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Food and nutrition policy

Food consumption and nutrition targets
Beyond the green revolution: some food and nutrition issues in the 1980s
Increasing the capacity of the international agencies for policy formulation and programme or project preparation in nutrition
History of breast-feeding in Chile

Food consumption and nutrition targets

Robert J. Muscat
USAID. Nairobi Kenya

BACKGROUND

To help governments improve food consumption and nutritional status among their populations, the UN agencies concerned presented to the World Food Council (WFC) a series of recommendations for action. The recommendations cover practical steps governments can take in problem identification, analysis, policy and programme development, and specific projects and activities that can serve to alleviate problems of malnutrition. Subsequently, the UN's ACC Sub-Committee on Nutrition, on which the above agencies are represented, considered the need for sharpening the focus of government and UN system efforts in nutrition, and for increasing the level of attention and resources. Although the recommendations to WFC refer to the need for goals and concerted policies relevant to nutrition, they do not specifically address the advisability of countries adopting nutrition targets-i.e., measurable nutrition-status objectives to be achieved by a specified date.

The plans of most developing countries are built around numerous aggregate, sectoral, and specific targets. In many areas, quantification of resource requirements and formulation of relevant policies are impossible without reference to quantified targets (e.g., per capita and sectoral income growth, job creation, food production!. Few countries have thus far articulated specific nutrition targets. Crop production targets are common, of course. However, although achievement of adequate levels of national food supply is of obvious importance for alleviation of malnutrition, aggregate food supply availability by itself is not sufficient to ensure adequate nutrition levels in the face of food maldistribution, inadequate purchasing power, poor child-feeding, and improper dietary practices, etc.

At the global level, inter-governmental bodies and conferences concerned with diverse aspects of development have attempted to establish various kinds of targets as guidelines for the international community (e.g., overall growth rates). A number of targets (and non-quantifiable objectives) have been adopted by inter-governmental conferences or bodies directly or indirectly related to food consumption and nutrition. As best as can be ascertained, the relevant targets and objectives that have been proposed are as follows:
1. Elimination of hunger and malnutrition within a decade (World Food Council 11/74).
2. Elimination of clinical forms of malnutrition by 2000 (World Health Assembly, 1977).
3. Increased assistance for nutritional research and training (World Food Council 11/74).
4. Nutritional considerations in aid programming (World Food Council 6/77).
5. Annual increase in food production of 4 per cent in food priority countries (World Food Council 6/77).Higher level of food aid (UN General Assembly 9/75).
6. Safe water supply and sanitation by 1990 (Water Conference 3/77)
7. Development of basic services (UNICEF 5/77).
8. Health for all by 2000 (World Health Assembly 5/77).
9. Infant mortality rate lower than 120 per 1,000 live births by 1985 (Population Conference 6/74).

In addition, a number of other institutional, structural, or process objectives have been adopted that are also relevant, some of which are instrumental in achieving one or more on the above list: strengthening of basic health services; integration of women in development; agrarian reform and other income-related objectives; development and improvement of irrigation systems and other increases in food supply objectives; world food security system.

Nutrition is specifically mentioned only in the first four points of the above list. Of these, items 3 and 4 are instrumental in nature, and without time or quantitative benchmarks. Item 1 appears unrealistic. A food-production target (item 5) would be a critically important part of a strategy to reach national nutrition targets in most developing countries, but would be insufficient by itself without accompanying food distribution and consumption patterns and specifically nutritional objectives. Item 6 is clearly an instrumental necessity, but again, for nutritional purposes, needs to be a part of a more comprehensive set of objectives more sharply focused for nutritional effect.

The experience with global targets has been mixed. Some have had little impact on either international or national decision-making. Others have had substantial impact, either in terms of specific operational achievements (e.g., smallpox eradication), or in terms of focusing attention and providing a basis for international negotiation or dialogue (e.g., the 0.7 per cent aid target). One cannot generalize on this experience, except perhaps to conclude that the usefulness of nutrition targets would appear evident, but will depend on their political appeal and implications, and also on feasibility and cost.

