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VI. NUTRITION EDUCATION IN MOROCCO

Background

The value of nutrition education in low-income countries has long been debated, though with little empirical basis. Opponents argue that deleterious belief patterns rarely are the primary constraint to improved nutritional status, and that where poor families have inadequate purchasing power, nutrition education is irrelevant. Advocates argue that, even in such cases, families with better knowledge of, for example, the importance of breast-feeding, timely supplementary feeding, and the management of weanling diarrhoea can compensate in part for scarce resources.

In recent years, serious discussion of nutrition education has also been introduced in the context of child-feeding programmes. A landmark study of pre-school child-feeding programmes operated by CARE in five countries found, in some areas, that only a small percentage of young preschool age children actually consumed the food intended for them in take-home feeding programmes. In these areas, where supplementary feeding traditionally is delayed because of its association with diarrhoeal infection, the delivery of such food without concurrent and effective nutrition education was found unlikely to be of any direct benefit to these children (11).

The Project

In 1975, with financial assistance from the US Agency for International Development, the Catholic Relief Services (CRS) began a project in Morocco to introduce nutrition education into 250 social education centres that were distributing PL 480 food to pre-school children and mothers. The project involved (a) the establishment of a nutrition institute for the training of supervisors, (b) the development of curriculum, and (c) the operation of monthly classes at the centres on nutrition, health, hygiene, sanitation, and food preparation. In all, 150,000 mothers and 300,000 children were reached, the latter representing an estimated 6 per cent of malnourished children in the country.

The education was provided as a complement to a large ration, almost four kilograms per person per month (526 calories per person per day) with a value of 24 per cent of the average per capita incomes in these families. The total cost of the programme was US$34.47 per person per year (comparable to the costs of other such programmes world-wide), of which roughly two-thirds is the value of the imported food. All participating families were asked to pay a small fee (US$0.54 per month).

Assessment

The programme as a whole exhibits many characteristics of a traditional top-down, externally directed nutrition intervention programme. Although Morocco's per capita GNP is roughly three times that of India (classifying Morocco as a middle-income country), its physical-quality-of-life index is lower than that of India, the result in part of an infant mortality rate as high as 170 per thousand in rural areas. In spite of this sharp disparity between resources and human well-being, the Government to date has been unwilling to assume full responsibility for child-feeding and continues to rely totally on imported food for this purpose. (The Government does pay in-country operating costs.)

The programme itself was designed entirely at the central level by CRS and its government counterparts. Not only was there no substantive local participation in programme design and development, but personnel trained for programme supervision were not selected from areas in which they would eventually work.

The above notwithstanding, the nutrition education project in Morocco must be considered a successful activity, and probably represents the first substantial evidence to support the complementarity of child-feeding and nutrition education. The supporting data, although not obtained from controlled research, are summarized below.

The first question addressed is whether or not the programme as a whole (food plus education) provided benefit. Using 1978 weight-for-age data among children 0 to 5 years of age, a comparison was made of children already in the programme (for an average of 21/2 years) and new entrants not previously in any such programme. Although one might have assumed the latter to be younger children, officials involved in the programme claim this was not the case. (But, strangely, even if new entrants were younger, there was virtually no difference in nutritional status found between the younger and older children within the new entrant group.) The other potential source of bias in such a comparison is that the 1978 new entrants might have been more malnourished than were the programme participants at time of entrance. A comparison of 1975 and 1978 new entrants indicated that these differences were not significant.

The results presented in table 4 suggest that the programme as a whole (food and education) resulted in a 69 per cent reduction in moderate and severe malnutrition. The reduction (equal to or higher than those found in comparable programmes in India, Brazil, Haiti, the Philippines, Jamaica, and Colombia-see ref. 12, table 16) might be explained, in part, by the large size of the food ration, which may have compensated for the inevitable food-sharing in such programmes.

The second, and for our purposes the more critical, question is the independent effect of education on this improvement. This was examined through analyses of two sets of data. The first set compared the weights of programme participants in 1978 with those of their brothers and sisters who had been in the programme in 1975, at which time the feeding programme had no education component. The results presented in table 5 suggest (assuming that other variables, including operation of the food programme, remained constant) that the education component reduced this moderate and severe malnutrition by half. The data also indicate a virtual elimination of severe malnutrition in the 1978 group.

