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THE INTERNATIONAL DIMENSION: NUTRITION'S ROLE IN WORLD FOOD AND POPULATION CONCERNS Marian F. Zeitlin The state of the art in international nutrition interventions improved dramatically in the 10-year period from 1977 to 1987. During this time most types of nutrition interventions improved in design as they went from being marginally or questionably effective to being demonstrably beneficial in improving either the nutritional status of vulnerable groups or the food consumption of the poor. At the same time, the world hunger problem has steadily worsened, particularly in Africa, where the toll of combined deaths from starvation and the acquired immune deficiency syndrome (AIDS) by the end of this century could dwarf any disaster in recorded history. Moreover, history may view our excuses for not preventing these massive losses of human life as rather thin, given that we live less than 24 hours away by airplane from the victims and that the victims have done nothing to deserve their disentitlement to the world's resources. The net transfer of resources from industrialized countries to developing countries, where the malnourished are concentrated, has decreased gradually and systematically from a positive transfer of about $39.4 billion in 1980 to a negative transfer of minus $31 billion in 1985. Simultaneously, over this period, the rates of malnutrition in developing countries outside of South and East Asia have systematically worsened and are continuing to deteriorate (Cornia et al., 1987~. Given this state of the world economy, nutrition programs in developing countries are, by definition, compensatory. 149

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Closer to home, the level of funding that enables the United States to assist developing country governments to develop nutrition programs has decreased. This level is now in danger of dropping below a critical threshold. Below this critical threshold it would be impossible to sustain the recent U.S. contribution to the growth of effective nutrition intervention models or the commitment of developing country leadership to the implementation and expansion of these models. In 1977, I was working at the Harvard Institute for International Development (HIID) as associate director of a project for the U.S. Agency for International Development (AID) to distill the state of the world's knowledge about nutrition programming into a set of guidebooks. Directed by James Austin of the Harvard Business School, this project produced the HIID Nutrition Intervention in Developing Countries series (Austin and Zeitlin, 1981) and seven other studies (see below). In this paper I review how we have progressed since that time and discuss future directions. THE DIMENSIONS OF THE PROBLEM Depending on the indicator used to define malnutrition, the manner in which the indicator is calculated, and the age groups on which the calculation is based, estimates of rates of malnutrition in poor countries vary anywhere from 5 to 90%. Global estimates of the numbers of malnourished individuals vary from about 0.5 billion to 1.5 billion (Food and Agricultural Organization of the United Nations [FAO], 1985; Grigg, 1985; World Bank, 1986) and are expected to double by the middle of the next century. One of the difficulties in rallying assistance for malnutrition has been the lack of common standards for reporting malnutrition rates. According to any of these counts, the numbers of malnourished people in all developing regions of the world are increasing with population growth. In most countries of Africa, Latin America, West Asia, and the Middle East, both the proportions and the absolute numbers of malnourished people are rising. In South and East Asia, the proportions of the malnourished are declining, but not 150

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fast enough to reduce the absolute numbers (see McGuire, in press, for a detailed review of negative effects attributable to malnutrition). The world hunger problem can be divided into the problem of periodic famine or food insufficiency and the problem of continual chronic undernutrition, particularly of young children and their mothers. Insufficient global food production or food production capacity are not the causes of either of these conditions, nor should food production be limiting in the future (Mellor and Johnston, 1987~. According to projections, the size of the worlds population will level off by the year 2100 at about 10.4 billion, according to the World Bank, or between upper and lower limits of 8 and 15 billion, according to the United Nations (Demeny, 1985~. Most experts believe that at the global level food production per se can technologically keep pace with increasing population growth over this time period and beyond, given that we are entering a new era of agrobiotechnology with almost limitless possibilities for innovation and for expanding production on marginal lands (Lipton, 1985~. In many poor countries, however, decreases in per capita subsistence food production, together with rapid population growth, are the immediate causes of hunger. In the simplest terms, the cause of world hunger is the maldistribution of food, the resources needed to produce or acquire food, and the knowledge and motivation to utilize food adequately. Distribution problems exist at two levels: the macrolevel of politics and trade and the microlevel of public and private programs and household and community uses of food resources. MACROLEVEL PRECONDITIONS FOR IMPROVEMENT IN INTERNATIONAL NUTRITION The - hi hi And for niltri ti onn1 improvement in developing countries lie outside of the realm of nutrition per se. Nevertheless, since the future outcome of nutritional programs depends on these conditions, it is important to note them in summary form. Several recent books on food and development policy detail the complex contributions of economic and historic forces to the present situation and its potential solutions (Biswas ~_ 151

