From: Claudio Schuftan, avivaatnetnam.org.vn

Date: Sun, 16 Aug 1998 14:10:16 -0500

Subject: Ngonut: The Lancet, Vol 351, June13/98, p.1812

Letter to the Editor:

To the Editor,

The authors of this letter represent three different continents

(Latin America, Asia and North America) and both the medical and social

science disciplines, but have come to similar conclusions about the

state of international nutrition and specifically the relative balance

of attention given to solving the problems of micronutrient deficiencies

and those of protein-energy malnutrition.

Before 1980, most nutrition attention in developing countries

focused on PEM. The culmination of this attention was the era of

multisectoral nutrition planning in the 1970s when we not only took PEM

seriously, but understood the importance of working with a range of

development sectors to address the problem. In retrospect, those of us

pursuing multisectoral planning met with disappointment, partly because

of the mainly "nutriocentric" lens through which we viewed development,

and partly because at least some of us failed to pay adequate attention

to the underlying socioeconomic and political determinants of

malnutrition.

The reaction of a large portion of the nutrition community

was to pull strongly in the opposite direction, one which has been

labeled "nutrition isolationism." (If we will not be taken seriously

by other development sectors, we will ignore them, and pursue nutrition

interventions we can carry out and control largely on our own). And

indeed there were attractive candidates. New understandings of the

consequences of micronutrient deficiencies, particularly vitamin A and

iodine, and improved technologies and logistics for delivering

micronutrients (massive dose supplements and fortification) made

possible significant and attractive achievements within relatively short

periods of time.

Accordingly, many of us have pursued these micronutrient

interventions, in some cases with remarkable success, and can take some

pride in these accomplishments. Nothing in this letter should suggest

any reduction in efforts directed toward micronutrient malnutrition. We

remain their staunch advocates. At the same time, it is clear that we

have, all too often, neglected the overriding problems of inadequate

caloric intake and its determinants which are continuing to take such an

enormous toll on vulnerable population groups.

We know considerably more today about addressing PEM through

the combined efforts of food security, nutritional care of women and

children and public health interventions than we did 20 years ago. But

the attention of the nutrition community and the resources of donors

nowadays often are more attracted by the glamour of micronutrients, a

largely technical and often top-down solution (as close to a "quick fix"

magic bullet as we are likely to get in this field), than by the messier

and often politically sensitive business of poverty alleviation,

people's empowerment, and equity necessary to assure that mothers and

children have access to needed services -- and adequate food to eat.

In India, micronutrient deficiencies are significant and

deserving of serious attention. At the same time, however, the poorest

three deciles of the population consume only 1681 adult equivalent

calories per day, while 78% of Indian children suffer from

undernutrition. Both sets of problems are wholly unacceptable, but they

need to be kept in proper perspective.

At a recent meeting of African nutrition experts, representatives of

one country with disturbingly high rates of moderate and severe

malnutrition listed 16 nutrition research "priorities," 13 of

which were micronutrient related. This may not be surprising given the

orientation of donor assistance and the appeal of journal articles.

But the list hardly reflects the most urgent nutrition needs of African

countries.

All too often, indeed, governments and donors have concluded

that they can "check off" their concern and attention to nutrition by

launching a micronutrient or an isolated breastfeeding project, and

ignore entirely the challenges of PEM so seriously affecting the

ultimate welfare of women and children, as well as longer term

development processes.

The challenge that we face, as we move forward into the next

century is not only to maintain our momentum in pursuing micronutrient

interventions, which clearly are reducing suffering and saving lives,

but also to redress the imbalance, and the relative neglect of the

problems of PEM and food insecurity which often require a very different

set of interventions. Our hope in the years to come is that the

technical skills and partnerships which have driven salt iodization and

vitamin A and iron supplementation programs can be coupled with the

political acumen which has sparked successful social mobilization

movements to bring about the significant reductions in global

undernutrition we all desire.

Claudio Schuftan, MD. V. Ramalingaswami, MD. F. James Levinson, Ph.D.