As a check on the reliability of this study-and given some concern that the 1978 participants may have received food for a longer period than their 1975 siblings-further analysis was carried out by an AID evaluation team. This time the 1978 participants were compared with comparable 1975 participants who had received food for approximately the same length of time. The results were similar to those presented in table 5. In this case 33 per cent of the 1975 feeding programme participants were below 80 per cent of expected weight for age, as opposed to 11 per cent of 1978 feeding and education beneficiaries.

TABLE 4. Malnourishment among Programme Participants and New Entrants, 0-5 Years Old, 1978

TABLE 5. Malnourishment among Programme Participants 21/2-5 Years Old, with and without Education Component

In conclusion, the data suggest that nutrition education, creatively and effectively combined with pre-school child-feeding, has the capacity to add considerably to programme impact. This, in turn, suggests a complementarity and synergism between food provision and education that, at least under some conditions, well exceeds the potential impact of each individually. These short-run results indicate substantial benefit to programme participants even in a context of minimal local participation.

VII. SUGAR FORTIFICATION IN GUATEMALA

Background

Serious interest in the concept of food fortification since the mid-1960s emerged in part from the difficulties encountered in carrying out nutrition education programmes. The case was made that, if nutritional deficiencies are difficult to alleviate through changes in dietary patterns, why not make the existing diet nutritionally acceptable by adding to it the nutrients in short supply. The advocates of this approach recognized that food fortification could not address the major problem of inadequate calorie intake. However, problems of nutrient deficiencies, particularly vitamin A and iron, which were increasingly recognized as critical in many low-income countries, did appear addressable through this type of intervention.

The fortification concept essentially enlarged that of food enrichment (practiced in some industrialized countries since the 1940s) that sought to replace nutrients originally in a food but lost through processing or because of economic factors. it was now argued that any food could be used as a carrier for any needed nutrient as long as several basic requisites were met:

- the food had to be consumed by those population groups in need of the nutrient, and in relatively constant amounts;
- the food had to be centrally processed to permit addition of the nutrient;
- the fortification could not significantly alter the taste or appearance of the food;
- the cost of the fortification could not significantly increase the consumer price of the food.

The careful examination of these criteria in the mid-1960s also made it clear that the best carriers were not necessarily the food grains or dairy products that, up to that time, had been the primary foods used for enrichment. Instead, on the basis of the example of salt iodization (itself enrichment rather than fortification), attention began to shift in the direction of unconventional carriers, often consumed by most of the population, yet centrally processed. Thus, in the late 1960s and early 1970s a series of experiments were initiated: fortification of salt with iron in India and later Indonesia; and fortification of tea in India and Pakistan, fortification of MSG in the Philippines, and fortification of sugar in Central America, these latter cases primarily with vitamin A. Except for fortification of tea, progress continues to be made with each of the above, in some cases involving large-scale demonstration projects. To date, however, the fortification of sugar in Central America has been the most successful. There, as a result of tireless work over many years by the Institute of Nutrition of Central America and Panama (INCAP)-and specifically by Dr. Guillermo Arroyave-there are now national laws in four countries requiring that all sugar for home consumption be fortified with vitamin A.

The Project

Since the 1950s, INCAP has been seeking means of addressing vitamin A deficiency, which affects almost 80 per cent of the population in Guatemala, with roughly one-third suffering from low or deficient levels of serum vitamin A (determined biochemically through blood tests on samples of the population). Most of the approaches originally considered by INCAP seemed to have some inherent drawback. Encouraging increased consumption of traditional foods rich in vitamin A-meat, eggs, and butter- would, by definition, eliminate benefit to the poor, among whom the more serious cases of vitamin A deficiency appeared to be concentrated. Low-income groups were also unlikely to purchase adequate amounts of vegetables high in carotene, given cost and taste preference problems. Massive oral doses of vitamin A represented a possibility, but this required a health system or distributional infrastructure not present in Guatemala.

