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INTRODUCTION This year, the Committee on International Nutrition Programs has been entrusted by the Food and Nutrition Board with the responsibility of organizing the annual symposium that which turn around chose more than a _ the board sponsors. ~. ~... . ~ v True to its purposes' the wore International,'' the committee subject, an intellectual exercise in perceiving the future almost already upon us. The focus should be the developing societies of the world, particularly the poverty-stricken families eking out an existence; the time, all the years up to the turn of the century; the objectives of the exercise, to perceive and identify major critical issues that impinge upon the deprived and impair their health and nutritional status. In choosing the time span up to the year 2000, the committee felt that it was a reasonable period for experienced scientists, endowed with exceptional wisdom, to "star gaze" and foresee how the nutritional problems and their determinants may evolve and what implications they may have for policies, programs, and research. Not everybody is impressed with the year 2000 as being a magic date, when everything will be brighter and every- one will be healthy and better off. What we all should hope--and strive for--is that the twenty-first should be a more humanitarian century with greater concern for human development and well-being. For many, this century, whose end we foresee, has been the most cruel one in the history of mankind. Man-made crimes in the name of all sorts of reasons and unreasons have been varied and abundant--despite the marvels brought about by science and the arts, the other face of this century, which has enlightened our lives. Hunger and malnutrition in the developing countries are on the increase, even on the basis of the limited information we have. This trend may well continue for the rest of this century. Poverty, population growth, overcrowding, unemployment, lack of food availability and of purchasing power, and behavioral patterns act synergistically to induce malnutrition and high morbidity and mortality. In absolute numbers, malnutrition is for many the most important social problem in the developing world. It is also so because it can affect human beings 1

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2 in all stages of life, from conception to senescence. In a number of them, it impairs intellectual development, school performance, and labor productivity and produces a pessimistic outlook on life. With reference to specific nutritional deficiencies, it is unforgivable that still no fewer than 250,000 children become blind every year for lack of vitamin A and that at least 3% of those living in the highlands become cretins. We have well-tested, highly cost- effective technologies to control both problems. Still, we have not applied them systematically. By its very nature, malnutrition is a complex problem for which there is no panacea. It results from environmental stresses on human beings poorly endowed genetically and metabolically. And these stresses are related to economic, social, biological, and agricultural determinants. We know most of them and how they act to induce malnutrition, but we do not know all their synergisms and antagonisms and their pathways in nature. This remains a large area of basic and applied research that could have significant program implications. We are aware that fiscal, monetary, and other economic policies, whose social consequences have not been carefully thought through, may have negative impacts among the poor, worsening their health and nutritional status. We are still struggling to understand the macroeconomics-nutrition connection. The on-going economic recession, particularly in the debt-ridden developing countries, is for us of great concern. We feel that the therapies recommended may be aggravating the patient's condition. Austerity measures, even with the best intentions, may be hurting badly those in the lower strata of the income scale. In certain countries, we can infer from the information available that this is already happening and that the numbers are increasing. For this reason, we are convinced of the need of economic adjustment policies "with a human face," to use the felicitous expression of Richard Jolly. This will require in every country a careful analysis, looking for measures that, at least, will palliate the impact of the on-going recession on the poor. It should be done by the government and international agencies concerned and by a mix of experienced professionals, not exclusively economists.