WHY HAVE TARGETS IN NUTRITION?

In general, targets provide: (a) points of reference for concrete policy, programme, and project planning and budgeting, and (b) political rallying points and visibility. In nutrition the general needs appear to be: (a) to raise the level of awareness and interest in an understressed problem; (b) to identify specific attainable goals; and (c) to overcome the artificial distinction, common among policymakers, between food and nutrition, as if the latter were marginal to the food supply problem, or "merely" a welfare subject.

At the country level, rationalization of ministerial competition for resources and priorities is probably not assisted by priorities and targets proclaimed by the UN system and intergovernmental conferences, because of the large number of such enunciations and the failure of the UN system thus far to order them or even test them for consistency and their interrelations, In addition, the impracticality of some targets and the failure to achieve others have led to understandable skepticism. However, the absence of definite nutritional targets can hardly be strengthening the level of attention given to nutritional problems. If the targets are well chosen and followed-up, their promulgation may well turn out to be useful for the needs outlined above. The proclamation of international targets, or international advocacy of national targets (two different approaches), can help national nutrition authorities sharpen domestic focus, increase the domestic level of attention and resource allocation, and thereby help increase the effectiveness of external assistance in this field.

Nutritional status is affected by, and is an indicator of, the level of general economic development. It is also a contributing socio-economic determinant of development through its effects on human performance, children's mental and physical growth, and the population's susceptibility to disease. Explicit inclusion of nutrition-status targets as an integral part of the range of development objectives helps focus on the need to integrate human-resource planning into overall planning, and helps test the favourable or unfavourable effects of other related objectives and targets.

TYPES OF TARGETS

International and National Targets

International targets would set forth for the world at large the achievement of some improvement in nutrition status by some target year. Such targets would have to pertain to nutrition problems sufficiently widespread to involve numerous countries, otherwise global characterization would be inappropriate.

Alternatively, the international community could call on countries individually to set their own targets in specific problem areas. The "call" resolution would refer to key problems and targets in broad terms, state illustrative feasible targets under different circumstances, and indicate that the system stands ready to assist countries that want help in turning those general recommendations into nationally or regionally appropriate targets.

Instrumental versus Status Targets

Targets could take the form of specific nutrition- status objectives, for instance, the elimination of goiter as a public health problem by year X; or of actions or of the building of institutional capabilities that a country would need as instruments to achieve improvements in nutrition status (e.g., nearly universal breast-feeding, provision of clean water, insertion of nutrition considerations into development and sectoral policy formation). To help order the possibilities and considerations involved, the range of nutrition-status targets has been set out in the accompanying table.

The Range of Targets

Reading downward, the table moves from the narrow, specific, and relatively do-able, to the more general and difficult. Thus, group A comprises specific micro-nutrient deficiency problems. Goiter is listed first; it is the "classic" case of a problem with a technological "fix" that is inexpensive, technically proven, and without side-effects; relatively easy to administer, the "fix" requires little or no behavioural or social change, and is almost completely effective in resolving a public health problem. (WHO has developed practical operational guidelines for goiter control programmes.) Goiter is not trivial but in the context of the world's nutrition and health problems, it would not serve by itself as a major world nutrition rallying point or campaign subject. The increasing recognition, however, of the permanent effects of even moderate iodine deficiency in early life on later mental development should increase interest in eliminating this nutritional disease.

Groups of Targets to Improve Nutrition Status

Reducing or eradicating xerophthalmia, or vitamin-A deficiency blindness, is more difficult, but also feasible. Short-run vitamin A supplementation is presumably technically proven, and largely a problem of administration. Permanent solution requires an underlying programme of dietary change and local production of foods rich in vitamin A. Although the number of children at risk is in the tens, if not hundreds, of millions, in terms of countries and affected populations the problem is more restricted than general undernutrition is A target in this case would require a moderate commitment of resources, especially during the short-run supplementation or fortification period upon which would rest the feasibility of reaching a realistic and near-term target. No significant economic or political change would be entailed, with the possible exception in some regions of the need to ensure a sufficient supply of appropriate vegetables or fruits (the underlying solution) to populations that are either landless or own only mini-holdings. As children would be the main beneficiaries, the economics of avoiding blindness are very favourable (i.e., the difference between total consumption dependence for life and ability to generate even a modest income flow from their own employment), while the humanitarian benefits and appeal need no elaboration.