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and Pinstrup-Andersen, 1987; Cornia et al., 1987; Eicher and Staatz, 1984; Gittinger et al., 1987; Timmer et al., 1983~. The following list of preconditions for improving the nutrition of people in developing countries is taken primarily from Adjustment with a Human Face, edited by Giovanni Andrea Cornia, Richard Jolly, and Frances Stewart (Cornia et al., 1987~: A steady expansion of world economic output. Restoration of long-term positive net resource flows from industrialized to developing countries, including increased direct aid or assistance to developing countries. Debt restructuring and/or relief for developing countries. Elimination of agricultural policies in industrialized countries that protect domestic producers by exporting below-market-price, subsidized surplus food grains and other agricultural products. o Reduction of protectionist trade barriers in industrialized countries against importing primary commodities and manufactures from developing countries. Support of poor countries' real earnings for commodity exports during severe slumps in the international market. Reduction in real international interest rates Improvement of international credit systems set up to provide loans as a buffer to hardship conditions in poor countries. 0 Adoption of indicators that would rapidly reflect worsening conditions and would trigger eligibility for buffer loans. Economic adjustment policies in developing countries that combine adjustment with the restoration of economic growth and with the protection of the welfare of vulnerable groups. 152

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THE ROLE OF NUTRITION AS A DI SCIPLINE The role of nutrition as a discipline Is primarily to improve microlevel distribution, although nutritionists also educate policymakers concerning the severity of nutrition problems, their social consequences, and the need for social and political change. Many who enter the field with the vague hope that studying international nutrition will transform them into macrolevel political activists end up disillusioned. For example, a colored South African student who was completing her master's degree program at the Tufts University School of Nutrition realized with growing anger that research and proposed nutrition interventions did not attack the root causes of hunger. For those who remain in the field, the hope endures that good work at the micro level not only will alleviate suffering and lead to the development of basic services and skills but will have a leavening effect on macro level policymakers. THE DANGERS OF CUTBACKS The role that nutrition as a discipline will play in world food and population problems depends, to no small degree, on the commitment of the U.S. government to continuing to fund international nutrition activities. To date, the United States has provided most of the funding for technical assistance to international nutrition activities, with the result that most of the state-of-the-art knowledge in international nutrition interventions is U.S. based. It can be argued that there is a critical threshold level of funding above which U.S. technical assistance to nutrition is needed to keep up the momentum in contributing toward development. So long as this momentum continues to grow and programs continue to expand, political leaders and professionals in developing countries gain increasing awareness of nutritional concerns and continue to advance their skills in nutritional problem solving. Above this level there is the hope of advancing the potential of the brightest and best of the next generation's leaders. There is hope of nurturing effective demand for a basic needs, or "human 153

