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Kalyan Bagchi
Health and nutrition are complementary. While nutrition is recognized as a vital component of health, the latter is an ultimate objective of nutrition. With the widespread prevalence of malnutrition in a given country, no health-care strategy will ever reach the goal of "Health for All" by the year 2000, until and unless nutrition measures are made an important component of health strategy. Similarly, without a sound health-care strategy, nutrition measures, however well conceived and executed, will have very marginal impact.
Though there is a growing realization of the importance of health among the nutrition strategists, unfortunately, there is no corresponding appreciation of the importance of nutrition for health strategy. Nutrition is a classical example of a back-bencher among the health sector programmes for several reasons. Fortunately, there is now more dialogue between those responsible for health planning and for nutrition. The efforts to develop nutrition strategy within the framework of primary health care to research the goal of "Health for All" by the year 2000 by the countries of South-East Asia is an excellent example of the appreciation of the close linkage between nutrition and health.
The appreciation of this interaction between nutrition and health has been facilitated by a number of facts. On the one hand, the nutrition planners and programmes became disenchanted with the marginal impact of most nutrition measures, which was explained by several reasons, the two important being the inability of nutrition programmes to reach areas where they are needed most, and the unrealistic inappropriate approach of un-integrated "vertical" programmes. Rational health strategists recognized the health and social implications of malnutrition, and the possibility of having high "health dividends, " if nutrition measures were incorporated. Maternal nutrition and improved birth weight, nutrition and immuno-competence, and several other functional aspects of nutrition are directly related to health programmes.
At the operational level, the question arises as to whether these have produced any significant improvement in the planning and implementation of nutrition and health programmes.
It is surprising that, though health and nutrition are complementary and so closely interlinked, the programmes in these two sectors have gone almost on parallel tracks for a very long time. Nutrition has made ceaseless efforts to establish its own identity within the health sector, and health planners did not make much effort to utilize nutrition for health promotion. While human nutrition is recognized as a vital component of health, the latter is the ultimate objective of nutrition. There is general agreement that, without appropriate measures for maintenance and promotion of nutrition, no amount of classical health measures would be effective in ensuring total health. Similarly, in a given country with widespread prevalence of malnutrition, no amount of health planning and health-care strategy will ever reach the ultimate objective. On the other hand, without a sound health-care strategy that includes an appropriate health-care delivery system, nutrition measures, however well-conceived and executed, will have very little chance to go out to those who need them most.
It is interesting to recall that human nutrition promotion through health services, or public health nutrition as it is often designated now, never received priority or was it given even importance among the health sector programmes. In fact, nutrition is a classical example of a back-bencher among various programmes of the health sector for several reasons. Firstly, nutrition means different things to different people. Garry (1953) rightly said that ". . . it is wise to regard it as a meeting-place of the sciences rather than a single scientific discipline." There is real difficulty at present in defining in any precise way what constitutes the field of endeavour in nutrition, let alone priorities within it, for there is a nutrition component in virtually every branch of biology and medicine (Blaxter 1979). It is no wonder that in the past, and even now, nutrition is hardly understood by health administrators, even those at a crucial decision-making level. For a long time, malnutrition was equated with food shortage, and the solution invariably proposed was to produce more food. Thus, when allotting resources in the health sector for various programmes, the tendency was to refer any request for funds for nutrition to other sectors, since control of malnutrition was considered to have had something to do with food and agriculture. The general attitude could be summed up in a sentence: let enough food be produced and malnutrition will automatically disappear.
There is another important reason why nutrition never got recognition as a priority programme of the health sector, even though the dangers of malnutrition were constantly being cited. While communicable diseases and epidemics immediately drew public attention and forced the hands of the health administrators in allotting priorities and resources, malnutrition with its creeping effects hardly attracted any notice. Moreover, even the large number of deaths in children as a result of malnutrition was always regarded as due to communicable diseases with which they frequently were afflicted with little realization that malnutrition reduces the power of resistance of the victims and leads to infectious disease. malnutrition hardly receives mention as a cause of child mortality in death records. The Inter-American Mortality Studies in Latin American Countries provides conclusive evidence that in these countries more than 60 per cent of all deaths in children under six years of age is caused by malnutrition directly or indirectly, though the immediate cause of death was infectious disease. Though the study was conducted in the Latin American countries, the result is no doubt equally applicable elsewhere in the developing world. Thus, the creeping nature of malnutrition and its masked effects led to failure to recognize that malnutrition is an important cause of morbidity and mortality. While other health programmes were always accepted as part of the total health strategy, nutrition programmes in the health sector remained foreign. Even when resources for nutrition were to be allocated, for some reason or other no one at the highest level was ever clear as to what was expected of it.
