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Conference report - Ending hidden hunger: A policy conference on micronutrient malnutrition
Ellen Messer
A joint WHO-UNICEF initiative to eliminate micronutrient disorders was launched with the support of a conference on micronutrient malnutrition with the theme "Ending Hidden Hunger," held in Montreal, Canada, 10-12 October 1991, involving approximately 300 policy makers, ministry of health personnel from less developed countries (LDCs), and scientists. The conference was aimed at the "summit"—to build political support at the highest levels for ending hidden hunger, particularly mild to moderate deficiencies in vitamin A, iodine, and iron that ordinarily are not manifested as symptoms of outright disease and disability but that contribute to the levels of morbidity, mortality, and dysfunction of peoples and individuals worldwide.
The Honorable Monique Landry, Minister for External Relations and International Development in the Canadian International Development Agency (CIDA), set the tone for the donors at the opening reception/dinner by announcing CIDA's commitment of major additional funding to UNICEF's ongoing immunization campaign.
At the beginning and end of the conference Dr. Hiroshi Nakajima, Director-General of the World Health Organization, and James P. Grant, Executive Director of the United Nations Children's Fund (UNICEF), shared the podium to indicate the joint-ness of the initiative among UN agencies to address micronutrient problems. During the conference, participants had the opportunity of viewing the cutting edge of knowledge (assessment, analysis, and action) and plans to develop common approaches to common problems and. where possible, joint activities among LDCs, scientific institutes, and donor agencies. Workshops on the second morning provided LDC participants the opportunity of focusing on demands they might make on the donors. Concurrently, the donors met to discuss what resources they might supply.
The products of the meeting were (1) an increased visibility of the problem of "hidden hunger" arising from micronutrient deficiencies and promising interventions to overcome them among donor agencies and LDC government ministries; (2) a formal commitment of resources on the part of the two major sponsoring UN system agencies—WHO and UNICEF—and, less visibly, other donors to make ending vitamin A, iodine, and iron deficiencies their next major public health priority and to cooperate on ending micronutrient disorders; and (3) linkage among the three micronutrient deficiencies to treat them as a common policy agenda rather than as three competing agendas.
Highlights
Dr. Ramalingaswami skilfully presented the challenges of linkage—of the micronutrients to each other, of micronutrients to various ministerial policies and programmes in public health as well as outside of it, and of international donors to national programmes and social processes and programmes outside of government or closer to the community level of participation. Three successful country case studies—on Indonesia, Tanzania, and Ecuador—were presented, and Dr. Lincoln Chen masterfully summarized the consensus on the problems and approaches.
These highlights were supported by detailed accounts of the current state of the art in food-based approaches, including fortification and supplementation, and of assessment, analysis, and action activities in vitamin A, iodine, and iron, plus detailed discussion of individual LDC situations in three-hour workshops held on the second day of the meeting.
Consensus emerged around approaches to programmes where donors might best contribute their resources. These were training (human resources); the development and delivery of low-cost, simple tools to monitor the micronutrient status of human beings and also of the vehicles, especially iodized salt, for delivering micronutrients; the promotion of cross-sectoral programmes (e.g., in health, education, community development) that might provide sustainable micronutrient sufficiency; and, finally, summit-level policy that would encourage LDC governments to put resources into ending hidden hunger. UNICEF, USAID, and perhaps other donors already have committed substantial investment to training programmes in micronutrient assessment, analysis, and action planning.
The early success of these efforts was visible in the country reports, where carefully thought-out approaches to raising consciousness about micronutrient deficiencies at all levels, plus preliminary action plans on delivering vitamin A, iodine, and iron, are already being set in place. In addition to the three case studies presented at plenary sessions, case studies from Zimbabwe and Thailand were noteworthy examples of the fruits of these early efforts in training. Central training in methods also brings LDC personnel in touch with experts, policy makers, and field workers in other nations, networks with whom they should be able to interact to raise and solve problems in the future. At present, most training takes place in the setting of the United States and other industrialized nations, but in some cases LDC settings are ready to take on training responsibilities.