The idea of fortifying unconventional foods with vitamin A had been considered as early as the 1930s by R.R. Williams and others. The limiting factor then, and for years afterwards, was the absence of a sufficiently stable form of vitamin A that could be mixed with solids. This problem was solved in 1968 when a Swiss pharmaceutical firm developed granular preparations of retinal palmitate appropriate for such purposes.

Of the carriers considered, salt was eliminated because of its extremely low consumer price relative to the cost of the nutrient. Corn was eliminated because of large on-farm consumption. White sugar was found to be particularly attractive as a carrier, given: (a) its consumption by roughly 85 per cent of the population; (b) its consumption in relatively constant quantities-36 grams per day in rural areas, 70 grams per day in urban areas-with substantial consumption by children; and (c) processing of the entire national supply in 13 large mills. Further research indicated that retinol palmitate could be added with only slight discolouring of the sugar and at a cost of US$0.001 per pound of sugar-a cost increase of one to two per cent.

As is often the case with such initiatives, the first steps in INCAP's efforts to introduce sugar fortification in Guatemala (early 1970s) were gratifying. The Health Ministry indicated active support. One of the mill owners expressed interest and agreed to initiate pilot-scale fortification. The fortified product was tested in rural areas and found to be acceptable, with no settling or deterioration. Tests done on the vitamin A content of breast-milk in these areas also indicated considerable improvement.

Buoyed by these results, INCAP staff under the direction of Dr. Arroyave intensified and broadened their efforts. Alternative means of introducing the vitamin A pre-mix into the refining process were examined, with the conclusion that it is best added immediately following centrifugation and washing, with the final mixing function performed by the dryer. Further tests were carried out on taste and biological effectiveness. Feasibility and cost studies were initiated. INCAP went so far as to draw up draft fortification legislation for the Government.

It was at this point that opposition to the project began to coalesce. The most serious came from the mill owners who viewed the undertaking as a no-win proposition. They realized that neither sales nor profits would be increased, yet the forticiation would add an extra problem in their production process. The mills also feared the additional governmental monitoring of the industry that might result once fortification was under way. Even the support of the initial mill owner began to weaken, and there was strong opposition to the idea that compliance by the mills be mandatory.

Added to these issues were a series of technical ones raised by the College of Chemical Engineers about stability, separation, and decomposition. That virtually all of these issues had already been resolved by INCAP did not deter these attacks, which may not have been unrelated to the mill owners' opposition. Also not unrelated was political opposition voiced by members of the national Congress.

The opposition from industry proved too strong, and when the proposed legislation came before the Congress in September 1973 it was defeated. At this point, INCAP wisely chose not to resume their efforts immediately in Guatemala, but instead, shifted their attention to Costa Rica. There, after similar technical and political groundwork laid by INCAP, sugar fortification was introduced by presidential decree. In this case, the mills were due for a legitimate sales price increase based on rising costs. The mills agreed to accept fortification as part of the package.

INCAP then used its Costa Rica victory in returning to its task in Guatemala. Here, as has been so common with technical innovation, the demonstration effect proved far stronger than did any pioneering instinct. With the precedent established in a neighbouring country, support shifted rapidly, beginning with local newspapers and statements issued by professional groups. INCAP itself used the media judiciously to counter remaining technical criticism. In June 1974, nine months after defeat of the original bill, the fortification case was re-introduced and enacted into law.

Nutritional Assessment

Fortification on a national scale began in December 1975. In the two months prior to this, INCAP staff carried out a baseline study of the population with respect to vitamin A. Follow-up surveys were then carried out at six-month intervals (thus covering the dry and rainy seasons) for the following two years. These surveys were carried out in 12 randomly selected rural communities. Within each community, 30 families were randomly selected for study. The studies concentrated primarily on determining the extent to which the families were actually consuming the fortified sugar, and the estimated intake of retinol from this source.

In examining the delivery system, the evaluation team tested sugar samples at the retail and household levels for vitamin A content. Over the course of the surveys, they found just under 75 per cent of the sugar was actually fortified. These data were used both to reassure technical personnel of the efficiency of the fortification procedures, and to warn the factories about deviations and irregularities.

