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PANEL DISCUSSION DR. WATERLOW: I would like to react to what Dr. Chafkin said about emergencies or disasters. I was not trying to say the obvious, that a strategy is needed for disasters and famines. I had in mind the more serious cases throughout the world, the most seriously deprived families, which are at greatest risk of severe malnu- trition, the disaster families. The reasons for the problems of these families are different in different areas. In Jamaica, for example, it is usually some kind of family disruption, such as abandoned mothers. In one group I read about in Kenya, it was most often because the mother was unmarried--an unacceptable situation in Kenya, as opposed to the Caribbean. In Nepal, the key factor is lack of land. Although the conditions vary, everywhere one finds the 10% that are in a very bad state. That is what I was referring to in discussing an emergency strategy; I am not thinking simply of the famine situation in the Sahara. DR. MAHLER: People have been emphasizing the devel- opmental ideology--whether we are playing development by proxy or not. Most of us who came into development work some 35 years ago began as missionaries. The first director general of WHO told me in Delhi in 1951: "The trouble with you, Mahler, is that you have too much sympathy for those poor Indians. What you need to de- velop is empathy with their predicament. Then, perhaps, you can start seeing what kinds of problems they can tackle themselves." This is a very important thing in nutrition, too. I was nearly fired from WHO because in 1956 I said, "It is not a question of amino acids; it is a question of calories," and the nutrition adviser was not there. The emphasis should be on developing the capacities of nations to solve their own problems and on develop- ing the self-reliance to try to tackle these problems through research. There is a lot of impatience in the donor community. We provide countries in need with preconceived development packages neatly contained in envelopes--conventional envelopes. Development in my language means getting out of envelopes; that is the etymologic sense of the word "development.'' The devel- opment technocrats are anxious to provide new kinds of envelopes, so that they can bask in the sunshine. A 97

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98 lot of our demoralization has been with those envelopes, and we will gradually have to give others the capacity, rather than looking for our own catharsis. If we let the nationals be themselves in dealing with their problems, we have every reason to believe that it can be done. I am grateful that somebody mentioned the Tropical Disease Research Program, the World Bank, and the United Nations Development Programs, organizations that have shown that one does not have to play it by proxy, but that the first objective can be developing local capacities. The second objective is developing, as fast as possible, new solutions to old problems. This is difficult, but an absolute sine qua non in the global food and nutrition situation. There is no reason to become disillusioned, cynical, or skeptical. The rich man always has a tendency to say that the poor man should be very rational; however, coming from a poor family, I can say that it is difficult to be rational when you are poor; and this is true tor a poor country, coo. It is remarkably difficult to make rational decisions when you cannot afford to take any risks, because, lacking the money to learn through doing, you cannot learn. DR. MEILOR: I will go on directly from Dr. Mahler's point, with which I agree. In economic matters, what we are fighting against is an orthodox view generated in the developed countries that systematically plays down the human element. If one wants to raise money, it is not respectable to talk about supporting food subsidies. I am pleased to say that the World Bank has just released or is about to release a document that disproves that oversimplification. A country which is economically squeezed cannot afford just any food subsidy. But well- targeted food subsidies in the urban areas, as Dr. Lunven has been stressing, are an essential component of poli- cies that lead to high agricultural prices as a way of stimulating agricultural production in rural areas. It is a rational combination--one that was brought out earlier here. Virtually every industrial country prac- tices this policy in one way or another. At the moment, the dominant international economic orthodoxy still focuses on how to cope with debt, how to get a country back on the right track so that it can seek financial assistance. But the international good-financial- housekeeping seal of approval is obtained by abandoning

