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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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86 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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87 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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88 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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89 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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91 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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92 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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93 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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94 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.