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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
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5

Considerations for Future Activities

◆ ◆ ◆ ◆ ◆

This chapter provides suggestions for the future content and conduct of USAID nutrition surveys and surveillance activities. The committee offers these in the hopes that they will be of use to USAID in its future work in the NIS.

  • To the extent that there are ongoing changes in the NIS that threaten market and household food security and the quality of the food supply, the food and nutrition situation in the NIS should continue to be monitored. Suggested minimal and optimal measures have been described in the report.

  • In future surveys and surveillance activities, attention should be paid to obtaining qualitative information prior to study design.

  • Study methods, content, and analysis should be designed with the outcome in mind: enhanced decision making, particularly by health policymakers in the NIS. These activities should be designed considering the ethnic and sociocultural characteristics of their target populations and in consultation with national/regional/local decision makers, key informants, frontline service staff, researchers, and others with an interest in these activities. More attention should be paid to tailoring monitoring systems accordingly.

The committee believes that the three previous suggestions will help minimize problems that have occurred in some past surveys. These problems have resulted, in many cases, in a relatively small amount of available information useful for decision making, a lack of useful current information, and an uneven quality across surveys.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

ADDITIONAL AREAS TO PURSUE

Assistance should be provided to implement food fortification programs in order to reduce the problems of rickets, goiter, and anemia, to the extent that these problems are documented. Evidence of decreasing iodine intake or increased rates of goiter or rickets should be viewed as an emergency. In some areas or population groups, there may be a need to investigate further the causes of anemia, including the potential role of environmental pollution. To reduce the prevalence of micronutrient deficiencies in the population, a combination of assistance from the FDA to establish standards for processed food composition and micronutrient fortification and from the private food-processing industry in techniques for food fortification would be extremely desirable in ensuring that the food-processing sector makes as rapid and widespread a contribution as possible.

Additional opportunities for joint participation in, and coordination of, activities with other bilateral and multilateral organizations should be explored and defined.

Evaluation of the situation in the NIS differs from the assessment of a chronically malnourished population, which is the more usual situation, and for which accepted survey methods have been developed. There is, therefore, a need to develop new methods to detect “hunger ” in generally (or previously) well-nourished populations such as most of those in the NIS. Declines in nutritional status in such populations, especially in the short-term, may be more difficult to detect reliably than a simple determination of nutritional status at a given point in time.

The committee suggests that USAID consider the formation of an advisory group, whose function would be to expand upon, coordinate and advise on the many qualitative activities described in the report; coordinate and, perhaps, standardize future survey and surveillance activities; and help interpret, disseminate, and follow up on results and on surveillance activities in general.

Emergency feeding in the form of direct feeding programs should be based on evidence of food shortage, rather than a lack of purchasing power. One exception is the careful targeting of vulnerable groups who consume a relatively small proportion of the food supply. These vulnerable groups may differ from those usually targeted in developing countries.

Based on evidence that women of reproductive age have a high risk of morbidity and mortality due to a high prevalence of anemia and high rates of abortion, consideration should be given to ways of increasing nutrient supplementation to this group (perhaps through UNICEF), as well as enhancing access to contraceptive technology.

In no document was consideration given to food rationing. If food availability is scarce, this programmatic action may be helpful. Any decision of

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

this type should be made by the appropriate policymakers in the NIS, taking into account the serious political implications.

SPECIFIC SUGGESTIONS REGARDING ON-GOING NUTRITION SURVEYS

The RLMS is potentially a very informative survey. The CIN's recommendations on how to proceed with the RLMS are provided in Appendix B and are summarized as follows:

  • The first recommendation for the RLMS is to identify focused policy questions that the current protocol was intended to address and the specific data that are required to answer these questions. This task should involve decision makers from USAID and appropriate counterparts in the NIS. Dummy tables can then be drawn up and analyses produced as soon as possible. This process will enable all parties to review the usefulness and timeliness of data collection.

  • It is also recommended that a solid scientific review of the RLMS be undertaken after the above analyses are available. The committee did not have the necessary information or time to perform this service. The review will take experts several days to accomplish.

  • Based on the former two activities and qualitative evidence of food insecurity in Russia, USAID and NIS counterparts will be able to develop a core group of essential indicators for monitoring the ongoing effects of economic reforms. These indicators should take priority in collection and analysis and be sustainable within the current Russian infrastructure. The purpose of collecting additional data needs to be articulated and justified.