Hanoi, Vietnam New Delhi, India Cambridge, USA

Date: Thu, 13 Aug 1998 07:48:03 +0100

From: Ted Greiner <Ted.Greineratich.uu.se>

Subject: Re: Ngonut: The Lancet, Vol 351, June13/98, p.1812

Thank you for sharing this excellent article with us. On the whole I agree

with it but would like to add a few caveats:

First, SOME (perhaps often a small part) of what is keeping the poor down

is related to the effects iron and iodine deficiency have in reducing

worker productivity and child learning capacity. Solutions to neither

problem come automatically with general nutrition or food security program

inputs. It is an insult to poor people suffering from these deficiencies to

invite them to join in poverty alleviation programs of all kinds when they

still suffer from these relatively easy to solve deficiencies that hinder

them for moving ahead in developing their communities.

Second, all micronutrient programs should not be drawn over the same comb.

Food-based approaches to solving micronutrient deficiencies are being

neglected by the major donor agencies and governments which are dependent

on them for most of their nutrition budget. These approaches (excepting

food fortification) basically involve mobilizing communities to improve the

quality of their diets, something that often can be done at very little

extra cost and even be linked to income-generation, especially for women.

Third, in those golden days the authors refer to, "weaning foods" programs

were inappropriately launched without paying attention to the need to

achieve exclusive breastfeeding first. If we improve the quality of the

diet for young infants receiving a lot of non-nutritive or low-caloric

density foods (which is very common), then no doubt their nutritional

status will improve. But not as much or at such a low a cost as it would be

the case if we could achieve about six months of exclusive breastfeeding.

Once we begin having success on that front, we will need some research

telling us how to guide mothers to achieve complementation without simply

replacing breastmilk with food likely to be inferior in nutritional quality

and contaminated. We don't know how to do that today simply because

complementation (in contrast to "weaning") was never recognized to be the

goal. Those "integrated" nutrition programs of the past always ignored

exclusive breastfeeding and the harm this did may partly explain why they

failed to have much impact on nutrition in so many cases.

Fourth, complex nutrition programs demand high levels of institutionalized

local competence that neither existed in the 1970s nor does today, sadly,

in most African countries and the poorer states of India and other south

Asian countries. Bringing in outside competence has to be recognized as, at

best, an inferior and short-term solution. Let us utilize the opportunity

that funds for micronutrient and breastfeeding projects bring in to such

countries, not just for narrow problem-solving, but for general capacity

building and even institution-building. The latter is not only ignored by

many donors, but damaged, by their repeatedly offering funds for solving

problems in short periods of time rather than for building up capacity to

solve them over the long run.

Ted Greiner, PhD

Uppsala, Sweden

Ted Greiner, PhD, Nutritionist

Section for International Child Health

Department of Women's and Children's Health, Entrance 11

Uppsala University, 75185 Uppsala, Sweden

ph +46 18 511598, fax 515380, email Ted.Greineratich.uu.se

Ted Greiner's Breastfeeding Website: http://www.geocities.com/HotSprings/Spa/3156/

Date: Thu, 13 Aug 1998 09:35:42 +0100

From: Djamil Benbouzid Benbouzidataol.com

Subject: Re : Re: Ngonut: The Lancet, Vol 351, June13/98, p.1812

Dear friends,

You have my full support. I appreciated the way you put it, and Ted's comments

(as usual).

I think that we definitely need a Nobel price in Nutrition to make it more

visible and "attractive", far away from the CNN dramatization or the

commercial slim ads.

Congratulations.

Djamil Benbouzid

Date: Fri, 14 Aug 1998 12:05:54 +0100

From: armsurfatjuno.com (Paul D Sommers)

Subject: Re: Ngonut: The Lancet, Vol 351, June13/98, p.1812

The following article is most appropriate to the discussion. It appears

to be a spontaneous grass root action to address PEM/food insecurity. Is

this just the tip of the iceberg?

Paul Sommers

Jakarta Governor Says Poor Can Farm City Land

Published by City Farmer, Canada's Office of Urban Agriculture

From the: Agence France Presse (English), Thu 06 Aug 1998

JAKARTA, Aug 6 (AFP) - The governor of Indonesia's capital has given

the city's poor the go-ahead to use idle government land to grow food,

but urged them to get permission first instead of just grabbing it, the daily

Kompas said Thursday.

"I know what sufferings the people are facing, but I plead with you

to go through the proper procedures for taking over the idle land,"

Kompas quoted Governor Sutiyoso as saying.

Sutiyoso was speaking to hundreds of people who had swarmed without

permission onto land near the city's Pulo Mas horse racing track

Wednesday and dug it up for vegetable plots.