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face, n approach to development and, therefore, some hope of counterbalancing the negative macro-level flow of economic resources over which we have no control. By strengthening human resources and the commitment to ending hunger, we hope to empower developing country leadership to develop creative solutions to the economic dilemmas. Over the past 20 years, Martin Forman provided the vision and political astuteness that made it possible for AID's Office of Nutrition to operate above this threshold level. The Office of Nutrition and nutritionists in AID's regional bureaus, in the Bureau for Program and Policy Coordination, and in other affiliated offices in the U.S. government succeeded in expanding the research, knowledge, and programmatic skills base of an international network of concerned leaders and scientists. By the early 1980s, however, this network and its funding base ceased expanding and started to contract. If funding for nutrition continues to decrease, efforts to improve nutrition in developing countries might melt away or appear increasingly to be skillfully crafted window dressings for aspects of U.S. foreign policy over which nutritionists have no control. U.S. foreign policy, as it relates to food, appears to be increasingly driven by agricultural growers' lobbies. These lobbies are committed to withholding access from developing country farmers to the technology that they need to increase their production, out of fear that increases in developing country production would compete with U.S. agricultural exports. The recently passed Bumpers Amendment (Section 209 of the 1986 Supplemental Appropriations Bill) prohibits both technical and financial assistance by AID to projects that may be intended to develop the exports of recipient countries, when those exports could cause substantial injury to U.S. producers. Invocation of this amendment by growers' lobbies has made it difficult for professionals in AID to even speak of providing aid to increase production without substituting terms such as consumption or self-sufficiency for the word production. 154

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In Zaire, I evaluated a very small, exquisitely crafted U.S. Title II food program that sells milk powder to finance three excellent projects. One project provides for the upgrading of equipment and for increasing the capacity of a local commercial firm that produces a low-cost weaning food. The second project supports the distribution of subsidized cornmeal to Kinshasa's poorest markets by a local development group that uses profits from the sale of-corn under Title II to provide a producer's subsidy to farmers who grow corn locally. The third project supplies cornmeal under Title II to a primary health care umbrella agency for use in the promotion and sale of the subsidized and targeted corn-soy weaning food in the city's poorest maternal and child health (MCH) centers. One of this project's overall goals is to create demand for corn instead of cassavah (on which diets are based in Kinshasa) as a nutritionally superior staple. This project, which is run by the private and voluntary Organization for Rehabilitation and Training (ORT), is like a tiny jeweled watch, a tribute to the most clever and dedicated nutrition strategists and program developers. The watch tells time in a country half the size of the United States that is ravaged by poverty and social disruption. In Kinshasa, no detective work is required to understand that U.S. agricultural food surpluses function as one of the means by which the U.S. government props up and ensures the loyalty of an excessively corrupt regime; that this regime puts about 1% of its gross national product back into agricultural development when in some years it puts more than 30% into Swiss bank accounts for the private use of its president; and furthermore, that this regime is accused of operating through the village chieftain systems in rural areas to extort crops from farmers at such low prices that rural subsistence is barely possible. Minute in size, the ORT Title II project is one of perhaps 50 or more illuminating models of creative ways in which U.S. technical assistance can work in developing countries to craft solutions to hunger. With funding cuts, the creative spark will die out of these projects. New projects will not be developed, and those that continue to exist will retract to a lackluster, token, maintenance status. . 155

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FUNDING AND PERSONNEL CUTS Table 1 shows recent trends in funding for nutrition programs within AID. Both the absolute and percent TABLE 1 Child Survival Interventions, All Accounts Millions of S (% of total) FY 85 FY 86 FY 87 FY 88 FY 89 Oral 38.1 32.8 40.1 33.4 31.8 Dehydration (29) (21) (23) (21) (21) therapy Immunization 30.3 48.0 57.5 56.3 53.0 (23) (31) (33) (36) (35) Nutrition 25.8 20.7 24.4 13.9 16.8 (20) (13) (14) (9) (11) Child spacing 6.3 7.2 7.8 8.3 10.2 (5) (5) (5) (5) (7) Other child 30.0 47.1 43.7 44.6 41.2 survival (23) (30) (25) (28) (27) Total 130.5 155.9 173.5 156.5 152.9 attributions (100) (100) (100) (99) (101) NOTE: Includes attributions from Child Survival, Health, Sahel and ESF accounts, as well as small amounts from Population and ARDN accounts, where applicable. Attributions for fiscal year 1985 (FY 85) and FY 86 are derived from yearly reports from field HEN officers on program content and are gathered by means of a Health and Child Survival Reporting Schedule. Attributions for FY 87 to FY 89 are obtained from a combination of data from Child Survival Reporting Questionnaires and from FY 89 ABS (Table IV) submissions. FY 87 to FY 89 attributions will change as programs evolve and when reporting is completed at the end of each year. SOURCE: AID. 156