Ironically, the health sector in many developing countries is even now not very clear as to its precise role. In 1977, the World Health Organization (WHO) organized a technical session on nutrition during the World Health Assembly. In the course of the preparation of a background document for this occasion, the WHO sent out a carefully prepared questionnaire to the health ministries of Member States in order to get as much information as possible. When the completed questionnaires were returned, it was clear from the responses that nutrition meant different things to the health sectors of different countries. The approaches adopted differed widely according to what each country thought nutrition should do. This example is being given not as criticism, but because it shows that possibly national nutritionists even now are not very successful in making health administrators aware of the precise role of the health sector in the promotion of nutrition or the prevention of malnutrition.
I would even venture to state that this is apparent not only in the national health administration but in international organizations as well. Take the example of the World Health Organization itself. In 1980/81, it allocated only 1.01 per cent of its regular budget for nutrition despite its official declaration that malnutrition is a priority health problem in the developing world. In contrast, the total budget provision of the Food and Agriculture Organization (FAO) for nutrition in the Food Policy and Nutrition Division came to 2.83 per cent. This is reflected even in the status given to nutrition: WHO headquarters recognizes nutrition as a small unit in the Family Health Division, whereas in the FAO, nutrition along with food policy have the status of a full division.
National health programmes rarely have any nutritional component; nutritional programmes in the health services were developed and implemented as "vertical" programmes, and rarely had any links with other health programmes. During the 1950s many developing countries were formulating various types of nutrition programmes but these were always implemented as isolated activities, with very little dialogue with other programme areas. Instances were not rare when nutrition programmes and maternal and child health programmes in the health sector of a country ran almost on parallel lines, hardly ever converging.
A review of past performance reveals the following categories of national nutrition activities (Bagchi 1979):
Of these four activities, nutrition surveys can be regarded as the most important. On theoretical considerations, such surveys designed for situation analysis are indeed a basic activity. However, in the majority of cases, such surveys were not followed by action programmes. In other words, the surveys were not planned and executed to obtain data on which programmes could be built, but in fact were continued year after year as an isolated activity. Often the data were not fully analysed and interpreted.
Quite often, the sites for such surveys were selected on the basis of easy accessibility, and not with the objective of obtaining a representative picture of malnutrition. Even in one single country, methods for nutritional assessment varied from one region to another, posing difficulties in a uniform national diagnosis.
Supplementary feeding programmes and distribution of nutrient supplements are two examples of ad hoc activity, designed not for combating a problem, but basically to "do something in nutrition with donated materials." During the 1960s, national health sectors used to receive liberal amounts of milk powder from external agencies, especially UNICEF and CARE, to combat "protein malnutrition," which was then recognized as a problem of great dimensions for which milk was recognized as a definite solution. Distribution of this commodity, of course, was entrusted to hospitals and health centres and, most often, the commodity used to find itself on the "black market" in urban and peri-urban areas.
The population in the peripheral rural areas, who were in greatest need of any form of food supplement, never received any. It is ironic that, even in spite of a radical change in the concept of combating protein-calorie malnutrition, such feeding programmes continued in many countries as an important nutrition activity of the health sector. Distribution of nutrient supplements like vitamin tablets were in fact "misused" because in many cases such tablets were, and are even now, distributed indiscriminately for any form of illness in children and mothers. Frequently, this created an erroneous impression that these nutrients were more important than the consumption of an adequate diet in both quality and quantity. Evaluation of these activities was based on "number of beneficiaries," "weight of milk powder distribution in a month," or "number of vitamin A and D capsules, etc., distributed in a given period. "
Nutrition education is perhaps the most widely used measure in the health sector, with the intention of producing changes in food consumption practices for nutrition improvement. The method, by and large, is by person-to-person or group communication. There are several possible reasons why nutrition education was so commonly adopted by the health services:
In spite of the obvious advantages of the health sector, nutrition education activity was rarely taken seriously as an important task and, in most instances, was included as a routine low-priority activity conducted in a perfunctory manner. While clinical work was always supervised, nutrition education hardly ever was. It is little wonder that nutrition education as a health sector activity had very little impact on the nutritional situation.
There is clearly a need for rationalizing this activity through the health-care system (Bagchi 1977).
There is now a rapidly growing realization both among nutritionists and health administrators that there should be a closer dialogue between them. Public health nutritionists have realized that many health programmes have an indirect impact on nutritional status and can be very effective in supplementing their own direct efforts. Even in the absence of specific nutrition interventions, commonly adopted health measures can have appreciable impact on nutritional status (WHO 1980). Improved sanitation and provision of safe drinking-water can significantly reduce gastro-enteritis infectious and parasitic infestations. Immunization can control infectious diseases of childhood. The incidence, duration, and severity of bronchitis and gastro-enteritis could be reduced. Mothers could be encouraged into good child-feeding practices within the limits of their ability to follow them in the face of practical problems of hygiene, food preparation, feeding routines, and availability of the recommended food. Improved child-birth spacing would mean healthier mothers of improved nutritional status who could be better equipped for adequate child care . Programmes for malaria eradication and for expanded immunization are two recent examples of health sector interventions with considerable impact on nutritional status. All these health measures, which are not nutritional activities, can be of tremendous value in moderating the consequences of malnutrition, and even in its prevention.