"What is important is that when the government takes the land back,

they (the temporary users) should surrender it," he added.

Sutiyoso also said the market gardeners should limit themselves to 1.2

hectares (2.96 acres) a piece, Kompas said, citing its own sources as

saying that some 6,000 sites around the city could be cultivated.

Throughout Indonesia in the past two months, security forces have

been powerless to stop scores of incidents of people digging up golf

courses and parks to plant vegetables, banana trees and fast-growing

tubers.

A showcase cattle ranch owned by ex-president Suharto on the hills

overlooking Jakarta was invaded by some 300 villagers last month, and

plantation and fish farm owners have reported massive looting, and called

on president B.J. Habibie for security forces to help preserve their

crops.

Flying police motocycle patrols set up in the Jakarta last month to

prevent theft and looting as the economic crisis bites the poor, have

failed to stop the land grabs.

Inflation in Indonesia is running at more than 50 percent and** headed to

overtake an International Monetary Fund (IMF) predictionof 66 percent for

the whole year.

Paul Sommers

armsurfatjuno.com armsurfatearthlink.net, phone 760-944-8551

From: Claudio Schuftan avivaatnetnam.org.vn

Date: Mon, 31 Aug 1998 19:38:40 -0500

Subject: Ngonut: Follow up to the Lancet letter

THE DIFFERENT CHALLENGES IN COMBATING MICRONUTRIENT DEFICIENCIES AND COMBATING PROTEIN ENERGY MALNUTRITION or THE DIFFERENCE BETWEEN NUTRITION ENGINEERS AND NUTRITION ACTIVISTS.

The time has come for the nutrition community to more clearly separate micronutrient interventions from Protein Energy Malnutrition (PEM) interventions and to treat them as two completely different entities, two totally different challenges, addressing two different universes.

In short, they represent two separate domains.

More than before, in the last six to eight years, a significant number of nutrition workers have chosen to focus their efforts on the alleviation of micronutrient deficiencies. This is also true for many donor agencies working in nutrition. One can rightly wonder if this represents an attempt to 'run away' from the more difficult choices and challenges in the battle against (the real) malnutrition and --in the name of nutrition-- focusing more on its more achievable areas of impact thus choosing the relatively easier path to staying involved in nutrition work.

Often, this micronutrient focus represents swings from earlier work in PEM. Examples of these swings in assigning priority to micronutrients can be seen in USAID's Office of Nutrition work, quite a bit of the nutrition work of UNICEF and other bilateral donors and the work of the new Micronutrients Initiative (the latter not a real swing, but a fresh start riding this new wave of preference or new mood among many of our nutrition colleagues).

The difference between both areas of concentration in nutrition work is based on a matter of balance between an endeavor that is primarily technical with only few political overtones, and one that is the opposite: primarily political with some added important technical challenges. The former endeavor does have a potential for silver bullet solutions to work; the latter does not (and nutritionists seem to like silver bullets indeed...).

What we are talking about here is not an academic nuance only. This, because the solutions to PEM are greatly outside the field of nutrition itself and those for micronutrients are mostly inside the realm of what we can do technically. As a consequence, both these endeavors or components of nutrition work have to adopt different strategies and require different skills, approaches and tactics.

Colleagues that get involved in micronutrients work get absorbed in resolving mostly immediate and only some underlying causes of undernutrition (PEM), but they rarely touch its basic causes. (UNICEF, 1990) They also address more top down than bottom up programmatic challenges (e.g. management issues, distribution logistics, food technology issues, etc.).

Staff involved in micronutrient work traditionally lobby for policy changes which are less controversial, less political, and tend to get easier support from national decision-makers. Examples of such policies are: adding a Vitamin A component to EPI plans, pushing nutrient fortification or salt iodization legislation and regulations. (UNICEF, 1997)

When applying IEC techniques in micronutrient work, especially to change the dietary habits of a population (in terms of diet diversification) or the behavior of pregnant/lactating mothers, our colleagues face many more problems in succeeding, precisely because all the socioeconomic issues come to the fore (the same issues encountered in the battle against PEM); they are simply less well equipped (or less in control/less inclined) to handle those issues. Too often nutritionists end up teaching mothers to feed themselves and their families what they cannot afford, or --using social marketing techniques-- they seek mechanical changes in behavior without the people's understanding of why these changes are needed and beneficial to them; social marketing simply fails to put people more in control of their own lives. (Schuftan, 1996) Examples of this are found in the use of social marketing techniques in quite a few countries to promote the consumption of dietary sources of Vitamin A --an alternative whose effectiveness is, by the way, questioned by many experts.