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3 We all believe that food production per se, although fundamental, does not solve the problem of hunger and malnutrition, at least in the short run. Frequently, food consumption and utilization are interfered with by a web of economic, environmental, social, and behavioral determinants that must be identified and controlled. Some of them are country-specific. We understand the concepts of "food entitlements" and "food security" and their significance, but they seem difficult to implement. Despite the complexity of the problem, we have witnessed in the last 20 years an increasing number of successful programs that combine cost-effective health and nutrition interventions, improve food consumption, target mothers and children at greater risk of death and disease, and monitor and evaluate the different activi- ties. These efforts have resulted in sustained and significant declines in infant and early childhood mor- bidity and mortality, malnutrition, and low birthweight and an increase in breast-feeding and better weaning practices. What is more important, these outcomes have occurred in countries with a severe recession but with adequate health and nutrition policies, supported and financed by the government and effectively implemented. In some of them, the situation is considered to be ''a paradox of economic backwardness (despite] health development." For many, this is a prescription for the short term that can be successful, while economic development and sound agricultural and social policies create the conditions in the long term to prevent acute ill health and malnutrition. Science has contributed during this century fundamental discoveries of nutrients and nutritional processes in animals and human beings. We do not apply in the developing world everything that is known and has been proved effective, and we should. At the same time, we expect that pending issues will be unraveled, both conceptually and technically, so as to enlarge the scope of possibilities for controlling malnutrition through adequate policies and programs. We find ourselves at a crucial period. Malnutrition is on the increase as a result of man-made decisions and actions. We have more knowledge than we are using to reduce the deleterious effects of the problem. Further- more, hunger and malnutrition do not have the political

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4 support that is required for sustained government decisions and appropriate investments in order to apply well-tested technologies and search for new ones. How is malnutrition going to evolve up to the end of the century? How will its major determinants influence present trends in developing countries? Are the pre- scriptions needed to reduce the magnitude and conse- quences of this problem different from the ones in use? What is the role of the international organizations-- multilateral and bilateral? These and related questions were posed to the distinguished scientists that are with us today. We hope their thoughts will be both illustra- tive and provocative and will contain suggestions to stir the imagination of those whose role is to investigate basic issues, as well as those whose role is to transform scientific evidence into realities of well-being. ~~ C Abraham Horwitz, Chairman Committee on International Nutrition Programs (from 1980 to 1986) Food and Nutrition Board

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PROSPECTS FOR BETTER NUTRITION THROUGH PRIMARY HEALTH CARE Halfdan Mahler The governments of the world decided in 1977 that a main social target in the coming decades should be the attainment, by all the people of the world by the year ~nnn Of ~ ~ ravel Of heal Ah than wil ~ permit them to lead socially and economically productive lives. This goal has become known as '"health for all"--an approach in which health is considered in the context of its contribution to, and promotion by, social and economic development. In the Declaration of Alma-Ata in 1978, the same governments proclaimed that the key to achieving that target was primary health care. That is, essential health care should be made accessible at an affordable cost with methods that are practical, scientifically sound, and socially acceptable and that involve other sectors in addition to the health sector. Those last few words--"sectors in addition to the health sector"--are essential to an understanding of the reorientation of the health system, and not just the health care system, that is required if health for all is to become a reality. "Health for all" embodies the basic objective of the World Health Organization (WHO) defined in its consti- tution as "the attainment by all peoples of the highest possible level of health." It means accessibility for all persons to all levels of the health system. As a process, it demands the reduction within and between countries of the unacceptable differences in health ~ _ _ _ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ vv ~ ~ ~ V 1 ~-rT=t~ T.TOO ~;mm~r hi Ah Aqua status and In allocation ot health resources. But let me not place undue emphasis on "levels,)' "processes," and "systems." Health for all refers most of all to people and therefore starts far from the hospital and clinic. It begins in homes, in communities, in schools, in fields, and in factories, where people live and work. - ~ ~ ~ ~ ~ themselves can do to shape their lives and those of their families, to be free of the preventable burden of disease and disability, and to make the most of their social, economic, intellectual, and cultural potential. It is the fulfillment of that poten- tial that leads to socially and economically productive lives. It includes what people 5