Reduction of nutrition-deficiency anemias, especially iron-deficiency anemia, also has obvious humanitarian benefits and appeal. In the case of adult work-output potential, iron supplementation can have an extraordinarily high benefit/cost ratio. The technology has not been proven yet, compared with techniques for vitamin-A supplementation, but appears to be within reach and is under study by the International Nutritional Anemia Consultative Group. Like goiter and xerophthalmia, iron-deficiency anemia has the characteristic of technological solution, although it, too, would need a dietary change component in the long run.

The iron and vitamin-A technologies require much more administrative structure than is needed for goiter. In each situation, before either anemia or xerophthalmia targets could be formulated, intensive reviews of the state of the art, administrative and cost implications, campaign strategies etc., will have to be undertaken, and satisfactory conclusions as to feasibility reached. Guidelines for this are available from the International Consultative Group.

A second suggested grouping of nutritional targets (group B) is in terms of the so-called vulnerable groups that experience a high incidence of malnutrition. Different child-related targets could be formulated, depending on the relative severity of different nutrition/health status problems, and the age groups at risk. In the most general terms, the objective would be "healthy growth of all surviving children, with the infant mortality rate reduced to that of developed country levels." As priority health and nutrition problems vary from area to area, it might be best to specify, in addition to umbrella objectives, the kinds of sub-targets required in individual countries, depending on such local circumstances as, for example, length of breast-feeding, age when solid-food supplement tation is introduced, intake standards, growth norms.

Because nutrition-intake targets are insufficient by themselves, an umbrella objective that opens the door to planning multi-faceted programmes is obviously superior. The targets would not be simply nutritional, nor would the interventions. The table also lists a narrower form of umbrella, viz. a stated reduction in early childhood mortality (infant and/or child mortality, depending on the circumstances). This objective has the advantage of precision. Mortality can be measured or estimated at different points in time. In addition, by limiting a target to the pre-school ages, the size of the problem and target is reduced, although in many situations feasibility of successful accomplishment appears more difficult.

Closely linked to a child-related target, perhaps inseparable from it, are the nutritional problems of pregnant women and lactating mothers. Given the close relationships between maternal and child nutrition (especially through birth weight), any general infant health or growth targets (including, of course, sheer infant mortality) without improved maternal nutrition would be inadequate, if not scientifically derelict.

The third grouping of nutrition targets (group C) relates to the general undernourishment, or protein-energy malnutrition, of the poor as a whole. For each country or region the most general target should be the achievement of minimum daily intake standards for the entire population that is undernourished, by some earliest feasible time. Such a target is obviously inherent in the concept of basic needs, a necessary condition for "Health for all by the year 2000," and implicit (if not explicit) in the broad development and food-production objectives of the development plans of many countries. Because minimum dietary requirements vary among age groups, one quantified world target would be inappropriate. For any country, the target could be adjusted in time or scope, depending on the size of the problem and the resources required and likely to be available. Thus, an interim target could be defined, for example, in terms of bringing all those below the national average in year X up to it by year Y. even though the present national average is below the desired minimum.

In one sense, the achievement of minimum protein-energy consumption targets should be among the primary goals for development in any society. Most developing countries adopt food-production targets as key factors in their development plans. However, adequacy of food supply does not automatically ensure individual food consumption and adequate nutrition. In practice, many governments may be reluctant to adopt food-consumption adequacy targets by any near-term date for a variety of economic or political reasons. In certain countries, such targets would be feasible only if more or less radical changes were introduced in the distribution of income and of income generating assets, primarily land. In countries that have introduced such far-reaching changes, objectives of nutrition or even general wellbeing were not the basic rationale.