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Amounts allocated to nutrition have been decreasing. Since the early 1980s, the professional staff of the office of nutrition has decreased. The Africa Bureau of AID, which attend to the region where nutrition problems are most severe and volatile, does not have a directly hired nutritionist. The excellent regional nutrition adviser who was recently based with REDSO in Abidjan, Ivory Coast, and who generated nutrition programs throughout West and Central Africa, has left to serve elsewhere and has not been replaced. Reasons for these cuts have to do with the pendulum swings of trends in technical assistance, the ever present desire for simple technological solutions, and the fact that nutrition as a field tends to lose ground in economically hard times. Since the World Health Organization (WHO) Conference on Primary Health Care at Alma-Ata in the Soviet Union (WHO, 1978), where sufficient food was defined as the first and most basic human need, the focus in assistance to mothers and children has shifted to child survival. The twin engines of immunization and ORT have produced rapid reductions in infant mortality but have overshadowed nutrition. FUTURE TRENDS VERSUS IMMEDIATE DANGERS The United Nations International Children's Emergency Fund (UNICEF), which has been a trend setter in providing assistance to vulnerable groups, may now be on the point of shifting back from the highly technological to a more holistic approach. The term, adjustment with a human face, which is also the title of a new book from UNICEF (Cornia et al., 1987), refers to the incorporation of a basic needs approach into adjustment, with a strong focus on strengthening the informal economic sector through participatory community-level interventions, including nutrition programs. Moreover, as certain child survival program goals are achieved, there should be more room for nutrition. The EPI immunization program has targets of immunizing 80% of children in 70% of the countries served by the beginning of the l990s. As immunization programs approach these targets, there should be more room in the child survival agenda for nutrition and more emphasis on quality of life, in addition to survival. 157 -

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; The physiological effects of malnutrition on the immune system are proven and cannot be argued away (Chandra and Newberne, 1977~. Malnourished children, who are protected from dying of dehydration by ORT and from measles by immunization, have a greater than average risk of succumbing to malnutrition or to other illnesses for which no vaccines are available (Mosley, 1986~. Nutrition programs may also be recognized as an effective medium for dealing with the troublesome issue of neglect or underinvestment in the care of specific children, which appears to be increasing along with social disorganization in developing countries (Bulterys and Davis, 1987~. Malnutrition is the most sensitive available screening measure for detecting underinvestiment. Short of providing major material and psychological support to families practicing benign neglect of their infants, nutritional growth monitoring probably is the most useful programmatic action that can be taken to combat this problem. Growth monitoring provides potentially ambivalent caretakers with continuing social support and makes them publicly accountable for the growth and health of their children. In the meantime, while awaiting a swing of the pendulum, we could lose not only our positive momentum but also the efficient program designs and other achievements that have been built up over the past years Institutional memory is only as strong as the people who staff the institutions and keep up the files, records, and commitment to the continuity of professional excellence. Without sufficient professional staff, evaluations in a closet down the hall are just as lost to the programming process as if they had never been conducted. The accumulated wisdom from years of effort could disappear. There has been speculation in the Office of Nutrition that the Japanese might forge forward with technical assistance in nutrition if the United States gives up this line of endeavor. Yet, any other country or agency that took over the work the United States has been trying to achieve would probably have to reinvent the wheel. 158

