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Nevin S. Scrimshaw
Abstract
The objective of infrastructure development in nutrition is to ensure that every country has institutions with the competence needed for research, training, policy guidance, and dissemination of knowledge on all aspects of human nutrition and human food supply. The rapid advances in scientific knowledge of nutritional issues has increased both the importance and the scope of responsibility of national nutrition centres. It has also increased the number of disciplines that must be represented if institutions are to tee fully capable of utilizing existing knowledge and meeting national needs. Not only must all aspects of nutrition and food science be represented but also infectious and chronic diseases, health education, data management, anthropology and sociology, economics and political science. Examples are given of the stepwise development of successful national nutrition institutions as well as problems faced in their development.
Introduction
Everyone at this congress would agree that food is a basic human right and that every country should have the institutional capacity to engage in problem-solving research, to train personnel, and to formulate policy to achieve good nutrition for all its citizens. Unfortunately at the present time most developing countries lack the human and institutional resources required. This presentation focuses on infrastructure and institution building for competence in nutrition, with special emphasis on developing countries.
To banish hunger and malnutrition as public health and social problems, and to achieve environmentally sustainable food security, countries must have the human resources to deal with every step of the food chain from production, conservation, storage, processing, and marketing to consumer education, handling of food within the home, and intrahousehold distribution. This means that institutions must have the capacity for determining agricultural and food policy, for measuring food composition and monitoring food safety, for determining dietary habits and nutritional problems, for developing locally feasible dietary guidelines, for providing effective nutrition education at all levels, and for confronting the causes of poverty, which is the root cause of most malnutrition.
Clearly, much of this goes far beyond the disciplines immediately surrounding nutrition, and requires the knowledgeable interaction of nutritionists with professionals in other fields and with almost all sectors of government. Even the core of disciplines that must be represented in a nutrition institute or department capable of dealing effectively with the wide variety of related issues poses major budgetary and training problems. It is clearly impossible for any one institution to encompass all of this expertise. The development of even a modest degree of multidisciplinary competence is a slow, cumulative process.
To ensure success, awareness of the need for a broad approach must be combined with the capacity to achieve such breadth through a combination of strategies. While one absolute requirement is to develop a staff with as broad abilities as circumstances permit, this must always be complemented to a greater or lesser degree by collaboration or co-operation with individuals in other institutions who possess necessary additional expertise.
Thus far I have briefly outlined the task in terms with which most nutritionists today agree. In order to contribute something new to understanding on this topic, I will undertake to build on personal experiences of what has and, equally important, what has not worked to achieve the stated goals. This includes examining factors involved in the development of nutrition institutes in Guatemala, Chile. Thailand, and India. In addition, comments are warranted on the United Nations University and other international agencies that have been actively promoting institutional development in food and nutrition.
UNU/SCN working group conclusions
A working group addressed to strengthening developing-country institutions concerned with food and nutrition was convened by the United Nations University and the ACC Sub-committee on Nutrition in March of 1984 [1]. It first stressed the serious lack in most emerging nations of institutions to meet the regional and national needs for training, research, and advisory services. I would add that this is also true of many industrialized countries.
The report strongly urged that international and bilateral organizations, foundations, and other donors give a high priority to promoting a variety of specified activities to accomplish this. The activities include establishing regional and national institutions, training food and nutrition professionals, promoting nutrition research by professionals in developing countries, and developing local managerial competence. These are all praiseworthy and important goals, but most international efforts directed toward achieving them have been relatively ineffective or even counterproductive.
There has been some misunderstanding of the recommendation of the working group that, in regions where countries lack strong nutrition institutions, assistance should concentrate on strengthening one or more national institutions that can serve regional research and training functions. The report also emphasized that every country should have one or more strong nutrition institutions; but, without regional institutions such as INCAP and INTA in Latin America, NIN in South Asia, INMU and NCP in South East Asia, all persons would have to be sent out of the region for advanced training. This is not only costly but also highly undesirable.
Several examples of successful building of nutrition institutions of various kinds that have regional importance provide lessons from which both positive and negative conclusions can be drawn.