On the other hand, there are many governments that might be prepared to consider general nutrition targets if these were formulated in a manner and time-frame that did not explicitly imply major shifts in economic and political power. Such general targets could take the form of a combination of micronutrient and maternal-child objectives, with instrumental (or means) targets aiming at the problem of general undernutrition. These latter would comprise appropriate sets of subsidy, food aid, agriculture policies, taking account of nutritional considerations in major projects, avoiding negative nutritional effects, etc.

The extent of progress toward raising consumption levels would depend on the magnitude of resources applied to these instrumental efforts, the degree to which policies and programmes favouring the poor were carried out, and in what manner, etc., not to mention the general success of development strategies and the speed with which they reduce unemployment and under-employment and begin to result in upward pressures on real wages. General improvements in well-being, income, and nutrition status have been achieved under both radical and incremental development approaches. The UN system should encourage governments to adopt objectives as ambitious as possible in relation to their nutrition problems, constrained only by the limits imposed on feasibility by resources and administrative capabilities.

Room should be made for some special targets peculiar to certain situations that for some countries, and at some times, may be numerically significant. Two are cited in the table: the cassava-protein problem, and the problems of deterioration in quality of the diet as money income rises, experienced by urban migrants and other people in transitional situations.

It will be noted that reduction/elimination alternatives have been listed for several targets. Whichever is the best formulation depends on technical factors pertaining to each problem, judgement as to feasibility of approaching elimination, and time-frame. Unlike smallpox, which appears to be totally eradicable, any nutrition deficiency can reappear, so that fulfilment of many targets would require continuing surveillance.

It is therefore important that international and bilateral agencies adopt instrumental targets through incorporation of nutritional considerations in all relevant recommendations and projects. They should also ensure that: (a) nutrition targets implicit in other targets incorporated within the UN's International Development Strategy for the 1980s are made explicit; (b) inter-governmental bodies drawing up this strategy include explicit nutrition targets and take nutrition objectives into account in drawing up other relevant targets (e.g., food production levels) for the 1980s or the year 2000; (c) recommended targets are also communicated to the World Food Council, individual governments, and the world conferences on Science and Technology and on Agrarian Reform and Rural Development. Adoption of any specific targets- whether global targets for adoption by inter-governmental bodies, or recommendations for national targets-should be reinforced by formulation of appropriate programme guidelines, such as those already issued by the Consultative Groups for Nutritional Anemia and Vitamin A. Such guidelines should spell out the key elements of target" oriented programmes, i.e., problem assessment, selection of intervention strategies, implementation systems, including monitoring, evaluation, and regular review of the targets, etc.

In many countries, malnutrition in various forms is widespread, but incidence data are not available, or are incomplete and subject to error. Nevertheless, elaboration of meaningful targets is possible. They serve as guides for the magnitude of resources and "strength" of policy needed, and as spurs to improvement of information gathering. In this connection, the data-generation facilitated by the development and strengthening of national sample survey capabilities (assisted by the proposed National Household Survey Capability Programme of the UN) will enable countries to define increasingly "hard" targets over the next decade and monitor progress with reasonable accuracy.

Beyond the green revolution: some food and nutrition issues in the 1980s

Sol H. Chafkin
The Ford Foundation, New York, New York, USA

The emerging issues facing the developing countries and, indeed, some of the industrialized countries in the 1980s, should be viewed from a public-policy perspective-What decisions will need to be made by governments and by international agencies? Nutrition research findings will shape the formulation of public policy and decisions on what governments and international organizations will do now and in the future about food and nutrition problems. But other events that seem quite separate from the words "food and nutrition" are often more important. Thus, the decisions of the OPEC oil cartel to increase oil prices have had direct and indirect effects on the lives of millions of people. These actions affected the pace of inflation, food prices, and, therefore, what and how much people could afford to buy. In that sense, such actions affected life and death. Existing forces that seem unrelated to nutrition can have an enormous impact on whether people eat enough of what they need to live and to function effectively.