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ACHIEVEMENTS AND PREDICTIONS The nutrition planning process has matured through AID-sponsored experimentation in more than a dozen countries. Although nutrition activities overall are diminishing from the lack of support, the nutrition planning movement exerted global influence in sensitizing governments to incorporate nutritional coals into their national plans. -rig - o~ When nutrition planners remain active, nutrition planning has become pragmatic and goal oriented and, hence, increasingly effective (Berg, 1987~. There is a sense that we have gone, in terms of the book Megatrends (Naisbitt, 1982), from using "high-tech'' models for nutrition planning to using "high-touch" skilled human applications for planning and programming. In the future, we can expect to see the following: Changing standards for assessing nutritional status in childhood, adjusting for the fact that normal breastfed infants do not grow according to the National Center for Health Statistics (NCHS) standards (Stuff et al., 1987) and that growth in height depends on the amount of animal protein in the diet. Increasing emphasis on maternal nutrition during pregnancy and lactation, on anemia, and on adequate child care. 0 More efficient rapid appraisal methods for all types of nutritional needs assessments and program evaluations. Widespread use of nutritional surveillance indicators to sensitize policymakers to changing nutritional conditions and the linking of surveillance to growth monitoring. More effective operational research methods for program design. Compensatory nutrition plans linked to economic adjustment strategies and, in general, to the global economy. 159

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o Increasing the movement of nutritional service delivery of all kinds out of government and into private, nongovernmental organizations and for-profit sectors, particularly in Africa. TYPES OF INTERVENTIONS The following summaries of intervention types outline the progress that has been achieved over the past 10 years and anticipated future directions, should funding be adequate. In general, the "high-touch" responses of extending and perfecting the applications of existing technologies will predominate. Agriculture Progress. In 1977 it began to be realized that increased agricultural production of food does not automatically lead to improved nutrition, and it was being emphasized that assistance to agriculture affects nutrition primarily through price, employment, and income effects (Goldman and Overholdt, 1981~. Over the next 10 years the negative effects that agricultural projects sometimes have on women and on the nutrition of marginal populations were identified (Join. 1 9~) and ~ -OF ~ ~ ~ ~ -''- strategies tor Incorporating nutritional goals into agricultural projects and for attaching compensatory nutrition programs to agricultural assistance programs were elaborated (FAD, 1983~. This period also saw the application of grass roots operational research to agriculture in the form of farming systems research (Caldwell, 1987), which, while labor intensive, provided a reliable method for incorporating concerns for nutrition and other basic needs into the design of agricultural technology packages. Future trends. ~. . . . . . The "green Gene" agrobiotechnological revolution is here, but the ways in which the first waves of the green revolution have failed to make technology beneficial to the poor are well documented (Pinstrup-Andersen and Hazell, 1987~. Ignorance of how to increase the productivity of small farmers on marginal lands or of the benefits to national economic 160

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development by focusing on small farmers is no longer an excuse for not doing so (Mellor and Johnston, 1987; Messer, 1987~. Health Progress. In 1977 the definitive case was made for integrating nutrition with health and family planning (Austin et al., 1981a.b) . Since then there has been a revolution In neaten care services delivery introduced by primary health care. The definition of the role of nutritional status has been narrowed; this has been accompanied by nutrition education and counseling and by the distribution of food and specific nutrients In special cases. It has also been learned that the nutritional component of primary health care and primary health care itself can be attached to family planning, agriculture, or other infrastructures, so long as _ referrals to health care services can be arranged. There are increasingly sensitive growth charts (Pielemeier et al., 1987) and effective regional growth monitoring programs in a few countries. Future trends. The efficiencies of self-financing models of primary health care service delivery, linked with other integrated services, should improve over time. when resources are not absolutely limiting. Local nongovernmental organizations, such as the Bangladesh Rural Advancement Committee, may increasingly assume a management role in large-scale grass roots development initiatives in which primary health care, weaning foods, and growth monitoring models will gel into forms that are adapted to socially, culturally, politically, and geographically diverse conditions. research also can be applied to make the educational and promotional components of growth monitoring more effective. . - Communications Subsidies Progress. Ten years ago the nutritional benefits of food price subsidies to the poor had just begun to be documented (Rogers et al., 19811. These benefits are now well known. There has been progress in targeting 161