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6 NUTRITION AND PRIMARY HEALTH CARE It is within this broad definition of the goal of health for all, and of primary health care as the key to attaining it, that WHO is promoting proper nutrition and wrestling with the consequences of malnutrition. The practical implications of this approach are best summed up in the two vital roles that the health sector plays in preventing and managing malnutrition. The first is a direct role in implementing health interventions that have an impact on the nutritional status of individuals, families, and communities, including the application of specific nutritional concepts at all levels of the health system. Monitoring the growth of infants and young children _ _ ~ v is a good example of that promotes health and development are reliable Indicators nor only or overall child well-being, but also of the quality of the environment in which children live. At the same time, meeting the special nutritional needs of women is essen- tial to ensuring their health and the health of their offspring. Malnutrition, including anemia, is a major underlying cause of maternal morbidity and mortality and a particularly serious problem for women who start their pregnancies too early in life or who have too many pregnancies too closely spaced. a core primary health care activity and prevents malnutrition; Growth r ~ _ . . Moreover, the nutri tional status of women influences their chances ot Having normal pregnancies and deliveries and of giving birth to children with adequate weight, as well as their ability to breast-feed without detriment to their own health. Because periodic checks of the health and nutritional status of children and their mothers imply regular con- tact with health services, they also provide ideal opportunities for imparting health-improving and health- preserving messages about appropriate nutrition. Such contact could expose those in need to a full range of preventive, diagnostic, therapeutic, and rehabilitative services--whether at the first point of contact between individuals and the health system, where primary health care starts, or, after referral, through intermediate and central levels, where more complex problems can be dealt with.

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The second vital role of the health sector is an indirect one and has to do with the multiple external causes and contributing factors of malnutrition. It includes advocating sound nutritional policies by advising those in the nonhealth sectors on the probable consequences of their actions for nutrition and health and by undertaking joint action with them to improve nutritional status. The best example of this indirect role concerns agriculture. To say that agriculture has an impact on nutrition and health, with respect both to the food produced and to the livelihood provided for most of the world's people, is to flirt with the obvious. Yet, I wonder how often agriculture and health sit down at the same table to discuss the impact of the policies and programs of the former on the priorities and plans of the latter. We are keenly aware of the contribution that the right choice of agricultural policy can make to human health, especially by providing cheap calorie sources for people whose main problem is getting enough to eat. However, the main impact of agricultural policies and programs on nutrition and health occurs via the employ- ment and income of laborers, who constitute most of the rural poor. Choices affecting employment in agricul- ture--including pricing decisions, cultivation of food crops vs. nonfood cash crops, land use and land reform policies, and selection of capital-intensive vs. labor-intensive technology--are thus critical in determining appropriate nutrition and the preservation of health. How often are these choices taken seriously into account? Health professionals have an important responsibility to make clear to agricultural professionals the health consequences of their decisions. To do so, however, we must first make certain that the message of health that we send to agriculture is relevant, accurate, and timely. That is why effective, efficient food and nutrition surveillance schemes are critical for generating the kind of data that will permit health professionals to convey clear and convincing messages about the probable outcomes of agricultural policies and programs.

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8 PROMOTING INTERS ECTORAL ACTION FOR HEALTH Nutritional status is the result of complex interactions of many individual, household, community, national, and international factors. Food must be produced and procured, whether directly or through cash or hv some other means payment, in exchange for labor, __ _~ It must then be stored, prepared, cooked, distributed, and consumed. Dependent persons--the very young, the very old, and the infirm--must be fed and cared for. Finally, ingested food must be digested, absorbed, and used by the body. To return to my earlier observation about the reorientation of the health system and the involvement of nonhealth sectors in achieving health for all: The major health policy declarations of the last decade, including the Declaration of Alma-Ata in 1978 and global and regional strategies and plans of action for health for all, have all stressed that health Is a social goal that has to be integrated into overall development strategies and that a wide range of actions must contribute to its achievement. Thus, WHO uses the comprehensive term "health system" to signify all the interrelated elements that contribute to health in homes, educational insti- tutions, workplaces, public places, communities, and the physical and psychosocial environment. There is no need to belabor the importance of intersectoral action for health, central as it is to national, regional, and international health policy. What is necessary is to define, in operational terms, what kind of collaboration is required, with which sectors, and through what social, economic, political, and administrative mechanisms, if the consensus con- cerning the approach is to be translated into effective action. Moreover, it is essential that common goals be agreed on and that all concerned contribute actively to their realization. THE ROLE OF NUTRITION IN HEALTH AND THE HEALTH SECTOR'S INVESTMENT IN NUTRITION Malnutrition can be defined in many ways. What I would call a "health equilibrium model" describes it as a

