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Samir S. Basta
After two decades and a half in the field of nutrition, I have come to a reflective point: Why we have not advanced as well as we should have?
When I started my nutrition studies in the early 1960s in Great Britain, a solid background in animal nutrition and human physiology, and rigorous laboratory training in biochemistry and food technology promised to allow me to elucidate, understand, and treat all remaining vitamin deficiencies, inborn errors of malnutrition, and most endocrine abnormalities of a nutritional nature. "International" nutrition, nutrition planning, and so on received insufficient emphasis. Other than a lot of research in food technology and food science (weaning foods, protein-rich mixtures, etc.) and some reference to the then ANP (applied nutrition programme), relatively little attention was being paid to social, economic, and political aspects of malnutrition around the world. This seemed to be more the purview of economists and other social scientists. Hence, the late 1950s and early 1960s was a research phase for nutrition, with institutions such as INCAP and the old ICNND perfecting survey methodology and laboratory techniques.
Around the middle to the end of the 1960s, the emphasis shifted toward more studies on the malnutrition of deprivation, and the linking of nutrition to other fields such as psychology, early childhood stimulation, specific nutrient deficiency effects, brain physiology, and so on. The effect of malnutrition on mental development was the most exciting of these fields, and everyone, including me, soon flocked to Mexico and elsewhere to take part in the esoteric research connected with it.
In the latter half of the 1960s and the early 1970s, increased social and political awareness led to a heightened realization of the need to link nutrition and economics more closely. Research became more applied and politicized, such as the emphasis on malnutrition and land tenure, malnutrition and colonially imposed agricultural practices, productivity and malnutrition of the poor, the cost of the effects of vitamin and mineral deprivations such as vitamin-A blindness and anaemia, and the refinement and analysis of the effects of malnutrition on communities or nations. At last, questions of equity, land reform, and the plight of urban squatters, and the cost, production, and distribution of food versus, say, cash crops were being related to nutrition status. The World Bank, together with a small number of universities in the United States and perhaps more in Latin America, began to speak of nutrition planning, and very soon huge multisectoral nutrition programmes began to be put into effect. It was around then, as I recollect from my then perch at the World Bank, that FAO, IFAD, and UNICEF even began to talk of a possible end to hunger and nutritional deprivation. Those were heady times.
The end of the 1970s and early 1980s were times of confusion. All the big money given to multisectoral nutrition-planning projects was generating tons of data; but most of the analyses carried out revealed that little in terms of reducing malnutrition was actually happening. On the contrary, with the economic slump of the early 1980s, things were actually growing worse for many countries. The poor were becoming poorer everywhere, and some large institutions found themselves giving with one hand and taking with the other. Even the UNU, the World Bank, and UNICEF were now increasingly talking about such previously unheard concepts as the need for "adjustment with a human face" and joining the academic chorus bemoaning the weaknesses of economic prescriptions being launched from American and European capitals. A few nutritionists, seeing a new bonanza, tried to band together to help sound the alarm. (This alarm had, of course, been ringing for some time in the ears of the intellectual and scientific elite of the developing nations.)
Around that time came also the latest cycle of famine in sub-Saharan Africa. The early and mid 1980s concurrently became in fact the "age of famine." An unprecedented mobilization involved everything from youth and rock groups to ordinary housewives and truck drivers. Nutrition, or rather starvation, was really now in the news. Tragic scenes from Ethiopia, Sudan, and other African countries (along with the slightly earlier episodes of atrocities and starvation in Cambodia) became fixed in everyone's imagination; books were written, non-government organizations proliferated and became richer, and the United Nations bodies fought each other for slices of the huge publicity and private aid pie. For a limited time, issues of "adjustment" and "debt" were shelved, but they have reappeared with renewed and much greater force in the last couple of years. More nutrition scientists are now leaving their laboratories to join the economists in this vital endeavour, but it is not certain what they are going to do.
While nutritionists need to be more involved in the economics of malnutrition, it is not going to be easy. Economists and development planners will continue to appeal to nutritionists for guidance only on technical matters such as surveys and surveillance. On the other hand, nutrition as both a science and a profession has to renew itself and review why it has not sufficiently succeeded in tackling some of the more rudimentary things that people expect us to tackle. Doing surveys and setting up surveillance systems for economists and planners, while important, is not necessarily going to help people in the very dire circumstances so many find themselves in today, whether in parts of Africa or the intolerable conditions found in some Latin American slums. Nutritionists must be much more involved in advocacy and planning. They must be more vocal in predicting and describing both where and why large pockets of both chronic and acute malnutrition exist. They must come up with solutions on how to tackle some of these situations and be more honest and better informed about what has worked and not worked before and why.