Nutritionists realized that if direct nutrition measures could be linked with other health programmes of indirect value, then the total effect would be one of considerable benefit to people. This is the basis of the packaged or integrated approach in nutrition. Feeding programmes associated with the provision of safe drinking-water and with education on personal and food hygiene is an example of such an approach.
When the phase of vertical programmes in nutrition failed, it was realized that nutrition is an objective in health; it is not supported by any infrastructure or personnel, nor is this justifiable. For effectiveness, the nutritionists need a delivery system through which nutrition activities can be provided to those who need them most. Since nutrition programmes have no delivery system, it implies that they have to identify programmes or activities that go out to the peripheral areas. Thus nutritionists gradually started integrating nutrition with other health programmes that usually reach peripheral areas, like maternal and child health, family planning, control of communicable diseases, and so on.
The historic WHO decision to provide health care to all by the year 2000 through the medium of primary health care has opened up new potentials for nutritionists. Theoretically this is what they have been looking for all these years. Primary health care is an approach with full participation of the community, in which multi-purpose peripheral workers deliver at the same time one, two, or more of the eight elements of the primary health-care system as and when needed. The opportunity is now open for nutrition to be an essential component of primary health care, to be given along with maternal child care, rehydration in diarrhoea, immunization against communicable diseases, advice on birth spacing, etc. Thus, the two important factors limiting the impact of nutrition programmes in the health sector, namely inadequate coverage and an inappropriate approach, can be taken care of through the primary healthcare system. The consultation meeting recently convened by the WHO to develop nutrition strategy within the framework of primary health care in order to reach the goal of health for all by the year 2000 in the countries of the South-East Asia region is an excellent example of appreciation of the interaction between nutrition and health in this part of the world.
Let us examine the extent to which health planners and administrators have appreciated the importance of nutrition in total health development during these years. While health documents and health policies in the past just mentioned malnutrition as a problem almost as a routine, hardly ever in terms of resources and programmes, the present efforts of the health sectors in developing national health strategies to reach the objective of health for all by the year 2000 tell a different story. All countries of the South-East Asia region have included nutrition in the national policy document on health. The national health strategies of most countries have not only mentioned malnutrition as an impediment to total health development, but have identified nutritional indices as parameters for health improvement. In several countries, nutritional indices are being used to assess the quality of life in the total health strategy. In fact, this is possibly the first time that nutrition in its various aspects has been incorporated in national health policies and declarations.
What has led to such increasing recognition by health planners and administrators? The problem of malnutrition and its repercussions on total health is being brought home by nutritionists to national decision-makers. The alarming consequences of four priority nutritional problems, namely proteinenergy malnutrition, nutrition blindness, nutritional anaemia, and endemic goitre, are now the concern not only of nutritionists, but also of national health planners. The health consequences of child malnutrition and their socio-economic implications are of considerable importance to health planners. The health sectors have also taken note of the functional consequences of malnutrition that have been brought into focus in recent years. Its correlation with work-capacity, its association with blindness, and its cause and consequent relationship with infection have all brought home the importance of nutrition to health planners. It is being increasingly realized that nutrition measures if properly implemented might give a high health dividend. Better nutrition means improved maternal nutrition, which leads in turn to improved birth weight, less prematurity, less pregnancy wastage, less infant mortality, and less infant and childhood morbidity. Even in family planning, a programme with the highest priority in many developing countries, it is generally agreed that adoption of family planning would be doubtful without assurance of survival of children, for which adequate nutrition is a vital requirement. The child survival strategy of the family planning programme is indeed based on appropriate promotion of child nutrition.
One must also admit at this stage that the process of health planning has gone through revolutionary changes. The emergence of scientific health planning through prior analysis of the constraints and resources have led to the realization that malnutrition is undoubtedly a constraint and impediment to health development.
The future of an integrated nutrition health strategy for the improvement of people's lives is very promising. The strategy of health for all by the year 2000, referred to as a revolutionary idea, is in fact nothing new. However, the unanimous decision of the countries of the world to place AD 200P as a target is undoubtedly a bold step. This decision might not be of much relevance to the developed world where such health care is already within the reach of all, but in a developing country this decision is momentous. Unlike many other decisions in the past, there is already a frantic and concerted effort in most developing countries to give shape to this strategy, and primary health care has already been utilized as one component of the strategy. There is already evidence that countries are taking bold steps in the field of primary health care, and re-ordering their priorities to permeate all levels and sectors concerned with the promotion of health. It has not been treated as just the addition of yet another layer to the health service (WHO 1981a). Though the terms vary from one country to another and there is no set pattern for primary health care, the common denominator is the aim of providing essential health care to everyone in the foreseeable future.
