Nutrition Issues in Developing Countries for the 1980s and 1990s Proceedings of a Symposium (1986) / Chapter Skim
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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.
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It should be done by the government and international agencies concerned and by a mix of experienced professionals, not exclusively economists.
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_ _ ~ 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.
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_ _ _, rman Committee on International Nutrition Programs (from 1980 to 1986) Food and Nutrition Board
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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.
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Because periodic checks of the health and nutritional status of children and their mothers imply regular contact with health services, they also provide ideal opportunities for imparting health-improving and healthpreserving messages about appropriate nutrition. Such contact could expose those in need to a full range of preventive, diagnostic, therapeutic, and rehabilitative services -- whether at the first point of contact between individuals and the health system, where primary health care starts, or, after referral, through intermediate and central levels, where more complex problems can be dealt with.
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However, the main impact of agricultural policies and programs on nutrition and health occurs via the employment and income of laborers, who constitute most of the rural poor. Choices affecting employment in agriculture -- including pricing decisions, cultivation of food crops vs.
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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.
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The industrial countries face the deadly combination of faulty dietary habits and inappropriate 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 disequilibrium 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.
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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 infection 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 initiating the other.
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It shows that 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, Kenya, Lesotho, Nicaragua, Sri Lanka. and Thailand.
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CONCLUSION The universal acceptance of primary health care as the means for achieving health for all is a milestone in the prevention and control of malnutrition. There are many examples of families, communities, and nations of widely varied degrees of wealth, stages of economic development, and geographical location that are managing to protect and improve nutritional and health status by applying the principles of primary health care.
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DR. NESHEIM: Some have argued that the solutions to the problems of malnutrition in the world were only to be achieved through economic development, and I think I understood from your discussion of a primary health care system that the interventions that can be undertaken in primary health care have a role to play in immediately alleviating problems of malnutrition.
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14 are many avenues for making more calories available and thereby preventing and ameliorating malnutrition. Given that health is part of the soft social sector, compared with the harsh realities of economic growth, I believe that one can do much to ensure that the nutrient value will be more appropriate and better used and that nutritional interventions will be supported through the primary health care approach.
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Our mistake is in believing that the advanced industrial countries, socialist or capitalist in their developed form, are a guide and model for the poor countries. whose economic development and social development are less advanced.
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~ - ~ Agriculture -- not least in Britain -- was called and treated as "the basic industry." The older industrial lands have now largely forgotten this part of their own experience. When the question of the design for economic development in the new countries is raised, developed industrial countries look at their present industry, not at their past concern for agriculture, as their guiding example, and they stress industrialization.
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These last (in France, later in Mexico, to a marked extent in Russia, China, and Cuba, and now in Central America) -- and not the question of capitalism or socialism -- have provided and still provide the seeds of revolution.
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18 not survive and develop as a separate course of economic thought relevant to agriculture, but instead was swept into discard by the Industrial Revolution and the rise of urban capitalism. It was unfortunate that a current of economic and social thought relevant to agriculture did not endure and develop, withstanding the great competi-tive prestige of the industrial system.
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The independent proprietor, however, must be intellectually competent, so there is a compelling need in agricultural development for a good educational system. The mature industrial countries especially have gravely misunderstood their own history.
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We must surely agree that the industrial countries should be persuaded not to sell such weaponry to the new and poor agricultural lands and that these lands should renew their determination not to buy such weaponry. Nothing is less consistent with the agricultural stage of development than a complex and costly military apparatus.
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This is a standard, indeed universal practice in the industrial countries and has rendered major service in some countries, such as India. One must react -- = ~ - ~ - - -I countries to keep food inexpensive through public action.
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1985. Agricultural Price Policies.
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23 in India; but there is no easy answer At the earlier stages of economic development, countries are only slightly removed from hunger, and food production is the center of agricultural development. Nothing is accomplished by expenditures for steel mills, machinery, fancy airports, and arms.
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This close relation between food production and poverty means that it is necessary to understand the dynamics of food production growth if one is to understand changes in nutritional status. To set the more general framework for analyzing these issues, a review of recent trends in population, food production, and trade in the Third World is needed, together with an examination of the prospects for food production and consumption in various areas of the Third World.
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However, this aggregate figure covers sharply different rates of food production growth in various regions. For example, in Asia, an area that was once considered famine prone, per capita food production increased by 0.4% per year, but in sub-Sahara Africa, the new food-deficit area, per capita food production fell by a shocking 1.1% per year.
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For sub-Sahara Africa, the increase was from 1.5 to 8.5 million tons. In the Third World, two principal forces tend to fuel a steady rise in food consumption: population growth and TABLE 1 Growth in Population and in Production and Consumption of Major Food Crops in the Developing Worlda Average Annual Average Annual Growth Rate in Growth Rate in Average Annual Production of Consumption of Growth Rate Major brood Major Food Country in Population, Crops, Crops,b Group 1961-1980, % 1961-1980.
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CSum of population growth rate and the product of per capita income growth rate and income elasticity.