Developing-country institutions with regional and global influence
Institute of Nutrition of Central America and Panama, Guatemala City. Guatemala
In February 1946 the representatives of the ministries of health of the six countries of Central America and Panama met in Guatemala City to plan the Institute of Nutrition of Central America and Panama (INCAP). The mandate they gave could not be improved on today: (1) determine the nutritional problems of the region; (2) through research, find practical solutions to these problems; and (3) assist the countries in applying these solutions through advisory services, education, and training.
There were two important organizational provisions. One was the oversight that held INCAP to its mandate through a directing council made up of the ministers of health of the six member countries or their representatives. The other was the provision that INCAP would be administered by the Pan American Health Organization (PAHO) but that INCAP's director and PAHO would be responsible to the directing council for its programme.
External assistance played an important role in the form of a three-year grant from the Kellogg Foundation of US$15,000 per year for the salary, secretary, and travel of the director, and US$50,000 for the initial purchase of laboratory equipment, supplies, books, and journals. Even more important in the long run was the offer of the Kellogg Foundation to provide one-year fellowships to four persons from each member country to be trained for INCAP: a clinician, a biochemist, a nutritionist, and an agronomist.
When I arrived in Guatemala on 1 July 1949, the walls and a galvanized-iron roof were in place for a small, one-store adobe building in the botanical garden of the national university; only dirt trenches existed where the laboratory floors were to be. Although the formal inauguration was only six weeks away, the building, consisting of three laboratories. a darkroom, a library/conference room, three offices, and a store-room, was completed in time. It was not until seven years later that the Institute moved to its present site and a more adequate building.
The annual budget for the first year was US$25,500, based on the annual quotas paid by only three member countries, plus the US$15,000 from the Kellogg Foundation. Quotas were increased to US$12,500 the next year, and Nicaragua and Costa Rica began paying quotas. Panama ratified the agreement in 1951. Even in its first year, however, INCAP had begun to receive the outside funds in support of research that enabled it to become a leading international research and training centre despite a core budget that was always limited in comparison with the need and opportunity.
The factors most responsible for INCAP's early success were the quality, dedication, spirit, and hard work of the initial group of its professionals. This was achieved by a process similar to that of the great research universities and institutions of the industrialized countries: rigorous self-selection and peer judgement. The initial staff members were all Central Americans who had received some advanced training outside of Central America and who were searching for a way of using it in a satisfying way in their own region. To this group were added some of the finest students from Central American universities, who came to do their undergraduate or medical-school thesis research, and local physicians who wanted to be involved in research.
Of the former, most benefited and returned to their countries. A small number were sufficiently promising that arrangements were made for their graduate study outside Latin America until INCAP developed its own master's degree programme. Several of these, both physicians and non-physicians, ultimately joined the INCAP staff. Physicians who asked to collaborate in research with INCAP were always welcome, but most were not willing to accept the time and discipline the work required. Of those who did accept and begin research, only a few continued and completed a project, but these few made outstanding contributions and some joined the part-time or full-time staff.
It should also be mentioned that, during this early phase, an active and dedicated scientific advisory committee made an important contribution to INCAP's success. It met for a full week every year and reviewed every programme and activity in detail. Its reports helped to focus the programme on major issues, to explain the value of INCAP's research to the directing council and to PAHO, and to give it greater credibility in its approaches to outside sources of funds. It also helped to maintain high scientific quality of research.
The traditions of a weekly staff meeting for everyone and a weekly journal club were established in the first year. The professionals soon began meeting one evening a week in rotation at different homes to present new projects for comment and criticism and to keep everyone informed of research results. It was also expected that these results would be published promptly. INCAP's publication list [2] shows 198 scientific publications in Spanish and 137 in English and other languages in the first ten years.
The first decade was an exciting time for everyone involved in INCAP. The major emphasis was on field studies. The first nutrition surveys established that the major problems of the region at the time were protein-energy deficiency, endemic goitre, nutritional anaemia, and vitamin-A deficiency. Dietary surveys were completed in all the countries and a food composition table for Central America and Panama was published. Moisés Behar and Marcel Autret of FAO produced the first report on kwashiorkor outside Africa.
