Chapter 6: Nutrition Challenges and Gender in Asia

Nutrition in Asia: The Challenges
What’s Next?
Nutrition Development in Thailand: Lessons Learned
A Practical Approach to Effective Nutrition Actions in Asia
Final Notes
Acknowledgements
References
Discussion

Suttilak Smitasiri

Recall the face of the poorest and the weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him.
Will he gain anything by it?
Will it restore him to control over his own life and destiny?
In other words, will it lead to self-reliance for the hungry and spiritually starving millions?
Then you will find your doubts and yourself melting away.

- Mahatama Gandhi -

Over the last fifty years, science has contributed a tremendous knowledge on nutrition. Most nutrition problems are known today in terms of what are the etiological factors, referring particularly to immediate causes, and why they are so important. This is indisputably a proud achievement for nutrition scientists of this century. Nonetheless, as the close of this millennium is coming near, many remain perplexed by the fact that this vast body of knowledge has not been helpful enough for poor people. Malnutrition can still be found in almost every country in the world. Furthermore, it has recently been reported that even with progress, prospects for reducing malnutrition among the world’s children are grim (UNICEF, 1997). This is indeed a challenge for all nutrition workers in the next millennium.

This paper presents the view of a female nutrition practitioner - who works in an Asian developing country - on the nutrition situation in Asia and how to approach the problem more effectively in the future. A Thai experience in rapid reduction of malnutrition among young children is discussed. The issue of gender is critical to the success of empowering individuals (women and men), families and communities in taking positive actions towards nutritional improvement.

Nutrition in Asia: The Challenges

The Asian region consists of a few high-income countries such as Japan, Singapore, and South Korea, while most countries in East, Central, and South Asia have low- to middle-income economies. Estimates of trends in childhood stunting in the region show some improvement (ACC/SCN, 1997), with the most rapid rate of progress occurring in South-East Asia (at -0.9 percentage points per year), followed by South Asia (at -0.84 percentage points per year), compared with the estimated trend across all regions (at -0.54 percentage points per year). Nevertheless, the current Asian economic crisis will, to a certain extent, be an obstacle to this development.

As for childhood malnutrition (underweight), it is estimated that more than 40% of children under the age of five are malnourished in most countries in South Asia and a few countries in South-East Asia, i.e., Viet Nam, Laos, and Indonesia (ACC/SCN, 1996). Myanmar, Cambodia, Bhutan, Sri Lanka, Maldives, and the Philippines have around 30-39% malnourished children; Malaysia is reported to have 20-29%; while China, Mongolia, and Thailand reportedly have between 10-19%. No data are available for North Korea (World Bank Group, 1997), however, recent international media do indicate a severe malnutrition problem among young children in this country.

More than 80% of pregnant women in India and Bhutan are anaemic. In Nepal, Indonesia, Myanmar, Thailand, Malaysia, Bangladesh, Vietnam, and China, over 50% of pregnant women are anaemic (see Table 5). In many Asian countries where prevalence of anaemia is likely to be high, data are not available. In addition, 45% to 60% of women of childbearing age in South-East and South Asia are underweight. As a consequence, there are millions of low birth weight babies born each year (ACC/SCN, 1997). Thus, the malnutrition problem is perpetuated from one generation to the next in Asia.

Over the past decade, progressive country efforts have been recognised; for example, the distribution of iodised salt as a means to combat iodine deficiency disorders. In many Asian countries, well over a half of households consume iodised salt (UNICEF, 1997). Vitamin A interventions have also been implemented; however, it is estimated that around two million people still suffer from clinical vitamin A deficiency and as many as 34 million are currently weakened by sub-clinical vitamin A deficiency in the region (IVACG, 1998).

Table 5: Anaemia during pregnancy in Asia, most recent data available (1985-95)

Country	% pregnant women with anaemia
India	88
Indonesia	64
Malaysia	56
China	52
Pakistan	37
Bhutan	81
Myanmar	58
Bangladesh	53
Philippines	48
Maldives	20
Nepal	65
Thailand	57
Vietnam	52
Sri Lanka	39

Source: World Bank Group (1997)

What’s Next?

“Everyone says nutrition is important but no one does anything about it”. This paradoxical saying has often been heard over the last ten years. Is nutrition losing its own identity? Does nutrition no longer have a role in human development? As mentioned earlier, I believe one great contribution of this century is the fact that knowledge is now available to solve almost all undernutrition. Moreover, it is convincingly clear now why investing more in nutritional improvement is a sound idea (see Table 10, page 74). Nutrition in the next century should therefore have a new image; it should be an important subject that everyone should not only talk about, but should proactively address. Decisions are yet to be made. To make a difference, nutrition workers must collectively provide more evidence that such an investment would be rewarding.