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subsidies in a variety of ways: by subsidizing the types and qualities of foods eaten primarily by poor, by locating outlets for subsidies in areas with the lowest incomes, and by providing subsidized food or food coupons at health care centers to mothers and children who are at the greatest nutritional risk. Future trends. Effective targeting will become increasingly important during periods of economic adjustment, so that cuts in government expenditures for food subsidies may have less of an impact on the poor and so that compensatory subsidies can be established on low budgets. A global-level food stamp program administered by an international agency may be on the horizon (Reutlinger, in press). The future should also see increasingly creative and effective combinations of providing subsidies with nutrition education, as in a pilot oil and rice subsidy scheme in seven poor villages in the Philippines (Garcia and Pinstrup-Andersen, 1987), and with other program activities in nutrition, health, and agriculture, as in the ORT Title II project in Zaire or in the PAN food coupon program in Colombia (Berg, 1987~. In that program, food coupons were distributed through health centers to families with pregnant or nursing women or children under age 5 in the poorest geographic areas. Thus, the program simultaneously increased food consumption and participation in preventive health care services. Nutrition Education Progress. Nutrition education has experienced a great metamorphosis over the past 10 years. On the one hand, it has emerged from the domain of home economists, extension agents, and MCH public health nurses to become the new field of nutrition communications, behavioral change, and social marketing (Manoff, 1985~. On the other hand, ' ~' - ~ t nas spawned sunJecc-specific offspring in the form of weaning foods projects, growth-monitoring activities, breastfeeding promotion, and a forthcoming maternal nutrition project, which apply communications and methods of behavioral change to specific topics. More than any other type of nutrition intervention, nutrition education has become multidisciplinary and has 162

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allied itself with the applied social sciences. Moreover, it has grown from an activity that is believed to have little impact and that receives only token funding (Zeitlin, 1983) to an area in which significant investments are budgeted. For example, there is a $15 million project in nutrition communications and social marketing starting in AID's Office of Nutrition. Future Trends. To the extent that funds permit, support will be made available in selected countries to achieve across-the-board changes in the dietary habits of vulnerable groups through social marketing in nutrition. Alliances with prestigious medical authorities to enlist food processors and manufacturers in developing countries to produce and market healthful foods will be a key to the success of these efforts, as it has been in the industrialized countries. Formulated Weaning Foods Progress. Ten years ago there was a stalemate on the use of food processing technology to develop successful low-cost weaning foods (Heimendinger et al., 1981~. Over 100 such projects had been tried with very moderate success (Orr, 1977~. While failures of these products to reach the poor were blamed on price, the role of marketing and product image had been largely ignored. Today, there is evidence that such products can be successful if they are manufactured and/or marketed by the private sector, as in the case of CEREVAP, the weaning food produced by the VAP biscuit company in Kinshasa, Zarie, with assistance from the ORT Title II project. Future trends. As the world's population becomes more urban and as urban mothers in developing countries continue to support their families by working in manufacturing and other jobs that keep them away from home, the use of processed infant foods will increase. Technical assistance is needed to ensure the nutrient adequacy of processed infant foods manufactured by the private sector in developing countries, since it tends to be more profitable for manufacturers to produce and market nutritionally inferior products. _ ~_ 163

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Supplementary Feeding Progress. More has been written about the lack of impact of large-scale feeding programs than has been written about their success in combating malnutrition, apart from their role in famine relief and in supporting refugees (Anderson et al., 1981~. A municipal-level evaluation of the Philippines National Nutrition Program by Abt Associates (Kerpelman et al., 1982) found, for example, that the longer and the more intensively the municipality had received Title II foods in the targeted MCH feeding program, the higher the rate of second- and third-degree malnutrition, as measured by the community weighing exercise Project Timbang. Since children had to be second- or third-degree malnourished to qualify for the program, this finding was not surprising, nor was it encouraging. On the other hand, as evidenced by the Tamil Nadu (India) Nutrition Program (Berg, 1987) and the Zaire ORT MCH component, supplementary food distribution can be a valuable resource if it is embedded in a carefully designed and closely monitored integrated program. Historically, the availability of supplementary foods for mothers and children has served as an incentive for expanding MCH services in many countries. Future trends. With the withdrawal of the Catholic Relief Services from Africa, the old-style programs in which food distribution was a major end in itself may be phased out. They may be replaced by the more strategic use of food in programs in which distribution is highly targeted and/or in which the food serves multiple goals with respect to behavioral change and complementary development activities. Food Fortification and the Distribution of Micronutrients Progress. The biggest innovation in micronutrient interventions has been in the breaking off of vitamin A distribution as a separate intervention type. Food fortification proved its value 10 Years ado (Austin et . a. ., '~Ul",UJ "11" Wed ~llUWll ~ ~= Extremely ~eDenaen~ I ~ X I 9 1~ ~ =~^ t.T~ ~ e~.~ 0~ ~ ~ ~ _~ 1 .. ~ AN A_~ A_ _ ~ ~ ___ ~ on the political will of the government in power. The strength of fortification of which the greatest success remains the fortification of salt with iodide, is that it 164