Combating PEM is about poverty alleviation --not economic growth (as many development programs push these days)-- it is about equity, popular participation and wealth redistribution, about access to health and to education; it is about the appropriate care women and children get. All these variables are adversely affected by pervasive Structural Adjustment Programs worldwide. [The relationships between structural adjustment programs, poverty and PEM do not need to be insisted upon here yet again]. (See Werner and Sanders, 1997)

The above are the scenarios, then, that colleagues embarking in the battle against malnutrition will, by necessity, have to face and become more involved in.

As said, micronutrient deficiencies can (and do) respond when tackling immediate causes of malnutrition only, especially if well funded and well targeted: "get that capsule/pill/fortified salt into the mouth of beneficiaries, and it is done". And that is good; deaths and suffering related to those deficiencies are averted; no quarrel with that. (See ACC/SCN, 1997) But this concentration cannot be morally justified at the expense of postponing or foregoing actions to tackle PEM.

Conversely, PEM does not respond unless its immediate, underlying and basic causes are tackled simultaneously, i.e. interventions at each individual level are necessary, but not sufficient. (UNICEF, 1990)

As relates to sustainability, because micronutrient strategies so heavily depend on government (and donor) based service delivery and logistic interventions and on only some capacity building at the various levels, they very often do create dependency on a given technology and on the continuation of centrally funded and centrally controlled services. Ergo, sustainability remains elusive. [Note that very few countries massively distributing Vitamin A capsules at present could sustain the effort if the donor(s) discontinue(s) its (their) support].

On the other hand, resolving PEM depends more on empowering people and communities to get involved in actions selected by themselves and, although not often achieved, this has the potential of creating less dependence and more self reliance and sustainability. The example from the UNICEF-sponsored Iringa (Tanzania) nutrition intervention in the early eighties comes to mind)

Micronutrient interventions will foreseeably reach coverages in the 90% range almost universally sometime in the early 21st century --mainly due to strong pushes by the donor community. (ACC/SCN, 1997) And then, what? Will we see a switch back to PEM work (which by then will have become worse)?

PEM will not go away (or perhaps not even decrease) in the next generation. The donor community involved in it pays more lip service to needed basic changes than putting their money and actions where their mouth is. And governments are not tackling these basic problems on their own either. Moreover, macroeconomic policies imposed by the Bretton Woods institutions are actually, more often than not, acting against the alleviation of PEM. (Werner and Sanders, 1997)

I contend that nutritionists tend to choose tracks in their careers according to their preference plus the level of tolerance of frustration they can stand in their (nutrition) work. The question is: Do a political ideology and ethical commitments also play a role in their choices when faced with only snail pace progress? In other words, are ultimate goals of social transformation part of the equation in their choice? If the answer is 'no', I see a bleak future for the role our guild can play in the battle against malnutrition in the world. Changes will come about without and despite us; history will bypass us.

And I worry, because I see these future challenges that will have to be faced by our young and upcoming colleagues not being clearly spelled out in their curricula during their undergraduate and graduate training.

Some say we are training less than engineers (Berg, 1995). I would say we need more than engineers: we need nutrition activists.

Claudio Schuftan

Avivaatnetnam.org.vn

From: mwdemmentatucdavis.edu

Date: Tue, 15 Sep 1998 21:43:00 +0700

Subject: Ngonut: Follow up on Lancet letter (2)

I would like to respond to Dr. Schuftan's email. As I understand his argument he has distinguished two populations of people who work on nutrition but not two different nutritional/development problems. One group, the PEM people, is development oriented attempting to eliminate poverty by interventions that improve the quality of life and thereby improve the energy and protein status of their target groups. The other,focused on micronutrients, attacks the problem through interventions aimedat specific nutrient delivery systems that are somewhat disconnected and may be independent of the overall welfare of their target populations.

However I would argue that, unlike the dichotomy in the researchers and activists, the problem of human nutrition and development is conceptually a single problem. Micronutrients, and protein and energy are not different issues. Perhaps the people devoted to them approach it in different ways but there is much room for unification. There is a need to have a comprehensive approach to nutrition and at it center, have the object of development, not just economic growth but explicit objectives that target the cognitive and physical welfare of human beings.