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99 these things. The international community has an obligation to affirm that the human dimension is not just a byproduct of the economy. It is both an end and a means for reaching the very economic solutions that people want. - It is a parallel action to offset the misleading view, particularly in the last 5 years, of what good economic policy is. Leaders understand in a very basic way that you cannot starve your people to pay your debts. DR. SAI: I would like to comment on the issue of ~ A A__ ~ ~ ~.~m aeU=A ~1 i ~r about training and I think the question was slightly off focus. It appeared that the questioner was trying to say that training could be done better in the more industrialized countries. There are technical advances for which the training needs to be done externally; however, linkages have to be made to ensure that training facilities in Africa have access to some of the technologies or the scientific expertise needed for more comprehensive training. With respect to training, the international community has refused to listen to us for about 10 years. We have been trying to make people recognize that the training issue is going to return to haunt us when money is available for doing something; and if we do not obtain funds rapidly, we are not likely to succeed, regardless of how much money we start pouring into the field. We are trying to develop African expertise in Africa for African work. I do not think getting a lot of international experts to concentrate on Africa will do the job. In fact, it often creates an unhealthy com- petition that leads to the demise of African programs. When we talk about training, the time is now. Richard Jolly has mentioned that in Ghana and elsewhere the core of trained nutritional scientists and others on which to build another training approach seems to be disappear- ing. rralnlny . ~ up:: L-l'v[~ Way ~_~ If we do not move quickly, it will disappear. Re-establishing the situation could be difficult. Finally, let me plead that it is not necessary to say ohms -~1P .chn~,ld train Practically. Ally ~=V~1= =~v~ - rip ~ Doctorates and master's degrees are needed. The idea that people have to train in the subject, but not necessarily have degrees, should be buried for a while. People should

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100 have degrees that are relevant in the specialties they are choosing. In addition to the facility that has been mentioned, we need to begin another facility immediately to start re-establishing what should be included in training for the food and nutrition problems of Africa. DR. MELLOR: We have a series of studies at the International Food Policy Research Institute (IFPRI) on the question of improvement over time, particularly in India. The extent of improvement is striking in the lowest-income people, and we can document it, particu- larly in agricultural production. It is important not to stop where Lincoln Chen did, saying that we can show that there are still some problems somewhere in India, and leave the impression that the green revolution has not been so great. One must spread it to other areas; I think that Dr. Chen would agree that there is a need to extend it to the marginal areas. As a matter of fact, much of Bihar and West Bengal do not have poor resources. They have rich resources, but are being held back by inappropriate agricultural policies. In the central plateau, where the resources are poor, yields per acre have grown considerably in 20 years. Incomes-of the poorest people were lower than they were in Africa 15 years ago and have increased considerably. Although it has not done as well in these areas as in southern India, it has spread, and we need to extend it farther. DR. CHEN: If we had this meeting in India, I think there would be a very strong polarization within the Indian community. Although there has been progress, particularly in the green revolution in the Punjab and in southern India, there are deplorable areas in Bihar, in West Bengal, in Orissa, in Madhya Pradesh and in large cities. The particular question I was-addressing was whether agricultural modernization in itself leads to the reduction of poverty and improvement in nutrition. In other words, the technological transformation, as John Mellor himself has said, needs to be accompanied by employment, wages, and access to productive assets, rather than only by redistribution of programs. I believe our office supported some of the IFPRI studies in southern India. I agree with some of the findings that

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101 you have reported from Tamil Nadu, but I was pointing out that the Indian policy-makers themselves would not agree that everything is all right and that food self-suffi- ciency has been achieved. On the contrary, there are very serious worries that 30 million tons of food are deteriorating in storage and that the income and consumption levels of 150-300 million people are below those required for adequate diets. We are talking about the question of balanced growth. DR. HORWITZ: Dr. Chen, will you elaborate on two of your proposals for action--the Nutrition Project Develop- ment Facility and activities to improve information dissemination and documentation? DR. CHEN: I was hoping that the members of the panel representing international agencies and people in the audience would carry these ideas further. I have not thought in detail about their implementation. I would note that you suggested the Nutrition Project Development Facility in an early paper. DR. HORWITZ: The Subcommittee on Nutrition is exploring this possibility now, and we will see what comes out of that; but I agree with you. My impression is that for governments, even those which Dr. Mahler wants to be free to be themselves, the moment eventually comes when they need to present their proposals for funding. Funds are not easy to find today in the international community. Some of us have felt that it would help just to invest available resources better at the national level, let alone to seek international assistance. DR. MAHLER: I want to make it clear that I did not say "governments"; I said "people," and there is a big difference. The United Nations system was set up for people, not for ephemeral governments. They are more or less representative of a lot of people, but it is important to remember that they were set up for the sake of people. Therefore, we have to manipulate the system whenever it is necessary, particularly if governments are not permitting us to get to where the action should be in mobilizing people themselves, in examining their needs. That is what I meant.