Results of the dietary surveys included in the evaluation are summarized in table 6. As indicated, the fortified sugar essentially tripled the retinol equivalents provided by the natural food sources (mainly vegetables). Whereas in the baseline survey, over 80 per cent of families had retinol intakes lower than 50 per cent of adequacy, there were now over 80 per cent of families above the 50 per cent mark.

TABLE 6. Daily Per Capita Intake of Retinol Equivalents, 1975-1977

Source: ref. 13.

Concurrent biochemical tests on children found that the percentage with serum retinol levels considered deficient dropped from 3.3 per cent in the baseline study to 1.0 per cent in the first follow-up survey, and to 0.3 per cent in the final survey. In fact, by the time of the final survey, 10 of the 12 communities no longer had any children in the deficient category. Significant improvement was also found in the retinol content of breast-milk samples.

Finally, the evaluation included some examination of programme costs. The total annual cost in 1976 was found to be just under US$450,000, almost 90 per cent of which represented the purchase of the vitamin A. This amounted to an annual cost of US$0.07 per person in that year. The cost per child aged one to five years from low- or middle-income families and with initially low serum retinol levels was found to be US$3.66 per year, but this excludes the benefits to other population groups, including pregnant and lactating women. However calculated, the investment clearly has been successful.

CONCLUSIONS

What conclusions and generalizations can be drawn from this diverse set of studies? First and most immediately, the studies point to the conclusion that, with some threshold levels of commitment, imagination, and financial and political support, it is possible to improve the nutritional well-being of needy population groups to some extent through any of a number of different approaches. These approaches vary in terms of cost and the specific problems they address. But there is an underlying sense, looking at the set as a whole, that successful results have depended more on support and commitment than on the technical choice of intervention or on its design.

Design questions, however, are unquestionably important, and the studies, individually, point to several conclusions. The Sri Lanka and Bangladesh subsidy studies suggest that this approach, if appropriately targeted (by population group, geographic area, food commodities, and/or season) is capable of major impact without the exorbitant costs and disincentive effects often associated with them. The Indonesia UPGK Programme suggests that community health and nutrition activities with the greatest likelihood of success are those that {a) are based on community workers and community initiative, (b) include a set of complementary inputs, and (c) recognize the mother as the primary agent of change. The Morocco project suggests strongly that child-feeding programmes coupled with well-focused nutrition education are likely to produce more beneficial results than feeding alone. The Guatemala study suggests that unconventional carriers (sugar, salt, MSG, tea) probably are more appropriate than food staples for food fortification programmes.

Looking at the projects as a whole, another immediate reaction is that only the Guatemala sugar fortification project is based on what might be termed technology transfer. The one other case that might be so labelled is the oral rehydration fluid utilized in the UPGK Project. Looking at the other sets of success stories referred to at the beginning of this article, it is clear that technology transfer played an important role in none of them. This is a sobering observation in light of the enormous amount of time, energy, and resources that have gone into technological activity in the name of combating malnutrition over the past two decades.

The question of imports and dependence on external inputs is central in nutrition activities as in all development programmes. In this set of projects it appears that, on the whole, dependence on imported food has resulted in more harm than good. A substantial portion of Sri Lanka's high subsidy costs were in the form of costly food imports that probably did have a disincentive effect on local agriculture, at least in the early years of the programme.

In Bangladesh, the demise of the programme was wholly the result of its dependence on food imports. In Indonesia, irregular supplies of imported food commodities for the UPGK Programme had a highly disruptive effect. In Morocco, the complete dependence on food aid probably represents the weak link in a programme that otherwise might be taken more seriously as a domestic initiative and source of national pride. At the same time, there is no indication that the vitamin and mineral imports used in the Guatemala or UPGK programmes have had any such negative effects. Instead, they seem to be viewed as necessary ingredients that are not locally available.

This leads to the critical questions of how these activities were initiated and perpetuated. The cases of the Sri Lanka food subsidy and the NTT Lumbung Desa programmes are similar in that both were based on clearly perceived self-interest and need for protection. In Sri Lanka it was protection against food shortages and inflation during and after the Second World War. In NTT it was protection against the ravages of natural disaster and chronic food deficits. In neither case was external assistance involved.

