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AFRO-NETS> Follow up on the Lancet letter

Follow up on the Lancet letter

[see AFRO-NETS> Letter to The Editor: State of International Nutrition
Mon, 17 Aug 1998 10:11:33 -0400 (EDT)]


The time has come for the nutrition community to more clearly separate 
micronutrient interventions from Protein Energy Malnutrition (PEM) in-
terventions and to treat them as two completely different entities, two 
totally different challenges, addressing two different universes. In 
short, they represent two separate domains.

More than before, in the last six to eight years, a significant number 
of nutrition workers have chosen to focus their efforts on the allevia-
tion of micronutrient deficiencies. This is also true for many donor 
agencies working in nutrition. One can rightly wonder if this repre-
sents an attempt to 'run away' from the more difficult choices and 
challenges in the battle against (the real) malnutrition and -- in the 
name of nutrition -- focusing more on its more achievable areas of im-
pact thus choosing the relatively easier path to staying involved in 
nutrition work.

Often, this micronutrient focus represents swings from earlier work in 
PEM. Examples of these swings in assigning priority to micronutrients 
can be seen in USAID's Office of Nutrition work, quite a bit of the nu-
trition work of UNICEF and other bilateral donors and the work of the 
new Micronutrients Initiative (the latter not a real swing, but a fresh 
start riding this new wave of preference or new mood among many of our 
nutrition colleagues).

The difference between both areas of concentration in nutrition work is 
based on a matter of balance between an endeavor that is primarily 
technical with only few political overtones, and one that is the oppo-
site: primarily political with some added important technical chal-
lenges. The former endeavor does have a potential for silver bullet so-
lutions to work; the latter does not (and nutritionists seem to like 
silver bullets indeed...).

What we are talking about here is not an academic nuance only. This, 
because the solutions to PEM are greatly outside the field of nutrition 
itself and those for micronutrients are mostly inside the realm of what 
we can do technically. As a consequence, both these endeavors or compo-
nents of nutrition work have to adopt different strategies and require 
different skills, approaches and tactics.

Colleagues that get involved in micronutrients work get absorbed in re-
solving mostly immediate and only some underlying causes of undernutri-
tion (PEM), but they rarely touch its basic causes. (UNICEF, 1990) They 
also address more top down than bottom up programmatic challenges (e.g. 
management issues, distribution logistics, food technology issues, 

Staff involved in micronutrient work traditionally lobby for policy 
changes which are less controversial, less political, and tend to get 
easier support from national decision-makers. Examples of such policies 
are: adding a Vitamin A component to EPI plans, pushing nutrient forti-
fication or salt iodisation legislation and regulations. (UNICEF, 1997)

When applying IEC techniques in micronutrient work, especially to 
change the dietary habits of a population (in terms of diet diversifi-
cation) or the behavior of pregnant/lactating mothers, our colleagues 
face many more problems in succeeding, precisely because all the socio-
economic issues come to the fore (the same issues encountered in the 
battle against PEM); they are simply less well equipped (or less in 
control/less inclined) to handle those issues. Too often nutritionists 
end up teaching mothers to feed themselves and their families what they 
cannot afford, or -- using social marketing techniques -- they seek me-
chanical changes in behavior without the people's understanding of why 
these changes are needed and beneficial to them; social marketing sim-
ply fails to put people more in control of their own lives. (Schuftan, 
1996) Examples of this are found in the use of social marketing tech-
niques in quite a few countries to promote the consumption of dietary 
sources of Vitamin A -- an alternative whose effectiveness is, by the 
way, questioned by many experts.

Combating PEM is about poverty alleviation -- not economic growth (as 
many development programs push these days) -- it is about equity, popu-
lar participation and wealth redistribution, about access to health and 
to education; it is about the appropriate care women and children get. 
All these variables are adversely affected by pervasive Structural Ad-
justment Programs worldwide. [The relationships between structural ad-
justment programs, poverty and PEM do not need to be insisted upon here 
yet again]. (See Werner and Sanders, 1997)

The above are the scenarios, then, that colleagues embarking in the 
battle against malnutrition will, by necessity, have to face and become 
more involved in.

As said, micronutrient deficiencies can (and do) respond when tackling 
immediate causes of malnutrition only, especially if well funded and 
well targeted: "get that capsule/pill/fortified salt into the mouth of 
beneficiaries, and it is done". And that is good; deaths and suffering 
related to those deficiencies are averted; no quarrel with that. (See 
ACC/SCN, 1997) But this concentration cannot be morally justified at 
the expense of postponing or foregoing actions to tackle PEM.

Conversely, PEM does not respond unless its immediate, underlying and 
basic causes are tackled simultaneously, i.e. interventions at each in-
dividual level are necessary, but not sufficient. (UNICEF, 1990)

As relates to sustainability, because micronutrient strategies so heav-
ily depend on government (and donor) based service delivery and logis-
tic interventions and on only some capacity building at the various 
levels, they very often do create dependency on a given technology and 
on the continuation of centrally funded and centrally controlled serv-
ices. Ergo, sustainability remains elusive. [Note that very few coun-
tries massively distributing Vitamin A capsules at present could sus-
tain the effort if the donor(s) discontinue(s) its (their) support].

On the other hand, resolving PEM depends more on empowering people and 
communities to get involved in actions selected by themselves and, al-
though not often achieved, this has the potential of creating less de-
pendence and more self reliance and sustainability. The example from 
the UNICEF-sponsored Iringa (Tanzania) nutrition intervention in the 
early eighties comes to mind)

Micronutrient interventions will foreseeably reach coverages in the 90% 
range almost universally sometime in the early 21st century -- mainly 
due to strong pushes by the donor community. (ACC/SCN, 1997) And then, 
what? Will we see a switch back to PEM work (which by then will have 
become worse)? PEM will not go away (or perhaps not even decrease) in 
the next generation. The donor community involved in it pays more lip 
service to needed basic changes than putting their money and actions 
where their mouth is. And governments are not tackling these basic 
problems on their own either. Moreover, macroeconomic policies imposed 
by the Bretton Woods institutions are actually, more often than not, 
acting against the alleviation of PEM. (Werner and Sanders, 1997)

I contend that nutritionists tend to choose tracks in their careers ac-
cording to their preference plus the level of tolerance of frustration 
they can stand in their (nutrition) work. The question is: Do a politi-
cal ideology and ethical commitments also play a role in their choices 
when faced with only snail pace progress? In other words, are ultimate 
goals of social transformation part of the equation in their choice? If 
the answer is 'no', I see a bleak future for the role our guild can 
play in the battle against malnutrition in the world. Changes will come 
about without and despite us; history will bypass us.

And I worry, because I see these future challenges that will have to be 
faced by our young and upcoming colleagues not being clearly spelled 
out in their curricula during their undergraduate and graduate train-
ing. Some say we are training less than engineers (Berg, 1995). I would 
say we need more than engineers: we need nutrition activists.

Claudio Schuftan

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