Nutrition Development in Thailand: Lessons Learned

Good news for future nutrition work is the fact that through the hard work of so many people, there are several unique examples of successful nutrition interventions in almost every part of the world. Thailand is one of them. Thailand has been recognised by the nutrition community for its ability to eliminate severe and moderate malnutrition among children under five years of age, and reduce overall malnutrition from 51% to 19% in only one decade. What were the essential elements in this successful intervention?

From a macro perspective, it can be said that the contribution to Thailand’s nutrition success in the last two decades is due to policies and programmes that were created to reduce both poverty and malnutrition. Important elements included targeting poor areas, focused interventions, a primary health care structure that promoted community participation in planning, implementation and evaluation in community health development. There was also a strong emphasis on nutrition in rural income generation schemes and integrated small farming systems (Winichagoon et al., 1992).

Figure 11: Total population observed from 1950 to 1990 and projected from 1990 to 2050, by continent (medium variant)

Note: Based on United Nations projections

Because of the nature of this group, a strong commitment from many sectors for nutrition improvement became possible. Together, they provided strategic policies, participatory action plans for both macro and micro levels, as well as systematic monitoring processes. Most importantly, these leaders acted individually and collectively to alert the public about nutrition problems and their burden for the nation’s future. These leaders, from the very beginning, realised that nutrition is not only a human disease but a societal problem that can only be improved by collaborative efforts.

Grounded with a primary health care philosophy, a good technical background and strong management skills, a group of academics and practitioners from multisectors formed a core group for nutritional development in Thailand more than twenty years ago. This body helped merge nutrition work into the national poverty alleviation plan...

Also, these change-masters were keen to involve more people from the economic, agricultural, public health, education, social development, and research sectors as well as to include training in problem identification and planning. Concrete information was used for deciding upon priority problems, identifying goals and target groups, and for selecting appropriate actions. Professional, technical, and resource support were arranged on a continuous basis with adequacy of coverage manageable by the system. Furthermore, their initiation for the national planning authority to facilitate the planning process, to coordinate and to monitor food and nutrition policies in line with development policies was crucial for success. This body helped merge nutrition work into the national poverty alleviation plan which targeted high poverty concentration areas through the national committee to communities in the 1980s. Under this plan, nutrition activities, primary health care, food for family consumption, and other basic social services were integrated in the target villages.

In my opinion, this mass-scale operation for nutritional improvement in Thailand was possible because both planning and implementation strategies were based on holistic, multisectoral concepts, and on self-reliance. Community participation through primary health care, village financing systems, and basic minimum needs or quality of life indicators were key to the design, implementation, and monitoring of community interventions.

At least ten women and men spent their spare time working as volunteers to help improve nutrition and health in each rural Thai community. Information was provided to enable them to take action. This information-action loop has proved helpful for generating more participation needed to solve nutrition problems at the community level.

Political concerns, public opinion, and awareness of nutrition problems, as well as success stories, have been created strategically through several communication media, by credible leaders and decision makers, administrators at various levels, and the public in general. Effective policy communication, the use of the innovative information-education-communication approach, a continuous investment in capacity building at all levels and last, but not least, various kinds of support from international communities have been essential to good progress in nutrition in Thailand (see Figure 12).

Figure 12: Thailand holistic health and nutrition development process

A Practical Approach to Effective Nutrition Actions in Asia

A PARADIGM FOR NUTRITION DEVELOPMENT IN THE NEXT CENTURY

To improve nutrition actions in Asia, the search for remedies requires critical attention and the right thinking. The need for nutrition workers to realise that the causes of malnutrition are complex, context-oriented, and dynamic in nature has already been mentioned (Pinstrup-Andersen, 1991). A new way of thinking and doing the work now needs to be considered.

Indeed, there is more than one unique way to look at malnutrition in a society. What remains important, however, is the decision to agree upon principles. Table 6 shows the importance of different ways of seeing the world and trying to understand it. If the underlying reality is perceived differently, objectives, planning approaches and implementation will also be very different. Thailand’s experience seems to indicate somehow a mixture of modernism and post-modernism. However, post-modern thinking has probably created more changes when the total experience is examined carefully.