At the senior level, we must also, as a profession, involve ourselves more with actually managing all types of programmes and not just survey or write or do research about them. It is amazing how senior nutritionists seem to be overly concentrated in the policy and research fields. Consequently, they know too little about the management issues that are so vital to reaching the needy. For example, it was extremely disconcerting to discover, as I did in Sudan during the 1984-1986 famine and later when I was comparing responses in other countries, that we nutrition scientists, nutrition planners, and public health specialists (a) failed to predict the famine of the 1980s, (b) failed, once we knew it was inevitable, to use our professional clout to publicize it and obtain additional expertise or provide the basic help needed, and (c). once the famine was in full rage and the dying and dispossessed present in huge numbers, were unable sufficiently to train, deploy, and supervise large numbers of non-government and government volunteers, whose effectiveness could have been greatly enhanced. We somehow never learned management skills as they relate to famines and emergencies. Yet this, surely, is what people expect "nutrition" to be able to do.
Nevertheless, after the famine, now that we are in the late 1980s, we talk increasingly of setting up (and indeed, have set up) nutritional surveillance centres, groups, and task forces in selected countries of Africa (unfortunately, mainly English-speaking ones). Many of these are to monitor the so-called economic adjustment programmes set up the multilateral banks. Unfortunately, the infighting and competition among some of the foreign institutions, universities, bilaterals, and United Nations agencies concerned is causing wastage, and we are at risk once again of distorting and throwing a lot of money at a problem that in essence should function as a routine part and parcel of agriculture and health ministries. Instead of concentrating on basics, such as training and management, many nutrition scientists are now busily engaged in conducting huge surveys for these institutions. Who is going to afford the recurrent (and sometimes, capital) expenditures of maintaining sophisticated and expensive surveillance methods that rely on electronic gadgetry, expensive transport, and complicated data analysis? (This is not to speak of the salaries of hundreds of expatriate consultants determined to milk every penny from the generous, guilt-laden largess of the bigger foundations, multilateral banks, and UN bodies.)
Is it more surveys that we need?
I remember two occurrences in famine-affected Sudan that humbled me a bit. In one, a group of extremely undernourished amenorrhoeic mothers had ceased to breast-feed their infants and, worse, no longer seemed to have the energy to feed their slightly older children when we provide them with food and milk. They seemed to be in the ultimate stages of clinical depression, and many had lost all semblance of modesty and coherence. Even those of us who were seasoned workers did not know what to do to reanimate them. Once again, we did not receive that kind of training. Consequently, many of their children died and so did some of the mothers. Why had we not learned about this in school?
In another, more benign situation, in a fertile part of the country we were exhorting a group of seminomadic mothers about the benefits of eating certain vitamin- and mineral-rich leaves. A murmur went up and increased, and then one of the more outspoken mothers shouted that we were advocating they eat leaves, while we ate rich foods, bought expensive medicine, and had access to physicians when our children were sick. Why, she cried, couldn't they have the same? "Do you know," someone added, "that the best trees and bushes in any case belong to a rich landowner?" And where would the women get the water and have enough of it to irrigate any trees that they would plant on their meagre land?
This illustrates some of our failures. Are we receiving, even in the late 1980s, the right training in international nutrition? Are we doing enough to integrate agriculture, geography, and nutrition into our planning work? Do we receive, in fact, nutrition-planning training oriented to micro-systems and specific to at risk population groups? Are we, as nutrition planners and scientists, learning enough about development and distribution policies, agricultural policies, different experiences, methods and results of land reform, re-forestation, irrigation, population displacement, food subsidies, economic policies, and the like? Are we leaving too much of this to others and in the process becoming, once again, too insular? Are we too survey-, method-, or gadget-oriented?
Other priorities in training and in our work should be the use of newer, anthropology-based techniques of interviewing potential or actual beneficiaries and health nutrition workers to learn more about the origins and perception of a problem, so-called rapid assessment techniques [1]. Similarly, we are not doing enough to assist squatters and slum populations, learning about the intricacies of abandoned mothers and children, of poor working women or poor working children, all or whom are, in increasing numbers, the most nutritionally vulnerable. Indeed, if current migration and urban growth rates continue as they are, especially in Africa and to a lesser extent in India, the Philippines, Bangladesh, and Indonesia, we are going to be faced with many more millions of poor, extremely malnourished, and sick urban inhabitants. What are we doing about this in this field of nutrition?
Finally, but not exhaustively, what are the links between nutrition and the environment? What is the significance of the growing scientific evidence on the effects of atmospheric and water-borne pollutants on trace and other mineral and organic elements in the body? What does the increasing use of pesticides, food preservatives, colours, enhancers, stabilizers, artificial flavours, and so on signify in nutritional and physiological terms for the growing regions-the majority of the world's population-who are exposed to them? Why has our voice not been louder, and how many of us are working in this field? Why don't we talk more about this in the developing nations? It is not just a problem for the developed countries.
These are only some of the issues that nutrition, as both a science and an occupation, must tackle on a much broader scale.
Reference
1. Scrimshaw S., Hurtado E. Rapid assessment procedures for nutrition and primary health care. Los Angeles: UCLA Latin American Centre Publications. University of California, 1987.