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9 state of imbalance (whether deficiency or excess) at the cellular level between the supply of nutrients and energy and the body's need for them to ensure maintenance, function, growth, and reproduction. If viewed from this perspective, malnutrition is a major public he; problem the world over, not only in developing countries, where wasting and stunting are but its most conspicuous signs . Malnutrition is rampant in industrial countries, where obesity ranks first in importance with its allied conditions--hypertension, cardiovascular disorders, and (the circumstantial evidence continues to mount) some kinds of cancer. The industrial countries face the deadly combination of faulty dietary habits and inappro- priate life styles, including the uses of tobacco and too much alcohol and the lack of sufficient exercise or even genuine relaxation. The result is nutritional disequi- librium having just as disastrous consequences for health, even if they are not as dramatic, as the stereotypical skin-and-bones image at the other end of the malnutrition spectrum. We are only beginning to appreciate the irony of the coexistence of ill health from nutritional deficiency and ill health from nutritional excess. A Haitian creole proverb that I find delightful in its simplicity and directness says a great deal about the interrelationship between nutrition and health in the part of the world that concerns us here: Sak vice pa kampe--"An empty sack cannot stand on its own." A block at any stage of the normal flow of nutrients and energy from the external environment to body cells, starting with food availability and ending with metabolism, can prevent our sack from standing, that is, can produce malnutrition and ill health. In general, three important factors regulate the way a person strikes a balance between demand for energy and nutrients and their supply: quantity and quality of available food, health and physiological status, and behavior, including psychosocial state. For example, most malnutrition seen during periods of natural or man-made disaster is due to a temporary, acute deficiency of food intake. Malnutrition in developing countries generally results from the combination of a chronically marginal food intake with a high frequency and duration status. and For example, natural or

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10 of illness. Moreover, malnutrition in industrialized countries has its roots mainly in behavioral factors. The underlying causes of malnutrition in each of these environments are closely linked to such circumstances within and between families, regions, and countries as availability and distribution of food, purchasing power and production possibilities, information and education. and access to health and other social services. Broadly speaking, in developed countries and among minority elites in developing countries, the amount and variety of available food poses no particular problem, and the main role of the health sector is to influence knowledge and behavior regarding healthy life styles. But the situation is dramatically different for the majority in developing countries. Food availability itself (apart from choice in relation to quality) is a serious problem. A major focus of the health sector in this environment must be to keep the body as free from disease as possible to permit maximal benefit of whatever food is available. We have begun to understand that the disastrous nutritional status of so many of the world's poor is due to a large extent to the presence of infec- tion and disease, as well as to the absence of food. The high incidence and severity of many diseases in the developing world are due to an unbroken cycle of infection and malnutrition. each reinforcing and capable of i - ; t; Tree the rather , ~ . ~ _ ~ _ ~ . Children in particular often have defense mechanisms compromised from the start by low birth weight and are further assailed by a series of stresses that include measles, whooping cough, and repeated episodes of diarrhea and malaria. Each event sets back a child's growth and development; if the interval between events is too short, a spiral leading to death all too often results. The primary health care approach to community health problems is particularly well suited to break this cycle of infection and malnutrition, because it can bring so many essential elements to bear simultaneously. For example, individual, family, and community involvement is the key to ensuring that necessary, but simple and inex- pensive, preventive action is taken. Information and education help mothers and other family members to understand how to keep their children healthy, why their children might not be growing properly, and how to treat

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11 infection. Proper nutrition is important both as a preventive measure and as part of treatment. Safe water and basic sanitation, with personal hygiene and food safety, are essential to preserving health. Oral Dehydration salts are an important essential dr~ that can be made available to all. - ~ immunization prevents . . Infectious diseases that can precipitate malnutrition. And maternal and child health care, including family planning, has a mutually reinforcing effect on the health and nutritional status of mothers and children. THE LESSONS WE ARE LEARNING Eight years after the unanimous adoption of health for all as our main social target, can we say that our high expectations about primary health care's con- tribution to better nutrition are being justified? Information coming in from around the world gives rise It shows that to legitimate optimism in this regard. properly designed and implemented routine primary health care is having an impact on nutritional status in environments as varied as Botswana, China, Colombia, Egypt. E1 Salvador. Kenva. Lesotho, Nicaragua, Sri Lanka, of success registered at least four features Vim 7 _~ 7 ~ and Thailand. The varied degrees in these and other countries have in common: The primary health care activities being pursued in each have explicit nutritional objectives as measures of their successful outcome. Health care components are carefully selected to match identified problems, and their implementation is sustained at an adequate level and for an adequate period to be effective. Monitoring and evaluation are built-in facets of service delivery and allow flexibility for swift correc- tive action where necessary. Community involvement is considered a prere- quisite, not only in making use of services, but in developing suitable mechanisms for the planning, opera- tion, and control of community health care programs.