Table 6: Modern and post-modern currents in development

	Modern	Post-modern
Underlying reality	Simple, uniform	Complex, diverse
Objectives	Growth	Development
	Preoccupation with macro	Preoccupation with micro
Planning approach	Plan	Enable
	Model	Interact
	Top-down	Bottom-up
	Centralise	Decentralise
Implementation	Blue-print	Process
	Role culture	Task culture
	Standardisation	Flexibility, innovation

Adapted from Maxwell (1996)

A recent attempt to look into the issue of gender differences in nutrition and health revealed that more than anywhere else in the world, girls have poorer health and nutrition than boys in Asia (Kurz and Johnson-Welch, 1997). These findings seem to confirm the common saying that the male population is superior in Asian culture. Traditionally and currently, the Asian family still, in most cases, prefers a male child. However, the degree varies between countries and between different communities within a country.

Within Asia, data are indicative of the especially poor condition of maternal nutrition in South Asia. The shortage of private income, fewer opportunities for women to participate in the market economy, poor access to health services, and low female literacy, as well as the treatment of women (an aspect of its culture), are important in shaping the nutritional status of this population. More understanding about women will be helpful to improve nutrition (Osmani, 1997).

As it is defined, gender refers to the qualitative and interdependent character of women’s and men’s positions in society. Gender relations are constituted in terms of the relations of power and dominance that structure the life chances of women and men. Gender divisions constitute an aspect of the wider social division of labour that is rooted in the conditions of production and reproduction, and reinforced by the cultural, religious and ideological systems prevailing in a society (Ostergaard, 1992).

Gender issues are thus very important not only for nutrition but for all aspects of human relations. More understanding into these issues would definitely be valuable for human development as a whole. Nevertheless, gender, like nutrition, is a very complex and sensitive issue. But it is important not to let this complexity detract from action. Therefore, it is proposed that nutrition workers realise the importance of gender issues as related to nutrition and take a practical approach in utilising this new understanding. From a practitioner’s view, taking a gender perspective to nutrition development is to better understand the needs and priorities of both women and men. This understanding can then be used to influence both genders to work together towards successful nutritional improvement (which reduces gender disparities and promotes equality) at family, community, national and international levels.

In Thailand, the Institute of Nutrition at Mahidol University has been working with both women and men at various levels to improve micronutrient nutrition in the Northeast of the country for the last ten years. Our experience shows that both genders can work together to improve nutrition, and the poor can take an active part in nutritional development. We have learned that it is necessary to start where the poor can make a difference. Knowledge is important but it should lead to solutions that are relevant to the lives of the poor. Therefore, it is important not only to understand nutrition problems but also the cultural realities of men’s and women’s lives, as well as their ways of thinking about the situation.

Participatory techniques, for example, the Appreciation-Influence-Control (A-I-C) Approach (Smith and Landais, 1991) and the Community-based Nutrition Monitoring (CBNM) problem-solving model (Pelletier et al., 1994), should be used to create more participation among all stakeholders in planning, implementation, and control of the intervention. Provided with adequate information and good facilitation processes through social marketing and implementation (Smitasiri, 1994), the poor can be key players for their own nutritional development.

THAILAND AND SOUTH ASIAN COUNTRIES GENDER SITUATIONS

My understanding about the South Asian situation regarding nutrition implementation, when compared to Thailand, marks at least three important differences:

1) South Asia faces more difficulties in terms of food production and living standards;

2) South Asia has a much wider economic and social gap between those who have and those who have not;

3) the role of ordinary women in society in South Asia is more limited.

Generally, both belief and religious practice in this region create a condition where ‘sons are important’. Parents without a son cannot enter into heaven. A woman therefore has a responsibility to get married and produce male children. As an individual, her parents will take care of her when she is young. Once married, her husband will do so and when she becomes old, a son will take the responsibility. A woman thus cannot survive without a support from a husband and a son. This is one reason she needs to take better care of them.

Moreover, according to religious teachings, a woman should not be trusted with a decision, be it big or small (Kabilsingh, 1992). This has been a belief and practice for more than 2000 years in this area. It has changed to a certain extent in the upper classes, but not among the less advantaged population. Despite these known difficulties, lessons learned from successful food and nutrition interventions in this area indicate that active participation by women is critical (Quisumbing et al., 1996).