Let me layout a conceptual model of the problem as I see it. The challenge is to deliver a suite of nutrients at appropriate levels to populations that allows normal cognitive and physical development, and the maintenance and performance of mature individuals. One could think of this as an optimization problem where the objective (function) is to maximize the nutritional status of a population (call this grossly "human capital"), subject to a set of constraints (economic, ecological, agricultural, structural, cultural, infrasturctural, health etc) by the judicious selection of a set of potential interventions. The interventions change the availability of foods, each of which would supply a subset of nutrients to the diet.

Assume that for each nutrient we can describe, with varying levels of accuracy, the relationship between the level of that nutrient in the diet and some measure of human capital (a simpler model might just use minimum levels or daily requirements of the nutrient). We have finite resources at our disposal: how should we allocate them to get the greatest increase in human capital? What set of interventions is optimal? On one hand we might intervene with increasing the efficiency and sustainability of cereal marketing, distribution and production systems to supply needed calories and on the other, increase household income and knowledge to allow the purchase of animal products to supply critical micronutrients.

Supplementation and fortification programs could be bridges to future sustainable food systems. Interventions could include policy analysis to make foods more available, disease interventions, improved sanitation, better food processing. In sum, the objective of development becomes development of healthy people who can be productive because they express the their full capacity to work and to be creative, and to develop themselves. The approach is a broad based, unified approach to the supply of the optimal nutrient levels given the local constraints.

One important caveat is that certain nutrients are more critical for survival than others. This characteristic could be considered in this framework by giving priority to fulfilling those nutrient requirements first. But the survival issue raises an interesting point related to Dr. Schuftan's email. Perhaps this distinction is the historical basis for the dichotomy that has developed, since calories and protein are most essential to survival. The factors that control survival are many and diverse, and the solutions to the problem necessarily ones that range across the spectrum of development activities. This perspective is likely a reason for the evolution of the "nutrition activists".

Recently micronutrient malnutrition has been elevated in the development community because of its links with human capital, such as survival, cognitive and physical development of children, disease resistance. The micronutrient picture has emerged, with some exceptions, from very specific, focused studies. Some, like the work on Vitamin A and female survival in India, have produced remarkable results. In the face of such work who is not tempted to encourage the "silver bullet approach", to be a "nutrition engineer".

However Dr.Schuftan's concern is real. Should we not be taking a comprehensive approach with a development strategy that attacks the "root causes" of the problem of malnutrition not just its symptoms? I would argue that a broad based conceptual model of nutrition and development with a specific nutritional/welfare objective can provide the context in which to allow the integration of the approaches of both groups. This integration would be a powerful tool for international development and the role of nutrition in this process. Not unimportantly it would also provide a potent link between nutrition and other disciplines in agriculture, economics and health science that are critical areas impinging on the delivery, availability and utilization of nutrients.

>From: Tracy AtwoodatG.EGAD.AFSatAIDW

>I found this a very perceptive analysis and fundamentally why I think we

>must continue to focus on undernutrition as well as micronutrients. It's

>why I resist considering "micronutrient" work as the only possible use of

>"child survival" funds as well.

From: Claudio Schuftan avivaatnetnam.org.vn

Date: Wed, 16 Sep 1998 13:33:06 +0700

Subject: Ngonut: f/u on Lancet letter (3)

1) Dear mwdemmentatucdavis.edu (sorry, don't know your name),

We all read your response. Thank you. We agree on quite a bit. But I am not sure you fully understood me.

The intention and outcomes you pursue are noble, but the process you seem to envision, in all but your last paragraph, is still top-down.

Things you suggest are reasonable, but it should not be for us (yet again...) to decide courses of action.

In my piece, I am not calling for fair, consciencious and committed engeneers; I am making a call for activists (and a preliminary set of things we should begin doing differently is humbly suggested).

The conceptual framework to 'comprehensively' blend-in macro and micro interventions you suggest in your last paragraph already exists (!). It is the UNICEF conceptual framework of the causes of malnutrition. We just pay too little attention to efforts to address malnutrition's basic causes...

2) Dear Emmy Simmonsatg.egadataidw (I think it is you...),

Right on! Please continue resisting micronutrient work as the only possible use of Child Survival funds in USAID!

Cordially,

Claudio Schuftan, avivaatnetnam.org.vn