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102 DR. GWATKIN: I was interested that the question of whether we are doing better or worse came only from the next-to-last commentator in our conversation. I thought that this would be fundamental in a discussion of nutri- tion issues for the rest of the 1980s and the l990s. This unresolved question of whether nutritional status is better or worse is a very persuasive argument in favor of the kind of documentation facility Dr. Chen was suggesting, and I know that there have been conver- sations about this within the nutrition community as well. I second his suggestion that this be given serious consideration. The need for it is brought home by a striking example. A top-priority item should be simply tracking nutritional trends--what we are doing best, what we are doing worst, what we are improving in. This would be comparable with what has traditionally been done for birth rates and death rates. It is particularly important if there is some possibility, as you suggest, that the two might start moving in different directions. I have long assumed that the two would move in similar directions. Nutrition is important in keeping mortality low. If death rates are falling, we need not be too concerned about independent nutritional measures, because we can assume that nutrition is improving. I am not prepared to abandon that assumption yet, but there is an argument that it is going the other way; that is an important reason to start collecting independent information. That is in part because of the mortality information-; but, even more important, for the reason that Richard Jolly implied, this kind of information is needed if we are going to have economic progress with a human face. I would suggest that this is something that the Food and Nutrition Board might look into. DR. HERTZ: Some 10 or 20 years ago, birth control would have been a prominent topic in a conference like this. Although most speakers have mentioned birth control or child spacing here, it was only in passing. wonder why that is so. Have we given up on the concept? i DR. MAHLER: Dr. Mertz, I agree that perhaps it was pushed aside in the discussion, although I wanted to bring some emphasis when I spoke of maternal and child welfare, including family planning, because I speak from the health angle. I

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103 I believe that "God does not speak to an empty stomach," as Gandhi said. The food and nutrition issue is a powerful instrument to address concerns of families, their home economics, future vision, and hopes. A broad- based food and nutrition program gives a much better opportunity to address family planning and make people feel the need for child spacing and education. Food and nutrition must be used as much as possible as one of the vital points of entry to reach families in need in addressing family planning DR. CHEN: You are raising a very important point. In our push in health and nutrition technologies in some regions and societies, careful attention needs to be paid to the balance of technologies made available. The rapid population growth in Africa is a very serious concern. I also expressed concern about the introduction of single isolated health interventions and technologies without adequate attention to such problems as birth spacing. It is of deep concern, although in other countries it might not be as important. In some regions, I believe that it is incumbent on the scientific community to generate the knowledge and the support for a balanced technological approach. DR. SAI: Unhappily, we are beginning to feel that the population issue is a nonissue, or at any rate an issue not subject to critical intervention in the same way as other issues. That might not be serving the cause of development. I agree with what Dr. Chen has just said, that any approach to the needs of people, especially women and children, should consider their roles in society, their educational and employment needs, and population planning. If we look at this question from the point of view of maternal and child health, anyone working in maternal and child health in Africa who omits family planning for child spacing is omitting one of the most powerful preventive medicine tools that is available today. DR. ROGERS: Dr. Galbraith has suggested that we were trying to impose characteristics of development that were perceived from the perspective of developed countries. If I recall correctly, in the days when the United States