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74 recognized: breast-feeding, growth monitoring, oral Dehydration, immunization, nutrition education, food and micronutrient supplementation, and treatment and reha bilitation of the severely malnourished. Indeed, the wide dissemination of several key health technologies (such as oral rehydration and measles immunization) could generate enormous nutritional benefits. Similarly, nutrition can be improved through consumption-oriented macroeconomic policies in the food and agricultural sectors (Timmer, 19851. Food policy analysis~affecting prices and marketing provides greater specificity to and thus increases the power of broader socioeconomic development policies. Particularly responsive to intervention are micro- n~rriQnt {iron, vitamin A, and iodine) deficiencies. ~ ~ _ _ , ~ These are also linked to poverty, but they are highly responsive to targeted technical intervention. Iron and iodine-fortification of salt, vitamin A fortification of sugar, and the mass distribution of vitamin A supplements are feasible and highly cost-effective. KNOWLEDGE GAPS Despite much research and experience, major knowledge gaps remain. The field today lacks strong, sustained human and institutional capacity to address major policy and operational issues. How are international economic adjustments and malnutrition linked? How can these policies adapt to short-term fiscal austerity while protecting nutritional status in the disadvantaged? What are the cost structures and impact of nutrition delivery systems? How can these public systems be improved through better matching of individual incentives with overall program objectives? _ How should limited nutri tional resources be targeted to prevent severe, mouer- ate, and mild cases? Is nutrition behavior rational from the health vantage point, and what is the role of nutrition education? These questions need to be answered according to specific people, times, and places. The problems and solutions are likely to differ between regions. Thus, filling these knowledge gaps requires investments in building human and institutional capacities in developing countries.

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

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76 countries themselves. Given the current international however developing countries require economic climate, .~ , ~ ---a . more financial resource transfers under concessional terms. Development assistance continues to represent a major share of flexible, investable resources for problem-solving. .__~__ ~ increase concessional assistance, particularly that directed at alleviation of poverty and malnutrition. The Task Force on Concessional Assistance of the Development Committee (an interministerial committee of 18 World Bank and IMP member governments of developed and developing countries) recently concluded that foreign assistance is likely to grow at 2% per year in real terms for the remainder of the 1980s--a decline from the 4% during the 1970s (Development Committee, Task Force on Concessional Flows, 1985~. The explanations for this decline in the growth rate of foreign development assistance are complex. The task force failed to find any evidence of the "aid fatigue" syndrome. With few exceptions, the public in developed countries is not hostile to foreign assistance, and the alleviation of poverty and hunger commands much stronger support than other development investments. A me ; or Question. therefore. is how to In a 1982 poll commis- sioned by the Chicago Council on Foreign Relations, 60% of the respondents said that they viewed "combating world hunger" as a "very important" objective of the United States (Eberstadt, 1981~. important." Only 5% felt that it was "not Combating world hunter was far ahead of "protecting American business abroad," "ensuring our Allies' security," or even "matching Soviet military strength." The task force noted that the volume and allocation of foreign assistance depend on a dynamic process between the general public, the legislature, the executive branch, and special-interest groups. Within the range of public support, there is far more scope than heretofore appreciated for creative leadership by the executive or legislative arms of government in response to public initiative. Nor does political conservatism in developed coun- tries explain the situation. Conservative politics might have dampened the growth of concessional assist- ance, might have shifted the pendulum away from the "basic needs" approach to development, and certainly has

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

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

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

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

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

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

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II INVITED COMMAS

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