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They therefore depend heavily on food imports to meet their food needs. According to Table 3, between the periods 1961-1965 and 1973-1977, net food imports by the Third World increased by a factor of 4.3, from 5.3 to 23 million tons per year.
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A basis for this assumption is being pursued at International Food Policy Research Institute, but results are not yet available. CExcluding People's Republic of China.
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This impressive aggregate figure covers widely different rates of food production growth in various regions. For example, in Asia per capita food production is projected to increase at an average annual rate of 1.4%, and in sub-Sahara Africa per capita food production is projected to fall by 1.2% per year.
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CBased on 1977 trend estimates and 2000 projects of trend income growth. dIncludes 105 Asian, African, Middle Eastern, and Latin American countries.
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STRATEGIES OF ECONOMIC DEVELOPMENT: Given the key role of agricultural production in reducing poverty and improving nutrition, it is useful to examine the outlines of an agricultural strategy of development. Such a strategy can best be distinguished by reference to other strategies of economic development.
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Each of these characteristics has important implications for the pattern and pace of food production growth, and each constitutes a sharp contradiction of a capital-intensive strategy of development. Emphasis on consumer goods is central to an agricultural strategy, because agriculture is basically an industry that provides consumer goods.
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It also helps to build the type of small-scale industry that stimulates further rural growth and development. Third, an agricultural strategy of development helps to produce the export goods needed to fuel the development process.
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In many developing countries, calorie-protein deficiencies might well exist in the presence of plentiful food. Thus, efforts to increase total food output should be coupled to attempts to determine how they will affect the nutritional status of various types of consumers.
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CONCLUSIONS Protein-calorie deficiencies are widespread in many Asian, African, and Latin American countries. Absolute poverty, poor health, and lack of knowledge of nutrition are among the principal reasons for the high prevalence of malnutrition.
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1979. Rapid Food Production Growth in Selected Developing Countries: A Comparative Analysis of Underlying Trends, 1961-76.
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In Food PolicY Issues and Concerns in Sub-Saharan Africa. Washington, D.C.: International Food Policy Research Institute.
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Research Report 52. Washington, D.C.: International Food Policy Research Institute.
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This requires that national agricultural research systems be developed. The stronger the national agricultural research system, the greater the speed with which basic science can be borrowed and strategic science can be adapted from other countries.
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What should the policy be in the Third World to press for the importance of nonmeat diets?
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. The encouragement and assistance that international, bilateral, and voluntary agencies can provide will make a critical difference (Scrimshaw, 1985~.
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In the United States and United Kingdom, nutritional science has gained much of its strength from animal husbandry, as is obvious if we look at the institutions in these countries and the traditional nutritional journals. I do not think it would be unfair to say that perhaps the greater part of scientific output in nutrition is irrelevant to Third World problems.
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The difficulty, of course, is that nutritional status is a continuous variable, so it is artificial to draw a line between those who should and those who should not be called severely malnourished. Nevertheless, in real life
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In Britain, we have just finished a very large trial of the effects of lowering the cutoff point of blood pressure for antihypertension treatment: It appears that the gains are small in relation to the enormous cost of hypotensive drugs. Thus, the choice of where to place the cutoff point depends on two things: biological knowledge (how the risks vary in degree and kind as one moves down the ladder of worsening nutritional state)
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People tend to have low weight if they are heavy smokers, alcoholics, or in some way ill. In contrast, the average BMI of healthy people in Third World countries is typically about 19 (Eveleth and Tanner, 1977)
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Anyway, TABLE 1 Prevalence of Malnutrition in Children Less Than 5 Years Old According to Diagnostic Criterion Condition Malnourished, according to weight for age Proportion of Children, % Vietnam Refugees 66 Napalese Sri Lankans 56 32 Malnourished, 11 7 7 excluding those who are only stunteda aReduced height compared with international standards, but normal weight for height.
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If the hillman in Nepal can carry TOO kg, twice his body weight, from the plains of India to the frontiers of Tibet, which none of us here could do, can we say that he is handicapped by being small? Several studies have shown that, in terms of maximal working capacity per unit of body weight, these stunted children are as fit as or fitter than their taller and heavier counterparts, although in absolute terms they might still be handicapped.
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They also had very low food intakes. Many groups of people seem to subsist quite well on energy intakes much even w ten allowance is made for their low body weight.
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Exercise physiologists believe that the capacity to be either a sprinter or a marathon runner is determined by genes, not by training. Perhaps Third World people have undergone a genetic selection of fiber types that allows work to be done in the most economical way.
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milk. There is also evidence, from somewhat older children, that nutritional status has little effect on the incidence of infections, but much influence on the duration and severity of infections (Tomkins, in press)
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I am saying that rational choices about priorities for action require more biological knowledge than we have. My job has been to answer the question: What kind of knowledge?
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FAO/WHO/UNU (Food and Agricultural Organization/World Health Organization/United Nations University.
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Contributions of the UN agencies to nutrition: UNICEF. In Proceedings of the XIII International Congress of Nutrition.
