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OCR for page 149
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.
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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
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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
~_
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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.
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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
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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.
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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.
.
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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.
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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.
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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.
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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
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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
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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
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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.
_ ~_
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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
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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.
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