It is heartening to note that nutrition occupies an important position in these strategies. The Alma Ata Declaration identified nutrition as one of the eight essential elements of primary health care, but unlike previous declarations this has already come true. Many countries in the developing world have undertaken sizeable projects to determine the means for an effective integration of nutrition with primary health care. A large number of such projects in various centres have provided adequate answers to some vital questions, like the desirable nutritional tasks in the PHC package, identifying simple methods for undertaking these tasks, and the method of training necessary to enable PHC workers to undertake such tasks with competence.
If nutrition is regarded as the meeting-place of various disciplines, then primary health care can be regarded in these new strategies as the meeting-place of nutrition and health. There seems little doubt that future health strategy in developing countries will have nutrition in primary health care as the main weapon with which to fight malnutrition and at the same time provide total health for all.
An important area of future strategy concerns the development of human resources for such a combined nutrition health strategy. The training required for workers at the primary health-care level will be totally different from that provided by conventional methods. In fact, this is already engaging the highest national priority. It is obvious that nutrition trainers must also depart from conventional training, and provide training that would be really and strictly task-oriented. Here again there is frantic activity in many countries and also in international organizations. In WHO's recent document (1981b) outlining the salient points for the training of primary health care workers, there is adequate emphasis on nutrition in the context of total health.
In conclusion one might state that the time has come when nutrition and health are moving towards each other. It is interesting to note that the concepts of health and nutrition have undergone revolutionary changes and, in both, the socio-economic environment is recognized as the most important conditioning factor. The interaction between nutrition and health has possibly reached an ideal equilibrium for the betterment of people's lives.
Bagchi, K. 1977. Nutrition Through Health-Care Systems. World Health Organization, Geneva, (Document no. NUT/77.1.)
_. The Role of the Health Sector in Nutrition. World Health Organization, Geneva. (Document no. NUT/79.21.)
Blaxter, K.L. 1979. "Nutrition Research Priorities for the United Kingdom." Proceedings of the Nutrition Society, 38: 213-218.
Garry, R.C. 1953. "The Nutrition Society of Britain: The First 12 Years." Proceedings of the Nutrition Society, 12: 270 273,
WHO. 1980. Role of the Health Sector in Nutrition. World Health Organization, Geneva. (Document no. NUT/EC/WP/80.3.)
_. 1981 a. National Decision-making for Primary Health Care. World Health Organization, Geneva.
_. 1981 b. Guidelines for the Training of Community Health Workers in Nutrition. World Health Organization, Geneva.
In Sri Lanka, the range of calorie intake is from 1,859 to 2,600, which is almost exactly the value for the mean plus-minus-two standard deviations . Thus there is a fairly even calorie distribution at all income levels. The policy implication seems to be that if the price of one essential food commodity is subsidized or pegged, good nutrition for the total community will follow.
While good work on the tropical nitrogen cycle has been done in India, this has not been translated into general use. India has set up a tuber crops research institute that deals with production aspects, but in general too little attention had been given to tubers by food scientists, for example, their use in the manufacture of children's foods. Indeed the area of weaning foods is a fertile field for the operation of multinationals in developing countries like Bangladesh.
How can interface action be promoted in practice? An interregional ministerial group of countries in the region already exists, and has met once in Sri Lanka and again in Nepal. Many conferences, like the one recently held in Manila, have stressed interregional collaboration and exchange. Policy-makers must participate in these meetings to become sensitized to the many aspects of food supply. could not the present group, or an enlarged one, meet a year later, say at Dacca, so as to continue the dialogue? What is needed next is action, now that the need for various interfaces has been so clearly recognized, even when important economic and policy functions are un-represented. So far interactions have occurred almost in spite of individual activities, but now policy planning to positively promote them is needed. Fortunately, food consumption and processing are highly employment-generating activities, and therefore priority areas.
Networks between institutions must be developed. Institutions must be oriented so as to train people to become agents of change. This cannot be left to chance as hitherto but must be purposefully brought about. The United Nations University has started on this road, and can serve as the conscience of international action.
The strategies for a hill economy are not identical with those for a river economy. How much and what knowledge is transferable? How can institutions bring about such transfer? How can transferable technologies be generated? Such technologies as rice parboiling or pulse milling have very wide regional application, and must be furnished with institutional backing.
Demand is different from need: how can one increase demand, which is an economic function? Agriculture must be used as a resource to stimulate industrial development. A new science and technology effort must be mounted to build national capabilities in every way, and inter-country cooperation can help to bring this about more rapidly.