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1984. Adaptive changes in basal metabolic rate and lean body mass in chronic undernutrition.
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If we focus on the causes of small body size, rather than on small body size itself, we obtain a different perspective on whether stunting merits concern. Focusing on small body size alone is misleading.
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It will be necessary to decide what functions you are interested in -- physical work, mental development, or behavior. The relation between an anthropometric deficit and a functional deficit depends strongly on culture and on all sorts of factors.
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Results of the work in Guatemala and Costa Rica suggested that a very high proportion of the neonatal deaths result from prematurity. There are, of course, other complications.
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This will also make a contribution to mothers' understanding of how to treat their children. UNIDENTIFIED SPEAKER: If we omit the very severely malnourished child, how comfortable are you that we know chat ~nthrnn~m~tri ~ tori sari ~ should be applied during the r r ~ ~ first 6-12 months of life to identify the small child that you and Drs.
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DR. WATERLOW: Thank you for your comment about nutritional science in general.
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By the term "international nutrition," I mean the major problem of contemporary humankind: the deprivation of essential nutrients in a world of plenty among disadvantaged peoples, mostly in low-income countries. Our focus is directly on the nutrition-health-food consumption triad, which complements broader concerns related to food production, income generation, and socioeconomic development.
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Finally, several governments have created privately structured research funding agencies -- the Swedish Agency for Research Cooperation with Developing Countries, Research Centre of Canada, Assistance Bureau. the International Development and the Australian Development The work ot these public agencies is joined by the private efforts of foundations, international voluntary agencies, and universities.
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For most developing countries, particularly in sub-Saharan Africa and Latin America, the most optimistic economic scenarios project slow, stagnant, or even negative economic growth well into the l990s (World Bank, 1985~. Many developing countries -- already handicapped by the vestiges of colonialism, including underdevelopment of physical assets, institutional infrastructure, and human resources -- face a hostile international economic environment marked by heavy international indebtedness, adverse prices for primary products, protectionism within developed countries, and reduction in concessional development assistance.
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Wide-scale dissemination and adoption of simple, cost-effective technologies, such as oral Dehydration for diarrhea and basic immunizations for common childhood infections, could dramatically promote child survival, including improved nutrition. However, technological campaigns focused on single problems without balance (e.g., birth spacing, behavioral and environmental improvements, and building capacity of a stable, effective service infrastructure)
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Many developing countries will witness polarization between a growing middle class we an a, ecary affluence and the disadvantaged rural poor, whose productive land assets are ~ ~ balanced traditional diets, inadequate to generate or the urban poor, who lack the stable wage employment that would permit them to purchase adequate diets in the marketplace.
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with economic vigor, These countries have been blessed the accumulation of strong human and tnst~tut~onat resources, good agricultural and health research and extension systems, favorable food production environments, and strong transport and physical infrastructure. Southeast Asia, however, continues to experience rapid urbanization, which leads to commercialization of the food economy with its attendant hazards, including the decline of breast-feeding.
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crisis has profoundly affected virtually all Latin American countries, precipitating severe economic adjustments that undoubtedly will have profound effects on the poor (Jolly and Cornia, 1984~. Because most of the population depends on market economies in urban centers, the employment and wage effects of economic policy adjustments can be expected to affect the welfare of disadvantaged subgroups of the population directly.
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Earlier agricultural research to improve the protein content of cereals through genetic breeding was disappointing and perhaps misdirected. By the late 1970s, however, sophisticated methods for food policy analysis provided intellectually powerful tools to consider the impact of food price policies and marketing systems on food consumption in disadvantaged copulations (Timmer, 1985~.
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Malnutrition among children is high on UNICEF's agenda, but the nutritional components of the GOBI-FFF campaign have fared less well than health technologies. Nutrition funding constitutes only about 1% of United Nations Development Program and World Bank commitments (World Bank, 1984)
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Extensive program experience, however, has demonstrated that nutritional advances can be made within existing economic constraints and that nutrition programs indeed are important components of efforts to alleviate poverty (Berg and Austin, 1984~. MULTIPLE DETERMINANTS The causes of malnutrition are multiple, and approaches toward its solution must be flexible and locally adaptive.
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There are also enormous opportunities for integrating nutrition into primary health care and food policy analysis. Primary health care is a feasible, costeffective vehicle for the delivery of basic nutritional services (Nutrition in Primary Health Care, 1984~.
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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?
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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.
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Only 5% felt that it was "not important." Combating world hunger 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.
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How, then, do we explain the sense of dwindling support for international assistance, including nutrition programs? In part, the problem results from the increasing isolation of the international nutrition community from its public and special-interest constituencies.
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· The special program approach has been highly successful in promoting public attention, the participation of the scientific-technical community, organizational visibility, and financial' resources. A special nutrition program launched by international agencies should be considered.
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Food Policy 9:304-312. Development Committee, Task Force on Concessional Flows.
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Food and Nutrition: The FAO World Review of Food Policy and Nutrition 10~1~:5-31. Mitra, A
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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.
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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.
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