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OCR for page 1
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
OCR for page 2
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.
OCR for page 3
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
OCR for page 5
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
OCR for page 6
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.
OCR for page 7
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.
OCR for page 8
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
OCR for page 9
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
OCR for page 10
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
OCR for page 11
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.
OCR for page 74
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?
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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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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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Representative terms from entire chapter:
primary health
