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AFRO-NETS> Letter to The Editor: State of International Nutrition

Letter to The Editor: State of International Nutrition

The Lancet: Vol 351, June 13/98, p.1812

The Editor,

The authors of this letter represent three different continents (Latin 
America, Asia and North America) and both the medical and social sci-
ence disciplines, but have come to similar conclusions about the state 
of international nutrition and specifically the relative balance of at-
tention given to solving the problems of micronutrient deficiencies and 
those of protein-energy malnutrition.

Before 1980, most nutrition attention in developing countries focused 
on PEM. The culmination of this attention was the era of multi-sectoral 
nutrition planning in the 1970s when we not only took PEM seriously, 
but understood the importance of working with a range of development 
sectors to address the problem. In retrospect, those of us pursuing 
multi-sectoral planning met with disappointment, partly because of the 
mainly "nutriocentric" lens through which we viewed development, and 
partly because at least some of us failed to pay adequate attention to 
the underlying socio-economic and political determinants of malnutri-

The reaction of a large portion of the nutrition community was to pull 
strongly in the opposite direction, one which has been labelled "nutri-
tion isolationism". (If we will not be taken seriously by other devel-
opment sectors, we will ignore them, and pursue nutrition interventions 
we can carry out and control largely on our own). And indeed there were 
attractive candidates. New understandings of the consequences of micro-
nutrient deficiencies, particularly vitamin A and iodine, and improved 
technologies and logistics for delivering micronutrients (massive dose 
supplements and fortification) made possible significant and attractive 
achievements within relatively short periods of time.

Accordingly, many of us have pursued these micronutrient interventions, 
in some cases with remarkable success, and can take some pride in these 
accomplishments. Nothing in this letter should suggest any reduction in 
efforts directed toward micronutrient malnutrition. We remain their 
staunch advocates. At the same time, it is clear that we have, all too 
often, neglected the overriding problems of inadequate caloric intake 
and its determinants which are continuing to take such an enormous toll 
on vulnerable population groups.

We know considerably more today about addressing PEM through the com-
bined efforts of food security, nutritional care of women and children 
and public health interventions than we did 20 years ago. But the at-
tention of the nutrition community and the resources of donors nowadays 
often are more attracted by the glamour of micronutrients, a largely 
technical and often top-down solution (as close to a "quick fix" magic 
bullet as we are likely to get in this field), than by the messier and 
often politically sensitive business of poverty alleviation, people's 
empowerment, and equity necessary to assure that mothers and children 
have access to needed services -- and adequate food to eat.

In India, micronutrient deficiencies are significant and deserving of 
serious attention. At the same time, however, the poorest three deciles 
of the population consume only 1681 adult equivalent calories per day, 
while 78% of Indian children suffer from undernutrition. Both sets of 
problems are wholly unacceptable, but they need to be kept in proper 

At a recent meeting of African nutrition experts, representatives of 
one country with disturbingly high rates of moderate and severe malnu-
trition listed 16 nutrition research "priorities," 13 of which were mi-
cronutrient related. This may not be surprising given the orientation 
of donor assistance and the appeal of journal articles. But the list 
hardly reflects the most urgent nutrition needs of African countries.

All too often, indeed, governments and donors have concluded that they 
can "check off" their concern and attention to nutrition by launching a 
micronutrient or an isolated breastfeeding project, and ignore entirely 
the challenges of PEM so seriously affecting the ultimate welfare of 
women and children, as well as longer term development processes.

The challenge that we face, as we move forward into the next century is 
not only to maintain our momentum in pursuing micronutrient interven-
tions, which clearly are reducing suffering and saving lives, but also 
to redress the imbalance, and the relative neglect of the problems of 
PEM and food insecurity which often require a very different set of in-
terventions. Our hope in the years to come is that the technical skills 
and partnerships which have driven salt iodization and vitamin A and 
iron supplementation programs can be coupled with the political acumen 
which has sparked successful social mobilisation movements to bring 
about the significant reductions in global undernutrition we all de-

Claudio Schuftan, MD. - Hanoi, Vietnam
V. Ramalingaswami, MD.- New Delhi, India
F. James Levinson, Ph.D. - Cambridge, USA

Claudio Schuftan
Hanoi, Vietnam

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