In my view, ordinary Thai women are not very different from other Asian women. A good Thai woman is called ‘Mae Sri Reaun’ which means a ‘good lady of the house’. However, equal opportunity for free basic education has made an impact on the development of the female population in Thailand. For example, the Thai Government Statistical Office reported that around 70% of Thai women were considered employers, government employees, private employees or own account workers since the 1980s. Thai women today are engaged more and more in social activities and employment. Furthermore, Buddhism, practised by most Thai people, though originating in India more than 2000 years ago, says that both men and women have an equal potential to understand the Buddha’s teachings. Also, most Thai husbands are proud to leave decisions regarding household management, including family food and nutrition, to their wives. This often includes money to be used in the family. With access to appropriate information, Thai women therefore are decisive in nutritional matters. Because of this background, women are key actors for nutrition in Thailand.

GENDER-SENSITIVE NUTRITION ACTION

Gender-sensitive nutrition action is important for all Asian countries and it is especially significant for those in South Asia. Systematic and concerted efforts are needed to create a critical mass of leaders - especially women leaders - who can understand the importance of this approach at various levels. Realistic goals and interventions should be grounded with the level of support that can be mobilised nationally and internationally for change. And, the work must be manageable by the system during and after the initial interventions.

Good nutritional science should be combined with good knowledge of the intervention context. Assessments need to be done not only for nutrition and health of populations, but also for any potential for change that already exists or can be strengthened within the target communities - be they large or small - and for any windows of socio-cultural opportunities, which could be built upon for nutritional improvement. In addition, good multi-disciplinary team work will be necessary in order to cope with the complexity of the food and nutrition system.

Nutrition work needs to be integrative especially where the process of female empowerment is already in progress. More knowledge will be needed about the integration process. However, action need not be delayed. An information-action loop or experiential learning process has proven helpful in successful interventions. In other words, a nutrition intervention should start where communities have a potential for change by aiming to create more examples and to generate more changes through community and social learning.

Final Notes

Malnutrition problems in Asia require immediate and concerted efforts. Nevertheless, well-calculated action is crucial. I believe that the Thai experience, which has evolved for over two decades due to the commitment and participation of people at various levels, can be considered by other Asian countries. Holistic and process-oriented development requires a lot of effort at the start but it can produce sustainable changes in the long run.

Jawaharlal Nehru once said,

“Strong winds are blowing all over Asia.
Let us not be afraid of them, but rather welcome them for only with their help can we build the new Asia of our dreams.
Let us have faith in these great new forces and the dream which is taking shape.
Let us, above all, have faith in the human spirit which Asia has symbolised for those long ages past”.

Thus, even with the sense of urgency to reduce malnutrition in Asia, it is very important not to bring in nutrition work that dis-empowers poor people rather than empowers them.

The balance between process and outcome indicators in determining the success of nutrition implementation is important and needs further discussion. Nutrition workers in the future should aim at significant and long-lasting changes by proactively learning from the people-communicating and working with them, both women and men, to do something appropriate to improve nutrition. Action should be based on sound knowledge, and knowledge must be grounded in the reality of the people. The role of international agencies as good facilitators and catalysts for this direction in the areas of implementation, research, and training is fundamental to minimise the usual time lag between thinking and practice.

Acknowledgements

The author would like to express sincere appreciation to Charrotte Johnson-Welch and Kathleen Kurz of the International Center for Research on Women (ICRW), Washington, DC, for their constant support. Working with ICRW, I have learned more about women and nutrition. Also, my heartfelt appreciation and respect go to all women leaders and people in Northeast Thailand who taught me to be practical through their committed belief and untiring efforts for nutrition and health improvement in their communities.

References

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ACC/SCN (1997) The Third Report on the World Nutrition Situation. ACC/SCN, Geneva.

IVACG (1998) Sustainable Control of Vitamin A Deficiency: Defining Progress Through Assessment, Surveillance, and Evaluation. Report of the XVIII International Vitamin A Consultative Group Meeting, Cairo, Egypt, 22-26 September 1997. IVACG, Washington, DC.

Kabilsingh C (1992) Women in Buddhism. In: Women Study. Kabilsingh C. (In Thai) Thammasat University, Bangkok.

Kurz K and Johnson-Welch C (1997) Gender Bias in Health Care Among Children 0-5 Years: Opportunities for Child Survival Programs. A Review Paper Prepared for the BASICS Project. Published for the USAID by the Basic Support for Institutionalizing Child Survival (BASICS) Project, Arlington, VA.

Maxwell S (1996) Food security: a post-modern perspective. Food Policy 21:155-170.

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Pelletier DL, Morris MF, Kraak V (1994) The CBNM Problem-Solving Model: An Approach for Improving Nutrition-Relevant Decision-Making in the Community. A manual prepared for the CBNM Strategy Workshop. Cornell University, Ithaca, NY.