Such country-to-country LDC cooperation is under way or envisioned for South-East Asia (Thailand and Indonesia, and perhaps also the Philippines, are taking the lead in offering the expertise in training or experiences to Myanmar, Cambodia, Vietnam, and other areas). Tanzania is trying to share experiences of its successful efforts with other African nations. Latin American nations. sharing language, cultural and historical backgrounds, and to some extent common public health problems and structures, are trying to bolster regional approaches to solving micronutrient problems as well as other public health problems they hold in common.
In addition, LDC representatives requested low-cost technologies that are simple to produce and use for assessing micronutrient problems and delivering solutions. These also appeared to be under way, at least in iodine and vitamin A evaluations.
Most participants agreed that the focus of micronutrient programmes should be on women, particularly those of reproductive age. Women's micronutrient deficiencies during preconception, pregnancy and lactation, and child-rearing years impact on the micronutrient status of their children in all respects. Therefore, providing women with supplements of iodine, vitamin A, and iron should be a focus of primary health care/family planning programmes. Efforts to improve their nutrient intake levels through broader based programmes on income generation and dietary diversification are also in order.
Mothers should be involved at all stages in defining problems, designing solutions, and evaluating whether programmes are doing any good. All of this may be more rhetoric than reality, however, as there was no plenary discussion of how to link programmes to mothers, or the summit to the grassroots, beyond statements at the outset and end that this is both desirable and necessary (Ramalingaswami's opening challenges and Lincoln Chen's summary) and will involve the linkage of UN, national, NGO, and private-sector efforts.
Dissension continues around issues of short-term and long-term strategies, which often translate into the relative weight given to medical-based versus food-based approaches to delivering micronutrients. In addition, participants expressed concern that focusing on hidden hunger might detract from devoting resources to and maintaining the visibility of visible hunger, namely protein-energy malnutrition, and that the focus on delivering micronutrients underemphasized "stopping the leakage" of micronutrients through parasite control, especially deworming.
While substantial time was devoted to pressing for interministry and interagency cooperation and collaboration on micronutrients, LDC representatives came mainly from health ministries, and there was some concern that the addition of micronutrients to the primary health care delivery system might overwhelm it. This meeting was aimed at top-level health agencies and to some extent related ministries; but some worried in addition that all the attention was given to the supply of services, and no presentations discussed the problems of creating the community demand for programmes.
A final issue is whether it will be possible to create cross-linked programmes in micronutrients that do not compete with each other for funds. Certainly it should be possible to dovetail delivery systems for supplements and, to some extent, to consider dietary diversification issues and food-based delivery systems in common, at least for iron and vitamin A. Synergisms should also be apparent and built into the beneficial effects of programmes. It is still the case, however. that iodine, iron, and vitamin A programmes are different and demand different strategies and that all need resources. While funders can encourage collaboration and cooperation through innovative funding programmes that demand cross-nutrient collaboration and cross-ministry or ministry-private sector-community-NGO) approaches to dietary problems, there will still be competition.
This conference raised significant promise of interagency and intersectoral collaborations, and discussed what such cooperation rather than competition can achieve. It also raised questions of how far the rhetoric goes toward actualization and saving lives. Alliteration was the order of the day, as summarized by Lincoln Chen's three P's (promise, policy, progress) and three A's (assessment, analysis, action). The overall agenda of the meeting was to make hidden hunger visible.
The concluding comment of the meeting was that usually things have to be seen to be believed, but, relative to perceiving micronutrient deficiencies as a major problem affecting one-fifth of the global population and forging a new global alliance for overcoming them, "some things have to be believed to be seen." Before too long, we will have the opportunity to evaluate whether WHO and UNICEF leaders, with their agencies and partnerships, are able to do things with words and use micronutrients as an entry point to creating a healthier diet and better health for all by the year 2000 by creating synergisms among efforts at all levels.