A popular weekly magazine of the time, reporting on INCAP's early studies with kwashiorkor, stated: "Most important is the development of a protein-rich cereal-based mixture known as INCAP Vegetable Mixture No. 8. . . more nutritious than milk . . . and much less expensive" [3]. This, of course, was the precursor of Incaparina, which is still useful in Guatemala and which inspired similar cereal-based weaning-food mixtures in many other countries.
Endemic goitre, with associated sporadic cases of cretinism, was identified as a significant public health problem in the region. In Europe and North America the condition had been eliminated by the iodization of salt. However, the compound used, potassium iodide, was hygroscopic and could be used only with dry, refined salt packaged to protect it from moisture. INCAP demonstrated in schoolchildren in El Salvador and Guatemala that the iodine in potassium iodate was stable in moist salt and was equally available when ingested. This made possible the iodine fortification of the crude, moist salt of the region without special packaging, and the method was soon applied in developing countries around the world. It was also the INCAP field observations of this period that called attention to the synergistic nature of the interactions of nutrition and infection, and that led to a WHO monograph on that subject [4].
It is worth noting that none of this work was done by expatriates sent in to do studies while local people were being trained. From the beginning, all of the staff, with the exception of the director, were Central Americans who took responsibility for tackling their own regional problems. Short-term advisers from other countries did play a helpful role, but they were selected by INCAP and were responsible to an INCAP professional staff member, not the other way around. In several cases where long-term consultants were selected for INCAP by an international agency, the individuals proved to be a waste of time and facilities. Except for the initial director, no other expatriate was given any administrative authority until the directorship was turned over to a Guatemalan, Moisés Behar. The first non-Central Americans he appointed were from Mexico and Spain.
Another key to success was that external support for research was for INCAP-designed projects to meet perceived Central American needs. Too often local institutions in developing countries are asked to use their scarce resources and best personnel for projects designed by others without taking into sufficient account their desirability for these institutions. Moreover, this often leads to someone from the sponsoring agency being sent in to direct or co-ordinate the project instead of trusting this role to local staff.
Two factors protected INCAP from this kind of exploitation and misdirection. First, every project was submitted to internal staff review and to the technical advisory committee. Second, the ministers of health or their representatives had to be convinced that the project was in their countries" interests. Like other successful institutions in emerging nations, INCAP learned early to maintain its control and authority over externally sponsored projects, or to refuse them entirely.
Offers of external support for specific projects were accepted only if INCAP considered them desirable and if INCAP staff had full responsibility for their execution. An example of an external offer that was accepted was one from the Soybean Research Council for a comparison of the efficacy of animal- and vegetable-protein-based supplements. It was accepted even though soybeans are not grown in Central America because a number of other local vegetable protein sources were available if it could be demonstrated that protein of vegetable origin could be equivalent in value to animal protein. Today such a demonstration seems unnecessary, but one prominent member of the advisory committee at the time insisted that some animal protein was necessary in any supplementary feeding programme or weaning food.
National Institute of Nutrition, Hyderabad, India
I cannot give a similar account of the early days of the successful development of the National Institute of Nutrition (NIN) in India, which was established thirty years earlier than INCAP, but there are parallels. Although its first directors were Englishmen under colonial rule, with Indian independence it became a wholly Indian enterprise, with P. S. Patwardhan as director. It began in humble quarters in Conoor and only later moved to its present impressive structure in Hyderabad. From the beginning, its Indian directors were strongly resistant to projects designed or managed by foreign donors. Research publications and regional training programmes were early responsible for much of the reputation of both NIN and INCAP and for the widespread influence that they have had in their regions.
NIN began with an outstanding group of Indian professionals, many of them with advanced training outside their country. Like the initial INCAP group, many have international reputations today. The second director of NIN, Patwardhan, preceded the second director of INCAP, Behar, as head of the nutrition unit of WHO. For fourteen years the third director of NIN was C. Gopalan, former president of the IUNS, who received the IUNS award at this congress.