Finally, due to the rapid decline in meat, fish, dairy product, vegetable, and fruit consumption in 49,000 Russian families between 1991 and 1992 reported in the Goskomstat survey (Volgarev, 1992), a detailed evaluation of the methodology and the suitability of the data for surveillance should be undertaken.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
This page in the original is blank.
Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

Appendix A

USAID's Request to the Committee

◆ ◆ ◆ ◆ ◆

MEMORANDUM FROM SAMUEL G. KAHN DATED 17 MARCH 1994

To: NAS/IOM/BIH, Christopher P. Howson

From: USAID/G/RD/N, Samuel G. Kahn

Subject: Committee on International Nutrition

The first meeting of the CIN is scheduled to take place this April 14 and 15. The topic is “Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States (NIS).” Accompanying this memorandum are background documents and information which are submitted to assist the Committee in addressing the proposed issues. Included are a memorandum (Klement to IOM, through G/N) which concisely describes USAID's nutrition efforts in the NIS, and four loose-leaf binders containing protocols, questionnaires, instructional manuals, trip reports, country profiles, other information, and an index to the loose-leaf binders. (Note: additional documents are forthcoming on the anemia studies in Kazakhstan and Russia, Binder III, Section B.)

Based on the background information, documents, and the knowledge of individual members, the Committee is requested to make recommendations as to:

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
  • interpretation of nutritional status and identification of potential issues of at-risk populations in Russia;

  • indicators and methodologies that would be adequate and optimal for conducting nutrition monitoring systems in the NIS; and

  • how USAID may programmatically apply the current findings.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

MEMORANDUM FROM JULIE KLEMENT DATED 14 MARCH 1994

To: Committee on International Nutrition/Institute of Medicine

Through: USAID/Office of Nutrition

From: Julie Klement, USAID/ENI/NIS/DIHHR, Chief of Health Programs

Subject: USAID's Nutrition Survey and Surveillance Activities in Russia and the Newly Independent States (NIS)

Background

As part of the United States government's effort to work with the Newly Independent States (NIS) of the former Soviet Union as they make the transition to democracy and a free market economy, the U.S. Agency for International Development (USAID) established a Task Force in April 1992. In late 1993, as the emergency reaction to the break-up of the Soviet Union lessened, the Task Force merged with the Europe Bureau in an effort to streamline the Agency. However, it is clear that the 15 republics of the NIS continue to be in a state of social, political, and economic upheaval. Concerns are increasing regarding worsening health and living conditions; four of the republics are in a state of civil conflict.

The USAID/NIS Office of Emergency and Humanitarian Assistance (EHA) is responsible for coordinating emergency food and medical activities. To date, nutrition activities supported by USAID in the NIS have been initiated primarily by EHA, thus focusing on emergency health conditions and immediate food security problems, However, as USAID shifts focus away from short-term emergency responses to health and nutrition problems, the Office of Democratic Initiatives and Health and Humanitarian Resources (DIHHR) is responsible for longer term health programs which focus on institutional development. The strategic objectives of DIHHR's program include: promoting vaccine and pharmaceutical security; supporting health care financing and service delivery system reform; strengthening health information and response capabilities; supporting women's reproductive health; and addressing selected critical country- or regional-specific health problems.

Description
Health/Nutrition Early Warning System

USAID initiated early warning systems in the NIS to help monitor health and nutritional deterioration as a result of the increasingly precarious country situations. In September 1992, USAID entered into an Interagency Agreement (IAA) with the Centers for Disease Control and Prevention's (CDC) Emergency

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

Public Health Information Surveillance System (EPHISS) program to provide assistance to health officials in three of the NIS Countries (Kyrgyzstan, Russia, and Uzbekistan). The purpose of the IAA was to strengthen their epidemiological information systems and provide timely warning of disease outbreaks. The system in Russia was initially designed to include a longitudinal survey on nutritional status, food consumption patterns, and purchasing power of the Russian population. However, due to project delays and lack of response from the government of Russia, the food surveillance component of the system was never achieved. Instead CDC conducted nutrition assessments in Russia and Kyrgyzstan. (The results of these assessments are included in the accompanying documents.)

In December 1992, an EPHISS activity was started in Armenia. It is the only EPHISS in the NIS that includes pediatric and elderly nutrition monitoring. An output of this activity in Armenia is the monthly publication of a public health bulletin and supplemental bulletins that report longitudinal trends for specific indicators (e.g., pediatric nutrition). (Selected bulletins and reports of the Armenian EPHISS are included in the document for review.)

Nutrition Surveillance

As an emergency effort to assist in stabilizing the immediate food security problems throughout the NIS, particularly of vulnerable population, to date, USAID has provided $45 million in food commodities in the NIS. As part of this effort, CARE was awarded a grant to distribute and monitor U.S. government commodities and coordinate with other U.S. PVOs. In addition, CARE was responsible for monitoring food security among certain vulnerable population groups and collecting quantitative and qualitative information which was not available from any other source in the NIS. This information was thought to help in the development of early warning indicators regarding future food security for certain target groups. CARE conducted survey on pensioners in four of the republics and a survey on children under two years of age and mothers in Russia. (Description of these surveys are provided.)