External assistance was involved in the genesis of the Indonesia UPGK Programme, but its value came in part from its timeliness. Rather than assuming a heavy-handed, design-directive posture, UNICEF responded to felt needs within the Government-to a disenchantment with the existing services and a basic change of personnel. This sensitivity assured that the programme would be understood and appreciated from the outset as a national initiative. Such did not appear to be the case in Morocco where the project was developed in the office of an external assistance agency and then "sold" to the Government. The strong nature of the project and the lure of free food kept the project viable, but only after several years has the Government begun to view the project as its own.

Interesting parallels emerge in examining the genesis of the Philippines, Guatemala, and Bangladesh projects. All three projects were initiated by committed individuals with varying degrees of support from their institutions. All included international involvement from the outset. All three met with brief initial success and then encountered serious opposition. In the Philippines opposition came from the foreign consultants and traditional economists on the staff of the Palawan Integrated Area Development Project; in Guatemala it was sugar mill owners, engineers, and politicians; in Bangladesh it was from ration dealers and the foreign food donor.

In the first two cases, these politics changed markedly as a result of major external factors that were in part engineered, and then wisely used by project advocates. In the Philippines the external factor was support for the incorporation of nutrition by the Asian Development Bank when the bank became convinced that this was the policy of the Philippines Government. In Guatemala the external factor was approval of sugar fortification in neighbouring Costa Rica and the demonstration effect that made it compelling to follow suit. In Bangladesh there was no such external factor to counter the opposition. The Government meanwhile was content to let the project die.

Finally, there are the related issues of size, effectiveness, cost, and viability. Because most planners view nutrition expenditures as a non-investment category, akin to welfare services, and therefore to be minimized, nutrition advocates continually are pressed to come up with activities that will solve the problem without disturbing the budget. This dilemma led many in the 1960s to look for a cheap technological solution and resulted in considerable activity, for example, in the areas of unconventional protein sources and synthetic amino acids. The one successful outgrowth to date of this search for the technological fix appears to be the fortification activities discussed in the Guatemala section. The sharp reduction in vitamin A deficiency resulting from sugar fortification has been impressive indeed, and at a cost of only US$0.07 per person per year.

Unfortunately, there appears to be no comparable solution to the more serious problems of poverty-related hunger and protein-calorie malnutrition that continue to result in high rates of infant and child malnutrition and in lives often characterized by suffering and deprivation for those who survive. It is, in fact, unrealistic to expect to eliminate the hunger and malnutrition affecting, for instance, 40 per cent of a national population with 0.25 per cent of a national budget.

On a more limited scale, projects such as Palawan, UPGK, Lumbung Desa, and nutrition education in Morocco offer the possibility of some benefit to needy population groups. If implementation of the Palawan Integrated Area Development Project proceeds as planned, low-income families from disadvantaged areas may become more active participants in the development process. (Indeed, this would be an opportunity to observe a rare operational case of agricultural/rural development programmes based in part on nutritional considerations.) Indonesian families fortunate enough to benefit from UPGK Programme services will have a somewhat higher likelihood that their young children will survive and avoid the afflication of severe malnutrition. Families participating in the Lumbung Desa Programme will increase their chances of protection in times of famine. Children participating in the Moroccan feeding/education programme will probably experience better rates of growth than those who do not.

None of these gains should, in any way, be diminished. They are important. They do save lives. On the whole, they work well. We need more successes like them. But in and of themselves, they are not likely to bring about major reductions in hunger and malnutrition in their respective countries, primarily because they are not central to the patterns of development being pursued in these countries. (In fact, in some cases these overall patterns appear to have the opposite effect on the well-being of the poor.) I was constantly struck by the number of senior government officials in these countries who were not even aware that such programmes existed.