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UNICEF (1997) The State of the World’s Children. Oxford University Press, New York.

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Discussion

Urban Jonsson (UNICEF): There are hardly any similarities between Thailand and South Asia. In South Asia, millions of women are missing, infanticide is common, and the population pyramid is continuing to change. Certain districts in Thailand have an unbelievable balance between men and women. The situation for women in South Asia is quite different from that in Sub-Saharan Africa. In Sub-Saharan Africa women are primarily the mothers of their husband’s children. In South Asia, a married woman is a commodity, owned by her husband and his family. In Sub-Saharan Africa, traditionally, infertility is the only legitimate reason for divorce. In South Asia, infidelity is the only legitimate reason.

Ruth Oniango (AGN): On both continents, women are marginalised and oppressed. In some local languages in Sub-Saharan Africa, a woman is not a person. The international donor community has assisted and instilled confidence in women, and has made men realise that without women, they are nothing. But communities are made up of men, women, children, livestock, and everything in it. It is better to include men, and to sensitise them, because then they support the women and they work together. It is important to include both genders in projects. In Africa, at the political level, you can find a whole commission made up of women, discussing women’s issues. Of course this never goes anywhere. In contrast, a commission that discusses economic issues doesn’t have a single woman on it. We need to understand the environment within which we are operating. We also need to instill confidence in women. If you go and sit in a women’s group and there are one or two men present, the women will not stand up and discuss their issues. They let the men do the talking. It has been instilled into women for so many years that firstly, they have no idea what they can contribute, secondly, that they have no business standing up to talk in front of men, and thirdly, that their business is to produce, serve men, and sit down. Instilling confidence, and at the higher level, leadership and training are very important.

Suttilak Smitasiri: In preparing for this presentation, I asked my Bangladeshi, Indian, and Pakistani colleagues at Mahidol for input. They said that even in India, there is a big difference between one state and another. In one part of India, females have even more power than men. We need to look at the problem in a way in which we can take action. There are so many NGOs and organisations that already work to empower women. When we think about nutrition we think about a problem. For example, if we are interested in vitamin A, we search for the problem and then we try different ways to solve it, but we never think about the potential for change. In South Asia, we need to start from what we have already. The difficulties for women to talk in South Asia are much greater than for women in my country. I spoke with a Bangladeshi NGO that has been very effective in working at the community level and asked ‘how do you learn this? Do you know what the women think?’ The man said that you don’t have to know what women think to be effective, you only have to know how to get into the system to be able to provide them with something. To understand would be very difficult. I challenged him to go back and do it, but he said ‘what is more important is that you have to work with the men to be able to get to the women’. So this is very critical. Even though we have to work with women to make a difference, we should not create more conflict within her family.

Lilian Marovatsanga (AGN): I am from Africa and have visited several Asian countries. One of the similarities between Africa and South Asia is the lack of economic and technological empowerment of women. Successful projects have incorporated this into their strategy.

Urban Jonsson (UNICEF): Women both in Africa and in South Asia are exploited - they are subordinated. But there are 34 million women missing in South Asia. The form of exploitation is totally different.

Mohamed Abdulla (UNESCO): I come from the South of India - Kerala State. Some years ago a group from Boston arrived and compared the status of women in Kerala with the women in Boston. The only difference they could find was in GNP - nothing else. The Kerala situation has shown that it is possible through proper education and proper training to overcome some of the health and nutritional problems. The UN has repeatedly said that we should follow the Kerallian model to make progress in developing countries.

Rita Bhatia (UNHCR): I would like to compliment my colleague from South India. One of the commitments of the Kerala project came from the community and the community leaders. It was very interesting to see your opening slide with a quote from Mahatama Gandhi and your closing slide with a quote from Jawaharlal Nehru - I was very proud to see those names - both men. That in itself shows that there is a need for political will and commitment. In Kerala, the literacy rates are very high. It comes back to what Dr Brundtland said earlier - you cannot improve nutrition without education.

The continent is so heterogeneous that you cannot generalise. To add to what Urban Jonsson said - the woman is a commodity to her husband. She is not a wife - she belongs to the family. In rural India, the head of the family is the mother-in-law. In Africa, women can choose their husband, but in Asia this still does not happen. It’s a marriage of not one man and one woman, but a marriage of families. One has to keep in mind the social values and context while you are trying to bring in some changes to improve the nutritional status and health of the population.