Institute of Nutrition and Food Technology, Santiago, Chile
Soon after INCAP, the Institute of Nutrition and Food Technology (INTA) was established at the University of Chile by Fernando Monckeberg, who assembled a remarkable group of young Chilean professionals. Some already had advanced training outside Chile, and others were sent for such training as soon as possible. INTA was multidisciplinary, and the professionals were given responsibility for programme development and execution. From the beginning, the Chilean director and staff maintained high standards of scientific excellence and autonomy. Soon INTA became an important and influential regional training centre and a leader in research oriented to national problems.
Institute of Nutrition, Mahidol University, Bangkok, Thailand
The development of the Institute of Nutrition at Mahidol University (INMU) in Bangkok began with the institutional development programme of the Rockefeller Foundation. In the 1950s the foundation set about to create an outstanding new medical research and training centre within what was already a leading university in Thailand. Its primary means of doing so was to provide fellowships for the advanced training of staff for new faculties of medicine and of basic medical sciences. Aree Valyasevi, who had received training with the famous paediatrician-nutritionist Paul Gyorgy, and had spent six months with INCAP, became chief of the new Department of paediatrics and later dean of the Faculty of Medicine. He immediately initiated an active nutrition research programme and embarked on the same kind of staff development that had characterized INCAP, NIN. and INTA. Initially some were trained with Rockefeller Foundation support, and the United Nations University later provided additional fellowships in key disciplines. In a few years Valyasevi was able to establish an Institute of Nutrition within the medical faculty that last year moved to a building of its own.
The professionals selected for training were excellent, a tribute to Dr. Valyasevi. INMU now not only is meeting Thailand's needs in clinical and public health nutrition but is also an outstanding regional research and training centre. While it has not developed expertise in the social sciences or in food science' its co-operative relationships for the former with Thammasat University and the latter with Kasetsart University have compensated. It is noteworthy that Thammasat University received extensive support from the Rockefeller Foundation to strengthen its competence in the social sciences and Kasetsart University was helped by the foundation in the agricultural sciences. At this congress Dr. Valyasevi received the prestigious McCollum Award and became president-elect of the IUNS.
Experience in industrialized countries
Considering the difficulties in finding appropriate advanced, multi-disciplinary staff in developing countries compared with industrialized ones, it is often assumed that it is easier and quicker or involves different principles to develop a strong nutrition department or institution in the latter. When I left INCAP in 1961 to set up a broad, multidisciplinary Department of Nutrition and Food Science at the Massachusetts Institute of Technology (MIT) in the United States, I found that this was not true. It took several years to identify and gradually build up an outstanding staff even under what seemed to be optimum conditions. There was the same value in presenting all programmes annually to an external advisory committee. as well as the same need to develop a mechanism for promoting internal scientific communication and internal critical discussion of new and continuing projects and to establish a sense of overall mission.
It soon became evident that even in an outstanding department in a famous university, collegial interaction is critical to maintaining quality, particularly in graduate education. We found that a graduate student working with a single professor sometimes came to defend his or her doctoral thesis before a faculty committee with work that could not be accepted. At this stage, deficiencies in the experimental design and execution are likely to be largely the fault of the thesis adviser, not of the student. An inadequate doctoral thesis that must be in large part the fault of the adviser can also be an embarrassing problem for anyone who consents to be an external thesis referee by correspondence, particularly when that person has been selected by the thesis adviser.
The solution at MIT was to appoint a thesis committee early and require that the thesis proposal be submitted to it for defense and approval. Later, when both candidate and adviser believed that progress was sufficient to justify entering the final writing stage, the project was submitted to the committee to determine whether they agreed. The adviser participated ex officio as an advocate for the candidate but not as a voting member. The procedure proved wholly effective, and it is strongly recommended to other institutions.
I have gone into this detail to emphasize that a common weakness of many institutions in both developing and industrialized countries is that individual scientists zealously guard their work from critical review by their own colleagues. When and if that work is submitted for publication, it can be an embarrassment to both the investigator and the institution if it is rejected or receives harsh external criticism. Internal review is a method of quality control that can have profoundly beneficial consequences for the effectiveness of individuals and institutions. An external advisory committee that periodically reviews all research is also highly desirable.