CARE Pensioner Surveys CARE surveyed pensioners twice (at 6-month to 1-year intervals) in five Russian cities (Moscow, Yekaterinburg, St. Petersburg, Irkutsk, and Gargarin), Kazakhstan, Uzbekistan, and Armenia from April 1992 to April 1993. The objectives of the pensioner survey were to: (1) identify high-risk groups of pensioners; (2) identify risk factors associated with pensioner malnutrition; (3) assess main aid support systems and other coping strategies used by pensioners to adjust for decreasing food supplies; and, (4) identify the most effective means of coordination and delivery of international food and economic aid.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

CARE Under Two-Years-of-Age Survey In April 1993, CARE conducted a survey of children under two-years of age in three Russian cities and outlying rural areas (Moscow, St. Petersburg, and Yekaterinburg). The survey's objective was to determine the nutritional status of young children and mothers and their “perceived hunger.” (Preliminary results are available on the urban sample and are included in the documents for review.)

Anemia Surveys

High rates of anemia among women and children have been reported throughout the NIS; however, the etiology and extent of anemia in the NIS is largely unknown. The USAID office of Nutrition funded anemia studies in Uzbekistan, Kazakhstan, and Russia using micronutrient funds designated for the NIS region. These studies examine the prevalence of anemia and investigate the etiology of the disease. Preliminary results are available from the Uzbekistan survey and are included in the review documents. The two other surveys, Russia and Kazakhstan, are in their preliminary stages; scopes of work/protocols for these two surveys are included in the review documents.

Russian Longitudinal Monitoring Survey

In 1992, the University of North Carolina began the Russian Longitudinal Monitoring Survey (RLMS) to establish a baseline and monitoring system of a wide-range of health, nutrition, and economic indicators which would aid in monitoring the health and nutrition status of a representative national sample. The project was launched with initial funding from the World Bank as well as the Russian government. USAID provided bridge funding from April 1993 through June 1994. Additional funding for the RLMS is currently being considered.

Rationale

As a result of these various nutrition-related activities carried out by a variety of organizations (e.g., U.S. government, universities, and PVOs) using varied protocols and procedures, DIHHR has requested assistance from the Office of Nutrition to convene a meeting of experts through the Committee on International Nutrition (CIN)/Institute of Medicine (IOM) to review selected nutrition surveys and related surveillance activities in the NIS. The purpose of this meeting is to review the findings of the various surveys with regards to the nutritional status of populations at risk, to recommend future survey/surveillance activities to be undertaken in the NIS and to recommend operational application of these findings to develop health and nutrition delivery programs which address the problems.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
Issues

USAID requests the CIN/IOM to review the accompanying background documents and make recommendations as to:

  • the nutritional status and identification of potential issues of at-risk populations in Russia (e.g., pensioners, women, and children);

  • indicators and methodologies that would be adequate (minimal safety net) and optimal for conducting nutrition monitoring systems in the NIS; and,

  • how can USAID programmatically apply the current findings.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

Appendix B

Recommendations for the Survey-Surveillance Activities Reviewed by the Committee

◆ ◆ ◆ ◆ ◆

The committee offers the following recommendations for improving the study methods of each of the five nutrition survey-surveillance activities that the committee reviewed.

RUSSIAN LONGITUDINAL MONITORING SURVEY

With the wealth of information collected in this multilevel survey, it is frustrating that very little could be said about the effects of macroeconomic reforms, based on the available data. The surveys as designed were intended to provide a rapid-response monitoring system that could provide critical data for policy formulation. What became clear from the documents provided was that local-level collaborators did not have the capacity to implement such a complicated and extensive survey and still provide the rapid analysis and interpretation of data. Therefore the review team felt strongly that there were four steps that should be taken to ensure that the current data, and any data collected in the future, are more useful for decision making. Specifically:

  1. The CIN perceives that more information has been collected in the RLMS than is essential to monitor macroeconomic reform in Russia. The utility of the various parts of the massive sets of questions for a monitoring system cannot be determined without some articulation of the policy questions that are meant to be addressed. Therefore, the first recommendation is that the RLMS research team identify the series of policy questions that the current survey is meant to address.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
  1. Based on this series of focused policy questions, dummy tables should be developed that indicate how the data from the various parts of the questionnaire will be analyzed and presented. This step is critical because as the CIN observed from the extensive number of tables already presented, few if any were presented in a way that is useful for decision makers.

  2. The CIN believes that adoption of Recommendations 1 and 2 will result in a more focused study. A direct result will be the identification of a core group of essential indicators for monitoring the ongoing effects of economic reforms in Russia. The resulting set of essential indicators will in most likelihood be sustainable within the current institutional infrastructure in Russia.