Such is clearly not the case in Sri Lanka and Bangladesh, where the food subsidy programmes have been highly visible and central to government concern. In Sri Lanka such concern has focused over the years on the basic needs of the poor, while in Bangladesh it has been directed to the government's urban middle-class constituency. In both countries, however, the magnitude of resources involved in this public food distribution make it the government's prime means of affecting food consumption among their population. Unlike the Morocco, Indonesia, and Philippines programmes these food subsidies have not been viewed simply as discrete projects, but rather have been key ingredients in governmental strategy and planning.

In terms of their respective purposes, there is also little question that the food subsidies in both countries were highly successful in meeting their desired objectives-this despite the major problems and inefficiencies and the lack of targeting. In Sri Lanka the subsidy succeeded in raising food intake in the country to nearly adequate levels (only 5 per cent of the population consuming less than 1,900 calories per day). This, in the context of an overall strategy committed to basic needs, contributed importantly to beneficial effects on the distribution of income, to a reduction in death rates, and quite likely to the marked reduction in the birth rate.

In Bangladesh the public food distribution has also been successful in achieving its objective. Over the years it has been able to deliver, at subsidized prices, between 55 and 62 per cent of the food grains consumed by the urban middle-class. The comparable percentage for the 15 per cent of low-income, rural households who receive food through public food distribution was found to be 7 per cent of total cereals consumed.

The Sri Lanka programme appeared to verify the contention made by the World Bank and others that, in the short and medium term (and in the absence of major social and economic changes), such food subsidies represent the only means of significantly reducing population-wide malnutrition in low-income countries where purchasing power is severely limited. Yet the fact that substantial otherwise investable budgetary resources were necessary to maintain this programme made it, over the years, a prime target of the International Monetary Fund and other large donors, who argued that such expenditures were inconsistent with sound financial management. The focus of this international pressure was not reform of the system or better targeting-this, in fact, had been under way since the mid 1970s-but rather the elimination of subsidies altogether and return to a free market economy. Similarly, as pointed out in the Bangladesh article, there was little international support -and some powerful opposition-to the effort at better targeting there.

The Sri Lanka case is not unique. Similar international pressure was brought to bear on Egypt, Jamaica, and Pakistan in recent years to shift resources away from consumer subsidies and similar expenditures and into capital investment. The uncomfortable conclusion is that, at present, in non-communist low-income countries that are dependent on international assistance, there is a limit, or ceiling, on the extent to which resources can be directed specifically toward alleviation of hunger and malnutrition. It is clear from developmental experience in all parts of the world that neither rapid growth in national income (the goal of the IMF) nor increased food production in any way assures higher levels of food consumption by the poor, and they may even result in a deterioration of the relative wellbeing of this group.

Reorienting agricultural production along highly labour-intensive lines and toward crops disproportionately consumed by the poor would help considerably, but such efforts, to date, have also been strongly resisted by governments concerned more with aggregate production levels and by international financial institutions promoting cash crops, with the most strenuous opposition voiced by agriculturalists within these organizations. (For a thoughtful discussion of these possibilities and problems, see ref. 14.)

More generally, major government action to generate employment among low-income, landless groups would, almost certainly, have high nutritional impact. Yet few governments have been willing to undertake such activity for fear of inflation, and none of the large food-aid donors has yet come forth to facilitate such employment generation by providing food aid as short-term insurance against inflation. Even where labour-intensive undertakings have been initiated, however (note, for example, the public works programmes in South Asia and Indonesia), prime benefits usually have not gone to needy, landless groups, but rather to contractors and to the large land-owners whose property has benefited from this infrastructure development. (Perhaps the best set of recent monographs on the distribution of benefits in these works programmes are those prepared by Hjalmar Brundin for the US Agency for International Development, Dacca, Bangladesh [1979]. For a larger discussion of employment generation and its relationship to food supply, see ref. 15.)

It is also relatively clear that the low-cost technological means of meeting specific nutrient deficiencies do not extend to malnutrition resulting from inadequate food intake. Interventions such as those in Morocco, Indonesia, and the Philippines are usually supported from external sources but, despite their considerable success in relative terms, are limited, as discrete projects, in the impact they are likely to on nation-wide problems of hunger and malnutrition. Yet, when governments attempt to take the next step and explicitly seek to augment the real income of needy families through subsidized food prices-indeed when they pursue the only approach that the World Bank believes capable of making a substantial and timely difference-they come under such severe censure and pressure from the international financial institutions that few of them can continue such activity in meaningful fashion.