Institutional and administrative structure
Perhaps the first lesson from a review of successful institutions is that no single organizational structure assures success or avoids failure. I have reviewed successful nutrition institutions that are multi-governmental, national, ministerial, local, and university multi-departmental and departmental. However, the administrative structure must not only facilitate programme development but also provide the opportunity to recruit the personnel required and to obtain additional funds beyond whatever core budget is provided.
Some institutions are free-standing, with some kind of a board or council that meets at least once a year; others must conform to the administrative structure and regulations of a university. One type seems to be as likely to succeed as the other.
Nutrition departments, sections, or units within the regular structure of a ministry often have dedicated personnel and make valuable contributions, but they have difficulty providing a full range of research and training as well as advisory services. One reason for this is the problem of achieving the critical mass of staff and the necessary representation of disciplines. Another is that the unit is captive to the severe budgetary constraints that characterize virtually all ministries of health, and to the difficulties of requesting and receiving supplementary funds from other sources occasioned by the constraints of a government bureaucracy.
The necessity of wall-trained and motivated personnel
It should be clear from the examples that what makes for successful institutions is an ability to develop a core group of well-trained professionals who have high morale and who work with dedication because they have the support, leadership, and freedom to make good use of their training. The physical quarters may be old and overcrowded, but if these individuals have a sense of their work being valuable and useful and the opportunity for pride of achievement, the physical inadequacies are somehow overcome. A fine and well-equipped building without this kind of staff has repeatedly proved to be useless in contributing to the solution of a country's problems.
The leadership issue
It would be foolish to say that such an environment can exist without enlightened leadership, but a leader without competent staff goes nowhere. Moreover, a good staff can sustain an institution through changes of leadership, or even compensate for a weak director. It is evident that several leadership styles can be successful if an institution is able to acquire a well trained and motivated staff.
The concept of a strong leader carries with it the picture of one who generates ideas and projects, raises money, and assumes primary responsibility for decision making. While this kind of leadership is sometimes effective, it usually makes the institution vulnerable when the individual ends. It is also less likely to be broadly innovative. More likely to be successful is the person who shares innovation, project development, and decision-making functions with senior staff. Such collegial leadership survives changes better and is conducive to a high morale. It cannot work well without the right professional staff, but neither can any other kind of leadership.
The selection and training of personnel
Without doubt the most difficult tasks facing any effort at institution building are the selection and further training of personnel. Few institutions have the luxury of hiring only those with established records, and exclusive reliance on such people, even if it were possible, is a poor way to build an institution. The influence of young professionals is essential, as they often provide some of the most innovative approaches and dedicated work. However, an absolute requirement for excellence is that they either demonstrate these characteristics or leave to make room for some other young professional.
In the beginning, INCAP carried this to an extreme because no established professionals were available, and so it gave an opportunity to all promising young people requesting it. It was not difficult at the end of thesis research, or at the end of a six- to twelve-month research appointment, to allow individuals to return to their countries with enhanced experience and prestige. When professionals who were competent and hard-working without being sufficiently productive stayed with INCAP for several years and became well liked by the other professionals. however, it was very difficult but necessary to have them leave to make room for others. Elite universities confront similar distressing problems in the necessity of denying tenure to persons who are very good but do not quite meet their high standards. The problem is even worse when professionals do meet the high standards but more faculty have been recruited than can be promoted. One of the reasons that government institutions often have such a hard time achieving excellence is the difficulty of discharging anyone who is on a government payroll.
Despite such difficulties, any institution striving for excellence must find a fair way of giving young professionals opportunities that will enhance their careers without being obliged to appoint them permanently to the staff.
International assistance to institutions in developing countries
The UNU institutional-development programme
The United Nations University (UNU) was established in 1975 with the mandate of helping to solve pressing global problems of human survival and welfare through the instruments of scholarship, research, advanced training, and the dissemination of knowledge. World hunger was identified as one of these problems.
Fellowship programme
The UNU's advanced-training programme was modelled after the Kellogg Foundation's institution building programme in Latin America from which INCAP benefited so crucially, and to some extent on the institutional development programme of the Rockefeller Foundation, which had been responsible for setting up highly successful institutions in a number of countries. Moreover, the UNU fellowship programme was established by persons who had personally been responsible for developing wholly indigenous nutrition units or institutions in Africa, Latin America, and Asia.