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is largely invisible to consumers. This lack of visibility also is its weakness, in that fortification programs do not readily develop a local political constituency and are therefore overly dependent on the benevolence and consistent long-term planning of the central government. Countries such as Burma, for example, have seen goiter eradicated in one era, only to reemerge in another when the government decontrolled the sale of salt. Future trends. All the evidence is in place for iron distribution to take on an importance equal to that now accorded to vitamin A. The scientific evidence implicating anemia in poor labor productivity (Baste et al., 1979) and reduced cognitive performance in children (Pollitt et al., 1981; Soemantri et al., 1985) is beyond dispute. Iron supplementation has proved that it can ameliorate these effects. Iron is therefore a known technical fix that is easier to promote than ORT and that is waiting for investments in operational research and social marketing. CONCLUSIONS There is currently a lack of fit in the United States between the increased knowledge and skills in international nutrition and the decreased funds available to implement programs. At the same time, economic conditions and the rates of malnutrition and hunger in most developing countries are steadily worsening. We are experiencing an advocacy and leadership vacuum in international nutrition and can only hope that the urgency of this situation will inspire new leaders and new advocates to step forward and speak in a language that politicians and the public can understand. Professionals and academics know what is happening in developing countries, yet their voices are muffled and they lack the forms of communication that would make the rising death tolls vivid and compelling, even to ourselves. 165

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REFERENCES Akin, J., N. Birdsall, and D. de Ferranti. 1981. Financing Health Services in Developing Countries. World Bank, Washington, D.C. Anderson, M.A., J.E. Austin, J.D. Wray, and M.F. Zeitlin. 1981. Supplementary Feeding. Vol. I. In J.E. Austin and M.F. Zeitlin, eds. Nutrition Intervention in Developing Countries. Oelgeshlager, Gunn, and Haines, Cambridge, Mass. Austin, J.E., T.K. gelding, R. Brooks, R. Cash, R. Fisher, R. Morrow, N. Pielemeier, D. Pyle, J.D. Wray, and M.F. Zeitlin. 1981a. Integrated Nutrition and Primary Health Care Programs, Study VII. In J.E. Austin and M.F. Zeitlin, eds. Nutrition Intervention in Developing Countries. Oelgeshlager, Gunn, and Haines, Cambridge, Mass. Austin, J.E., T.K. gelding, D.P. Pyle, F.S. Solon, T.L. Fernandez, M.C. Latham, and B.M. Popkin. 1981b. Fortification. Zeitlin, eds. Study III. In J.E. Austin and M.F. Nutrition Intervention in Developing Countries. Oelgeshlager, Gunn, and Haines, Cambridge, Mass. Austin, J.E., and M.F. Zeitlin, eds. 1981. Nutrition Intervention in Developing Countries: An Overview. Oelgeshlager, Gunn, and Haines, Cambridge, Mass. Basta, S., Soekirman, D. Karyadi, and N.S. Scrimshaw. 1979. Iron deficiency anemia and the productivity of adult males in Indonesia. Am. J. Clin. Nutr. 32:916-925. Berg, A. 1987. Malnutrition: What Can Be Done? Lessons from World Bank Experience. World Bank Publication, Johns Hopkins University Press, Baltimore. Biswas, M., and P. Pinstrup-Andersen, eds. 1987. Nutrition and Development. Oxford University Press, Oxford. 166

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