  3. There may be longer-term goals for which a more detailed survey protocol can be justified. Again, however, they are not clear from the current survey. Therefore, the CIN suggests that the RLMS research team articulate a potentially larger set of research-policy questions that justify additional data collection procedures above and beyond the essential set of indicators identified. The CIN does not believe that more data are necessarily more policy relevant. Indeed, considerable time was spent discussing the enormous respondent burden that is inherent in the current multitiered survey. The CIN decided against identifying specific sections of the questionnaires that could be eliminated or specific questions that seemed superfluous. However, the relevance of many of the detailed questions on tangential issues was questioned. Ideally, each of the individual questions should be linked to a policy question and a specific analysis plan.

CARE PENSIONER SURVEYS

In future studies, weight and height should be measured, not self-reported. It is also important to identify where and with whom pensioners live in order to determine what kind of social support system they have (e.g., a family-based support system).

Other questions to consider are the following: Are there intrinsic issues or characteristics about the pensioners that prevent them from using these social support systems? How serious is the food shortage among pensioners, and what is the situation of their personal food stock? What are some coping strategies by which pensioners can maintain their health and diet in light of these shortages? How do pensioners supplement their income? How much international food aid has been delivered, and what are the most useful forms of food aid to pensioners?

Surveys of pensioners living in rural areas should be undertaken to determine the extent of their well-being. Contrary to the usual presumption, other data available to the CIN appear to show that pensioners in small communities tended to live alone more.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

Social welfare programs should be monitored directly, particularly in Armenia where the health status of pensioners appears to be more grave.

CARE UNDER-TWO-YEARS-OF-AGE SURVEY

The committee hopes that the full data set will be analyzed and that possible risk factors for perceived changes in food consumption will be studied. Additional attention should be given to the analysis of food intake data, as the analyses provided were not easily interpretable. In addition, the purpose for which the food intake data will be used needs to be made clear.

Questions on perceived changes in food availability-accessibility should be validated and related to other objective measures of nutritional status. It is conceivable that these subjective responses may indicate some breakdown in food production, distribution, or accessibility that could be a forerunner of a larger food problem.

Additional information on the rates and etiology of anemia is needed, although this is probably a chronic, rather than emergent, problem —except if there is a current problem with availability of iron supplements.

Other longer-term issues that need attention are availability of modern family planning services and promotion of optimal infant feeding practices. Whether any changes in maternal employment patterns have been a recent factor undermining optimal breast-feeding practices should be explored.

ANEMIA PREVALENCE SURVEY IN UZBEKISTAN

Although there appear to be extremely high rates of anemia in all age groups, the application of appropriate age group-specific and physiologic group-specific definitions of anemia must be confirmed. These observations should be followed up with investigation of the etiology of anemia in each age group. Available serum plasma samples should be analyzed for iron, total iron binding capacity, and ferritin as well as other micronutrients (and toxins) such as retinol, folate, vitamin B12, riboflavin, zinc, and possibly others including lead and other heavy metals.

The etiology of the anemia and growth stunting is not yet understood, but poor diet seems unlikely to be the only cause, although this was difficult to discern based on the information provided to the committee. More analysis is needed on relationships such as that between anemia and tea drinking or between anemia and the use of iron pots.

It is also conceivable that the observed age-related differences in rates of stunting are due to methodological problems, such as failure to control for removal of shoes and inconsistent measurement of recumbent length versus stature. These alternative explanations could possibly be explored by examining age-related patterns of stunting in historical data, if available, and by examining

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

distributions of weight-for-height separately for children of different age groups in the current study population.

HEALTH/NUTRITION EARLY WARNING SYSTEM

Because data were not presented to the committee, no review could be performed. However, the committee feels that the use of the existing medical facilities and data collection systems appears to be an efficient and effective way of monitoring the health situation. The system also assists in institution building. As in all surveys, the data to be collected need to be clearly linked to possible interventions.

The committee could not ascertain what specific data would be available on a routine basis regarding the food and nutrition situation in the NIS apart from infant feeding practices (where the reliability of the data is doubtful) and anemia (which may increase due to lack of supplements rather than poor diet). In Armenia during January through April 1992, the EPHISS collected, jointly with the Red Cross, food security data on refugees. In a follow-on survey of a former CARE Pensioner Survey of April 1992, 347 pensioners were surveyed in August 1992 for assessment of nutritional risk based on food security.

The monthly public health bulletins provided a much-needed way to improve communication both within the NIS as well as between the NIS and international agencies involved in assistance for health and nutrition surveillance. This activity should be continued.

Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×

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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
Page 67
Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
×
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Suggested Citation:"Considerations for Future Activities." Institute of Medicine. 1994. Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities. Washington, DC: The National Academies Press. doi: 10.17226/9216.
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