The principles of the fellowship programme were simple. First, the objective was to build and strengthen institutions in developing countries. Of course, prospective fellows had to have good records and make good impressions in personal interviews in their own institutions. Site visits also had to establish that the candidates (1) were part of the staff-development plan of an institution that was making a significant nutrition contribution in the country, (2) had the training that was really required by the institution, and (3) would be able to use that training when they returned to their own country.
Second, an effort was made to provide the training that would be most beneficial to the individuals and their institutions. The objective was to ensure education and practice that met their needs and not force them to adapt to inappropriate programmes. A strong effort was made to recognize and develop good training sites within developing countries. It is for this reason that a significant part of the education of UNU fellows has taken place in associated institutions in Chile, Guatemala, India, the Philippines, and Thailand.
The programme was designed so that this training would not be a further drain on limited resources. Initially, the practice was to provide the equivalent of the salary of a senior professional for every four to six fellows accepted for nine to twelve months of training. Later the formula was changed to reimburse the institution an amount equal to the per diem rate established by the United Nations Development Programme, but the principle remained the same.
It was clear that it would be a disservice to force fellows to go to institutions that were not prepared to cope with their special requirements, or to deprive them of the most advanced training available when this was what they needed. Accordingly, associations were also established with a number of institutions in industrialized countries that were able and willing to provide training adapted to the fellows' needs. By 1987 more than 500 professionals in developing countries had received UNU fellowships in nutrition and food science and related disciplines in accordance with these principles, almost all for one to two years.
Although the maximum duration of a UNU fellowship was set at two years, more than 100 fellows managed to remain longer to obtain doctoral degrees because their performance was good enough that either their own institution or the host institution extended their fellowships or another organization was found that was willing to do so. Perhaps the most remarkable characteristic of the UNU programme is that, almost without exception, fellows returned to their own countries or, in a few cases where political change had occurred at home, moved to other countries in their region.
Unfortunately, the rise in the Japanese yen has doubled the UNU's dollar costs in Tokyo. This, combined with a reduced fixed-dollar income because of lower interest rates, has forced severe curtailment of the fellowship programme.
Research support
Research support was also considered an important mechanism for institutional development. Research proposals were initiated by institutions in developing countries and judged by peer review, supplemented by site visits. These visits often provided evidence that an inadequately presented proposal could still be well carried out, or made it possible to work out a more acceptable proposal.
With research support focused on a few specific areas, workshops could be held on topics in these areas, giving investigators a chance to present and discuss their findings with their peers and publish them in the proceedings of the workshops as well as in scientific journals. Support for institutions to organize workshops and short courses was another means of institution building used by the UNU.
Other international assistance
World Health Organization research grants contribute to institution building, but they are limited in number and amount. They are administered in a helpful manner, however, in response to research requests from institutions in predetermined priority areas. While useful, the WHO's fellowships are also few and usually of short duration.
UNICEF has no centralized system of institutional support in nutrition, but the individual UNICEF country missions have wide authority to back such research activities of local institutions. Country missions also often sponsor participation in workshops and conferences.
Unfortunately, in recent years the FAO has not had significant funds to help finance research and training in food and nutrition.
The World Bank has made a significant contribution to training, equipment, and research for nutrition institutions of the Ministry of Health in Indonesia, but this is an exception.
Of the bilateral agencies, the Canadian International Development Agency works in a manner most closely resembling that of the UNU and WHO. It provides research grants in response to the requests and needs of the institutions, usually with the guidance of site visits, and leaves full responsibility for execution with the institutions. Many foundations also more or less follow this pattern. Unfortunately, some bilateral and private industrial assistance is offered in ways that are not in the best interests of the institutions and should not be accepted.
Mistakes to avoid in institution building
Human resources are bound to be a constraint in establishing any institution, particularly in an emerging nation. I have concluded that, no matter how well intentioned, overcoming this limitation temporarily by providing outside experts to take responsibility for research sponsored by local institutions is usually counterproductive. Short-term advisers and consultants can be extremely helpful, however. In general, it is a mistake for institutions to tackle research that they are not capable of handling because of lack of suitable personnel.