Questions of design and technique continue to be important, and the nutrition community can learn by continued surveillance of what works and why across the wide range of nutrition-related programmes However, the inescapable conclusion from examination of these studies is that, ultimately, alleviation of malnutrition will depend less on design and technique, and far more on the extent of genuine commitment on the part of governments and international financial institutions to the principle of meeting basic human needs.

REFERENCES

1. Davidson R. Gwatkin, Janet R. Wilcox, and Joe D. Wray, Can Health and Nutrition Interventions Make a Difference? (Monograph No. 13, Overseas Development Council, Washington, D.C., USA, 19801.

2. William D. Drake, Roy I. Miller, and Margaret Humphrey, Analysis of Community Level Nutrition Programs (Community Systems Foundation, Ann Arbor, Mich., USA, 1980).

3. Arnfried A. Kielman, C.A. Ajello, and N.S, Kielman, Evaluation of Nutrition Intervention Projects (Johns Hopkins University Press, Baltimore, Md., USA, 1980).

4. B.L. Rogers and F.J. Levinson, "Subsidized Food Consumption Systems in Low-Income Countries: The Pakistan Experience" (Discussion Paper No. 6, MIT International Nutrition Planning Program, Cambridge, Mass., USA, April 1976).

5. Neville Edirisinghe, "Implications of Government Intervention in the Rice Economy of Sri Lanka" (thesis, Cornell University, Ithaca, N. Y., USA, 1975 )

6. F.C. Roche, "The Demographic Transition in Sri Lanka: Is Development Really a Prerequisite?" [Cornell Agricultural Economics Staff Paper No. 76-5, Ithaca, N.Y., USA, January 1976).

7. P. Isenman, "The Relationship of Basic Needs to Growth, Income Distribution and Employment: The Case of Sri Lanka" (The World Bank, Washington, D.C., USA, 1978).

8. Nutrition Survey of Rural Bangladesh, 1975-76 (lnstitute of Nutrition and Food Science, University of Dacca, Dacca, Bangladesh, 1977)

9. W. Rich, Smaller Families through Social and Economic Progress (Monograph No, 7, Overseas Development Council, Washington, D.C., USA, January 1973).

10. "Evaluation Report of the Food Stamp Scheme" (Food and Nutrition Policy Planning Division, Ministry of Health, Government of Sri Lanka, Colombo, 1981).

11. Mary Ann Anderson, "CARE Preschool Nutrition Project: Phase II Report" (CARE, New York, 1977). Although five years have elapsed since the completion of this study, it still has not officially been released by CARE,

12. J.E. Austin at al., "Supplementary Feeding," in Nutrition Intervention in Developing Countries (T.K. Hull, Boston, Mass., USA, 1980).

13. Evaluation of Sugar Fortification with Vitamin A at the National Level (Pen American Health Organization, Washington, D.C., USA, 1979).

14. Alan Berg, Malnourished People: A Policy View, Poverty and Basic Needs Series (World Bank, Washington, D.C., USA, 1981).

15. John W. Mellor, The New Economics of Growth (Cornell University Press, Ithaca, N.Y., USA, 1976).

ACKNOWLEDGEMENTS

It would be impossible to list all the individuals, organizations, and documents that were helpful in preparing the paper, but a few must be acknowledged: my colleagues in the Food and Nutrition Policy Planning Division of the Ministry of Health in Colombo for assistance in preparation of the section on Sri Lanka; Rezaul Karim and Manjur Majid in the Bangladesh section Marito Garcia, Benjamin Gaon, and Maura Mack in the Palawan section; officials of the Nusa Tenggara Timur provincial government in the Lumbung Desa section; Lukas Hendrata, Terrel Hill, Nancy Terreri, and Peter Berman in the UPGK section Carol Adelman in the Morocco section; end Guillermo Arroyave and James Austin in the Guatemala section. Alan Berg, as always, provided wise counsel and many good ideas on the study as a whole, as did Leslie Burgess.

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