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104 was a developing country and had an agricultural base, large families were very desirable. I expect, although I do not know it for a fact, that that was true in other agrarian societies as well. If we go back to the comments made earlier about the development process, we should lookout it from the perspective of those countries end' acknowledge that it is only with the certainty of alternative employment, and with it the certainty of a full stomach and good health, that we can even start to talk about substantial changes in fertility. All of us are aware that rapid population growth underlies many of the problems we have been discussing here, but I viewed the absence of discussion about family planning as healthy. We want to address nutrition, maternal and child health care, and the role of women as the most basic issues. When we do that effectively, population control will come along quite well. DR. LUNVEN: Dr. Mertz is right in saying that there is a decline in emphasis on family planning, and there are various reasons. There are doubts about its efficiency, and some governments, such as in Mexico, have been considering that increased population is desirable. The goal that the Mexican government has set is for 100 million people by the year 2000. r Conditions have changed in 10 years, and man-made and natural disasters have changed the picture. The view- points of governments have also changed. On the basis of the World Bank report, the African countries that met in the original conference last year produced the Harrari Declaration. In it, they agree with the World Bank's statement that, whatever-the amount of external assist- ance provided for agricultural development in Africa, the race for economic development cannot be won if the popu- lation problem is not taken care of. It was a voluntary declaration that-they would adopt population policies to limit population growth. . DR. JEFROM: I would like to address my question to either Dr. Mellor or Dr. Lunven; both spoke of urbani- zation or labor movement as affecting agricultural pro- duction. Having lived in both developing and developed countries, I assumed that the impact of urbanization was not as disastrous in developed countries as in developing

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105 countries. Some planners have suggested that decen- tralization should be promoted in developing countries. What are the tradeoffs? DR. MELLOR: I think the issue probably should be seen less as a matter of urban vs. rural than as a matter of the pattern of urbanization. What we have had is a megalopolis--one city that dominates the country and becomes extremely large. There has been a pattern of capital-intensive import displacement and export-led strategies of growth that has driven this pattern of urbanization. The alternative is a much more diffuse pattern of urbanization in which market towns are developed throughout the rural regions with different towns of different sizes. This took place in much of western Europe and North America during their growth from an original agrarian base. This pattern of urbanization produces more employment than the alternative pattern, which has lower per capita costs for central services in the urban area. I think no country would want to remain primarily rural, because that would mean that the production pattern and the consumption pattern are both mostly agricultural, and there is not much variety in that. There is almost no margin for error; if bad weather strikes, food consumption has to be cut. Presumably everyone wants to diversify consumption and production, and that calls for urbanization. However, there could be a much healthier pattern of urbanization. Investment patterns, rates of return of various programs, and so on would be different if the bulk of the urban population were in towns of 10,000 to 100,000, rather than cities of 10 million. When we start examining the mix between health and nutrition, we must think in terms of the nature of the development strategy and its effect on the pattern of urbanization. UNIDENTIFIED SPEAKER: For about a decade, there has been a division between people whose objective is to reduce the misery of mankind and those who look for strategies for growth and simply have not produced any food or any employment. What was not achieved by the disaffection with the growth strategies of the 1950s and the early 1960s is a

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106 reorientation of growth in a way that creates employment, values people's health, and leads to productive lives. I am not saying that the objective is necessarily growth per se. However, if a family cannot do anything to improve its economic well-being, improving its health and nutritional status will not solve its problems. It leads to continuous dependence on handouts from UNICEF or some other organization. We need to show humanitarian audi- ences that there is some-thing more than improving the physical well-being of people. People need to have some other objective and some way in which they are integrated into the society and its larger economic activities. Even given the humanitarian concern, the choices in development should be considered, and choices should be made that are related not only to the objectives, but to the instruments used to move toward the objectives. DR. MAHLER: To prevent our darkness of today from becoming our doubt of tomorrow, we need to increase our information on food and nutrition. I claim a knowledge about some things in India, and I disagree violently with some of the statements that have been made about India. We recently returned after 25 years to 100 villages chosen at random in southern India, and there had been dramatic changes for the better. So, let us not Just say blankly, "Well, nothing has been happening in India." Modernization can be shown in this random sample of 3 million in southern India. It is important to chal- lenge ourselves to look at our information base. We need better information so that we are able to say things with greater relevance.