Many bilateral agencies prefer to send in one of their own nationals to direct a project because this gives them tighter control and they believe it reduces the risk of being unsuccessful. Sometimes donors are more interested in securing a place for their own nationals to gain experience than they are in developing local personnel and institutions. This may be quite acceptable if the institution is sufficiently compensated and if the foreign staff come expressly to learn rather than to direct in situations where they are less qualified for the purpose than available local professionals.
A common pattern is to arrange for a local counterpart to the long-term consultant. In theory, the counterpart acquires added skills and can take over when the expatriate leaves. Even when the consultant is a good one, however, which is not always the case, too often this relationship works out in practice with the counterpart's becoming more a servant than a potential equal. When the project ends, the counterpart has gained little and receives no continuing support. Outside consultants who continue to do the work themselves and do not allow local professionals to take responsibility do not help the development of an institution and often inhibit it. The only appropriate institution-building assistance for developing countries is that which encourages independence and sustainability, not dependence and short-term results.
Far too often the donors do not understand the problems of building an institution under the conditions of a developing country and thus fail to provide assistance in the ways that would be most helpful. Their lack of understanding often leads them to demand too much or to expect gratitude for offers that are really burdens. During the development of INCAP, one major United States institution proposed paying travel and living expenses so that a group of graduate students could take a summer course in nutrition, but it was unwilling to pay tuition. Its programme head simply did not understand that the training expected was an impossible burden to superimpose on an already overworked staff without funds to pay additional personnel.
It may also be a mistake for foreign assistance to concentrate on a single institution in a developing country. I spoke earlier of the difficulty of developing strong research and training within a single ministry, and suggested that a university setting may be more appropriate for these functions. It is important to have a strong institution for nutrition research and training, but it is equally important to have, in addition, a nutrition unit in the ministry of health that is strong enough to use the research findings and take advantage of the staff and advisory services of the research and training institution.
Even with the best of intentions, international sponsorship of workshops and conferences in developing countries intended for local institution building is often of limited influence because, in the interests of a publishable report to justify the expenditure, the workshops end up involving little true local participation and might as easily be held anywhere.
Sometimes, as director of INCAP, I felt frustrated because it was so much easier to obtain support for activities that donor agencies considered important than for those that the INCAP staff knew to be important. This is still a problem in developing countries. In addition, fads and fashions in international support leave many urgent priorities orphans. Once again, part of the problem is paternalism and unwillingness to listen to the judgments of the professionals in the developing countries. Fortunately, some agencies do listen.
Summary and conclusions
It is important for every country to have institutions that provide the competence for research, advanced training, and advisory services in nutrition. Only a country's own institutions are likely to have the requisite influence and authority to promote nutritional goals and dietary guidelines for the health of the population and to advise the government on related policy.
Building these institutions requires a combination of adequately trained personnel, good leadership, and some physical and financial resources. Most important is the training and support of professional staff. Hence, external assistance can help most by providing the needed education and experience to personnel in the variety of disciplines required, and by offering money for research projects and pilot studies in ways that give the primary programme responsibility to the local institution. External assistance can do more harm than good if it perpetuates dependency or distorts programmes in the interests of the donor rather than the institution.
There is no one best type of institution or best division of disciplinary responsibility among institutions in a country. Programme development and application should generally be jobs for a government unit, but research and training flourish best in a university setting or in a government institution with some degree of autonomy from official ministries. Collegial responsibility of senior professionals for programme quality and an external advisory committee contribute significantly to research success. These principles apply to institutions in both developing and industrialized countries.
The fellowship and research programmes of the United Nations University, and the research support provided by the WHO, UNICEF, the Canadian International Development Agency, and some foundations are examples of the kinds of external help that have proved particularly valuable in advancing the institutions that are attempting to improve nutrition in developing nations. As in many other critical areas, however, the establishment, maintenance, and improvement of these institutions relevant to food and nutrition depend on national commitment.
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