It should be realized that nutrition problems also exist in some industrialized countries. In the United States, for example, these problems are engaging the attention of Congress, of other Government departments, and, more important, of hundreds of citizen groups across the country who are worried about everything from world hunger to the effects of additives in some processed foods. The United States ranks behind 14 other nations in the rate of infant mortality, which is related to low birth weight and maternal malnutrition. Of the more than three million children born in the United States each year, 7.6 per cent, or about a quarter of a million children, weigh less than five pounds at birth. The problem is not limited to developing countries. It affects the young and the poor, and especially the black population in the United States, and it reflects the same issue of distributive inequality that exists in developing countries.

Much of the significance of food and nutrition problems lies in the fact that what does or does not go into the mouth has a profound effect on how people work, learn, and behave. This is now receiving the attention it has long deserved. It is an extraordinarily complex area of investigation, but it is of immense importance because there is growing concern with the consequences of less-than-severe malnutrition, in which the signs of hunger and malnutrition are not as visible as in cases of severe malnutrition. There are hundreds of millions of people in the world who are subjected to less-than-severe malnutrition, yet we know very little about what that means in terms of their ability to learn, to work, and to function in other respects. If nothing is done about it, we will risk impairment of the next generation.

The magnitude of the problem of malnutrition is such that in some countries, 50 per cent of the population does not receive adequate supplies of calories. The investigators who have been studying the relationship between calorie deficit and its effects have done a series of analyses that suggest that inadequate supplies of calories may be more powerfully related to infant mortality and life expectancy than income itself or other variables. In this sense, among the whole set of basic human needs-food, housing, health care, education-it is possible to conclude that the most critical basic need may indeed be food. Chronic hunger is not only debilitating in itself, it is associated with many forms of ill health as a result of inadequate intakes of nutrients.

One solution that is offered for the problem of malnutrition in developing countries is to wait for the economic development process to increase the food supply, and, therefore, to concentrate attention on economic growth. The evidence thus far suggests that the preoccupation with increasing food production that has characterised the approach to food problems over the past 30 years is not enough. Calculations done at the World Bank on how long it would take to solve calorie deficits through the "normal" process of development indicate that this would take far too long. In many countries, it would be a matter of generations before development could be considered complete. It begins to be clear that something outside the "normal" course of economic and social development is required.

The world food and nutrition problem, like so many others, is intimately linked with financial resources, with policy decisions, and fundamentally with political decisions, and this is where the issues will centre in the 1980s. For example, how does a government harmonise incentive prices for farmers with low prices for consumers? How does a developing country facing serious problems in its balance of payments make decisions with respect to expanding agricultural exports, utilizing land that could be used for producing domestic foods? How does that government harmonize its balance-of-payments pressure for more food exports, for example, with its domestic food requirements?

This need to harmonize conflicting objectives extends to other matters. Thus, all governments, in one way or another, try to design an anti-inflation programme to keep prices under some kind of control. One part of anti inflation strategy is to try to reduce government spending. The chances are-and this is true in the United States- that those programmes cut will be welfare, health, education, and, where they exist, nutrition programmes. This gives rise, as is also happening in the United States, to the kinds of political tensions that are reported in the newspapers. Those in countries that are concerned with attempting to reduce the magnitude of serious malnutrition problems are going to run into rigid laws of internal financial stability and international financial survival, as well as a host of political interests that will be involved in all these decisions. These may be of overriding importance as governments consider both policy and programme approaches to reduce the dimensions and severity of nutrition problems.

Increasing attention is being paid to food-policy analysis-a broader perspective on food than mere food production-that encompasses manipulating the relative prices of food crops to make key foods available at lower prices to low-income populations. But most government action continues to be in the form of direct intervention programmes for feeding school-age and pre-school-age children.

It should be recognized that governments have difficulty in adopting significant policy changes one at a time. The complexity of the problems is such that changing a food policy often requires simultaneously changing several other policies, and it is asking a lot of governments to make multiple changes in an area where politicians are not certain about who loses and who gains when a policy is changed. It is for this reason that political leaders are more likely to rely on programme interventions to feed people. The people are visible, the programme can begin on a small scale, expanded if found to be effective, or eliminated, depending on what budget conditions are in a given year. While there are sometimes administrative scandals associated with food distribution programmes, these are manageable as well. The limitations on major policy changes and their constraints must be acknowledged.

