
and decreased in others, I think we will see increasing
malnutrition, in many more countries in the 1980s, rather
than even a leveling or a decrease. That is certainly
true of Africa and most of Latin America and increasingly
true in the United States, in Britain, and probably (if
one had the data) in the Middle East. Asia, I think,
Presents a much more mixed picture; in terms of numbers
~.
_ ~ . . . . . · . of. · ~ _ ~
ot people, the situation In lna~a ana Anna nas ~mprov~u,
and, because of the numbers, this is highly significant.
But in terms of countries, the tendency Is alarming.
This ties in with Dr. Chen's point about the role of the
international agencies. Not only is no international
agency concerned directly with nutrition (I am not saying
that we ought to have that), but we have a systemic ana
systematic international neglect that is actually worse
than simple neglect. The net balance of international
pressure on countries at the moment is to worsen
nutrition, to worsen health expenditures, and so forth,
and that is what we must reverse.
In the context of Dr. Chafkin's remarks, I would like
to focus on five key points that have come out of this
symposium.
First, underlying what every speaker said was
explicit recognition of nutrition and poverty concerns as
an essential objective of policy. This is in one sense
trivial. In the 1970s, we were saying all that, but my
point is that we have gone back. A lot of people are
saying that we need to bring a concern for poverty back
into development. It is not only long-term development
policy we are concerned with; it is also short-term
adjustments. If you talk to any minister of finance or
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go
any political leader in most parts of Africa or Latin
America or if you listen to the speeches made at the
United Nations, you will hear how the problem is to
survive economically in a situation of unprecedented
economic pressure. In the jargon, this amounts to
adjustment policy. We need to bring concern with poverty
and nutrition into adjustment policy, because adjustment
policies are dominating economic policy in developing
countries. This leads to ''adjustment with a human face,"
as I have written about elsewhere. When it came to the
struggle of World War II in Europe and I think to some
extent in the United States, the economic priority was
clearly to use economic resources for the effort. There
was no problem at all in incorporating human nutrition
concerns into that national strategy. The result was
that the nutritional status of the population in Britain
and a lot of other countries at the end of World War II
was better than ever before, despite the diversion of
resources. There is nothing theoretically or practically
contradictory about combining human concerns with tough
economic realities.
Second, we need to consider bringing the human and
nutrition indicators into economic policies. The
nutrition field is currently dominated by GNP, balance of
payments, and inflation rates. What we need are indi-
cators, such as food balances. Admittedly, we have the
statistical difficulties of defining malnutrition or
severe malnutrition precisely. These were well ela-
borated in several of the presentations. Nevertheless, I
see nothing wrong with choosing a standard related to
what a country thinks is politically reasonable. If one
could measure the change in relation to such a fixed
standard, the deterioration that we have been talking
about would be more visible. Efforts are needed to
strengthen international collection of data on the human
indicators and to put them alongside the GNP and the
other economic indicators, to show that adjustment of
development policy must be concerned with the human
dimensions. Indicators of this kind would create an
opportunity to bring the human dimension back to
development. The international agencies have an
important role in developing these data.
Third, as Dr. Waterlow and Dr. Mahler stressed, there
is need for action within countries on food and health
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together. Having been in development from an economic
point of view for many years, only when I joined UNICEF 3
or 4 years ago did 1 begin to appreciate bully one neaten
dimension of the nutrition problem. I am convinced that
that was not just a weakness on my side. I have seen a
systematic difficulty in the last year in getting the
problem across in Africa. We have done very well in
raising money for food, food in kind, food in cash.
Something like 40% of health programs and 45% of
water programs were funded from emergency appeals.
Donors have cross-examined recipients, saying, "Surely
you are trying to slip in, in the name of an emergency,
this health program or this water program, when we are
really concerned with hunger." This shows the
misperception that I think this particular community has
a major role in correcting. People can die of thirst or
die of disease as quickly, and sometimes if they are
young they will actually die of hunger, more quickly,
despite its visibility as a public issue.
Even last week when a friend of mine drafted a piece
for USA Today on child needs in Africa, the editor struck
out the health dimensions, unable to see that it was
relevant to the problem of malnutrition in Africa. I
agree with Dr. Mahler's phrase, 'when one can get people
together on the ground, the sparks will fly." This is
what we need to encourage at the country level: bringing
people together who can tackle their nutrition problem in
a way that matches the resources and capacities of the
country. I liked Dr. Waterlow's underlining of the
specific actions--with respect to vitamin A, goiter,
etc.--as well as the general need to tackle the poverty
problem.
Fourth, the international consortia of nutrition
action and support, which Dr. Chen suggested, will be
important. I hope the international agencies will play
their part. Of course, donors should be included, and
the nongovernmental organizations have an important role,
too.
Fifth, I would like to expand on the need for support
for nutrition research institutions in industrial and
developing countries. In particular, I point to the
problems in Africa. As opposed to the situation in the
1960s and even the 1970s, there is a very large number of
well-trained and competent Africans who are ready to take
-
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the lead in this. Unfortunately, many of them are no
longer in their own countries, but instead are employed
by international agencies or research institutions some-
where else. Conditions in Africa have deteriorated so
much that it is difficult to keep together the critical
capacity of competent people with minimal resources to-
tackle their own problems. This is a problem that needs
and deserves international support--to maintain people in
their own countries who have the capability to function.
In the 1960s, Makerere University in Uganda, the
University of Ghana in Legon and the University of Dakar
were some of the great institutions concerned with
nutrition. I learned recently that the library in Legon
has not received a journal since 1975. The students have
not even enough paper to write on. Bringing the best
people to Britain or the United States is not in the
interest of tackling these problems. What is needed is
to support them in their own countries with resources and
in other ways. It would be a mayor contribution to
recognize that--at a time when nutrition is worsening in
the world and capacity is at best stagnant and in many
parts of developing countries (particularly in Africa)
actually worsening, if not almost gone--the problem is
not a lack of potential or trained people, but a lack of
support.
I still believe that we should not be too depressed.
We have seen, beginning with the television programs on
the famine in Ethiopia in October 1984, a great change in
public perception and awareness. An article in Britain
about Bob Geldof stated that the recent public response
shows that it is not true that the younger generation
does not care. The enormous support for Band-Aid there,
Live-Aid here, and so forth shows a potential to be drawn
on, and that potential changed government policy
noticeably. Our constituency is not only governments,
but also public opinion. One needs to get across to the
public the importance of health and water, as well as
food, but also the potential for action.
This can be
done and is vital. In developing countries in the last
year and one-half, there have been some very important
points of hope, despite all the pressures.
When political leaders become aware of what can be
done, they can respond. The idea that the Third World
is ruled entirely by dictators with no concern for their
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people is neither true nor particularly helpful. One
should not underestimate the lack of awareness of what
can be done at low cost. That is the significance of
what we have seen at UNICEF and at WHO. In some key
components of primary health care, immunization, oral
dehydration, etc., you can get across to political
leaders that things can be done even in times of great
constraint, and it is amazing what political leaders
themselves will do to generate support and promotion.
For example, a million Dehydration therapy packets were
distributed worldwide in 1974, and we estimate that it
doubled in the last year alone and that in 1985 it will
be something like 200 million. The cost of oral
Dehydration is low, and if there is a political appeal, I
think there is a chance for it to be taken seriously if
we not only promulgate the vision, but present specifics
to support that vision.
PAUL LDWVEN
I want to raise one issue regarding nutrition in the
1980s and 1990s. It was mentioned by Dr. Mellor and is
what I consider one of the major issues for the 1990s:
the need for urbanization.
"It seems that the world's food supply is winning the
race against population increase. For example, average
dietary energy available to all developing countries has
improved as much as 10% between the mid-1970s and the
early 1980s. However, this global figure should not
conceal the deep inequalities in some countries and in
various population groups.
The striking fact is that in the 1980s in a number
of towns in developing countries, street riots were
triggered by changes in food prices; this happened in
Brazil, Tunisia, Morocco, Peru, and many other places
according to United Nations population statistics.
Between 1980 and 2000, the world urban population will
rise from 31% of the total population to 44%. Much of
this population is already living in large townships,
shantytowns, and slums in cities. In absolute figures,
this increasing percentage means that, between now and
the year 2000, 500 million people will move to towns and
create enormous problems for governments in ensuring food
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supplies and looking at nutritional problems with respect
to food quality.
When people move to the city, their dietary patterns
shift drastically. They can no longer rely on food that
they grow themselves. The adoption of an urban life
style means that they tend to use particular quick food-e
and snacks that must be absorbed by the body quickly.
Traveling to and from work and cooking present~competing
demands. Employed mothers have difficulty in breast-
feeding their babies, and publicity induces them to buy
processed foods with low nutritive value.
The only way to address this situation, which I
believe will worsen in the coming decade, is to help food
systems to adjust to the increasing demand for food,
especially processed foods. This implies a number of
strategies that have been mentioned here--looking at
better production, marketing and distribution of food,
and pricing and subsidy policies. In addition, special
nutrition programs are needed for deprived urban
population groups. A major task for governments and
international agencies is to formulate strategies and
policies that will enable the world of the l990s to cope
with this fundamental issue. As Dr. Mellor said,
agricultural strategies, agrarian reform, and irrigation
are needed to improve the food situation. We need to
design strategies and policies to address employment and
nutrition. Unfortunately, these require time, and it
might already be too late. Agrarian reform to address
the nutritional demands of the year 2000 cannot be
implemented overnight.
Representative terms from entire chapter:
primary health