It should not be a disappointment if governments choose direct nutrition intervention programmes. This may be the most practical step for a particular government at a particular time. However, a two-track approach ought to be encouraged in the 1980s, wherein governments can perceive those powerful policy changes that could make a real impact on malnutrition, while at the same time they support efficient intervention programmes that may not be as significant in terms of the number of people reached but that do at least provide some help.

Another major policy issue that governments will face involves the possibility of general food subsidies as distinct from those tightly targeted programme interventions, e.g., feeding children under age five. Food subsidies were adopted about a decade ago in Sri Lanka, though not primarily for nutritional reasons. They were adopted largely for political reasons. Those subsidies, however, produced dramatic health benefits and impressive improvements in life expectancy. They therefore raise the major issue of how much governments are willing to spend in a general food subsidy programme in order to achieve results similar to those realized in Sri Lanka. When the cost of subsidies almost bankrupted the country, Sri Lanka was forced to reduce the size of the subsidies in the early 1 970s and to cut the amount of the ration by 50 per cent. The result was an upturn in mortality rates. There was no other plausible explanation for changes in those mortality rates. This illustrates a finance/nutrition issue that other governments will also face.

The initial and recurring costs of any kind of government nutrition action, whether it is a programme or a subsidy on a countrywide basis, are a chronic problem that will confront governments in the 1980s and beyond. The task will become one of finding techniques for financing adequate programmes, or adequate large-scale policies, without burdening government budgets to the extent that other major services have to be dropped. Some of these financing approaches may be in the form of international assistance. Others, and in my judgement more promising ones, may be in the form of policies to encourage local-level, community self-financing of programmes to improve health and nutrition. A few such examples exist in a number of developing countries. They need to be examined urgently, and the lessons learned about what is possible and what is not possible to do in solving nutrition problems at the local level need to be disseminated. Relying solely on uncertain government budget decisions is too risky. Politicians change, budgets change, but nutrition problems go on.

One of the most interesting examples of the relationship between policies that are not directly related to nutrition and nutrition and health came from Brazil. Between 1964 and 1974 the production of traditional staple foods in Brazil remained constant. However, soybean production increased from about 500,000 tons per year in 1964 to nearly 10 million tons in 1974. During that same period Brazil experienced inflation and population was increasing. The tremendous attention accorded to soybeans, it might be argued, was misdirected in that it may have displaced the production of traditional beans that were a dietary staple. The soybean crop was largely exported. How could a country with such poverty as exists in Brazil's Northeast sector, for example, and such nutrition problems, export 10 million tons of soybeans? In that same period, child death rates that had been declining in some Brazilian cities began to increase. This illustrates the close connection between the responsibilities of a government toward its people and the exigencies associated with international financial policies. Brazil had a huge foreign debt and it had to determine how to service that debt. One way was to export soybeans. The priorities are evident. Soybeans were exported in order for Brazil to stay alive financially. This is the kind of priority that those who are concerned with nutrition have to recognize before they can find ways to harmonize policies with nutrition objectives.

Countries are groping to take specific actions to reduce malnutrition. There are many in the nutrition field who are uncomfortable with the idea of intervening without having a firmer research basis on which to act. But most of them, I believe, will recognize the importance of doing what can be done while trying to learn what would be better solutions. The results of research do not have to be in before intervening. It may even be an ethical error to wait until they are.

There are some in the nutrition community who feel that the only answer to malnutrition is a sweeping redistribution of political and economic power, and that it is a waste of time and money to undertake nutrition intervention programmes. That is a position that has a peculiar arrogance attached to it. There is no need to tell people who are starving or suffering from malnutrition to wait until there is a revolution before they can expect help.

What will be necessary in the 1980s is a search for ways to harmonize conflicting policies and a need to accelerate the identification and preparation of specific policies and specific intervention programmes while outstanding scientific issues are being clarified. These must proceed together. If we wait for research results or political revolution, we will be acquiescing to life-threatening deprivation for literally millions of individuals in the next generation.

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