NEWS AND VIEWS

Street Foods: Socioeconomic Benefits Versus Potential Health Implications
Supplementary Feeding Counteracts Effects of Diarrhoea on Growth

including:

World Summit for Children/Eradicating IDDs/Vitamin A progress/Street Foods/Diarrhea, supplementation and growth/Baby Food Code/Forthcoming meetings/Chernobyl assessment planned/more.

United Nations Secretary-General Javier Perez de Cuellar announced on 9 February 1990 that a summit meeting of world leaders will be held at United Nations Headquarters in New York on 29-30 September 1990 to address the urgent needs of children in the 1990s. The World Summit for Children will be the first global summit of heads of state or government from the East, West, North and South. They will address the single issue of children. The initiative was taken by Egypt, Mali, Mexico, Pakistan, Canada and Sweden. The announcement of the Summit for Children followed a series of consultations among the six Initiating Governments and other States since 1989. Since then the initiative has been endorsed by UNICEF Executive Board in a special session in late December and an expanded Planning Committee of some 22 Governments has been established.

The immediate purpose of the Summit is to focus world attention on the plight of children.

As UNICEF has emphasized, some 40,000 children die every day - one every two seconds, more than half of them from readily preventable causes. A substantial number are left disabled. Most of the endangered children are in the developing countries, but their counterparts in the industrialized world are increasingly imperilled by drugs, crime, homelessness and neglect. A new and more direct focus on the problems world children are facing is badly required. Further extension of efforts taken in the 1980s, with strong political support could help prevent some 50 million child deaths over the 1990s.

CHILDREN CANNOT SPEAK FOR THEMSELVES

They depend on us to speak for them.
They are powerless.
They suffer most when resources are maldistributed.
They need us to bring their very special needs to the notice of the powerful.

(Source: Reproduced from 'My Name is Today' (1986), Fig. 2. D. Morley and H. Lovel, TALC, P.O. Box 49, St. Albans, Herts AL1 4AX, UK)

(Source: United Nations' Information Office, Geneva, 19 February 1990)

National programmes for combatting iodine deficiency have enough promise that it is realistic to aim at "eliminating iodine deficiency disorders (IDD) as a major public health problem in all countries by the year 2000". The World Health Assembly passed a resolution to this effect in May this year.

Iodine deficiency "is so easy to prevent" - according to Dr Basil Hetzel, Executive Director of ICCIDD - "that it is a crime to let a single child be born mentally handicapped for that reason". In fact, knowing the progress in the last few years contributed to the decision on the ambitious objective. Significant progress was noted in prevention and control of IDD in some 40 countries. IDDs have been virtually eliminated in 20 developed countries, mainly through salt iodization, assisted by the increased dietary intake of iodine associated with development. Positive examples exist for a number of developing countries. For example, Nepal eliminated cretinism from many mountain districts through mass injections of iodized oil, followed by salt iodization. Similar progress was made in Indonesia and Zaire.

A striking example of success in eliminating IDD, and the benefits, is quoted from China. "The Jixian village of the Heilong-jiang province in Northeast China was known as a 'village of idiots'. Of its population of 1313 individuals the goitre rate was 65% and 11.4% were cretins. In 1978, the village began using iodized salt. No cretins have been born since, and by 1982, the goitre rate no longer posed a health problem. There were also clear economic advantages. The average annual income per person rose from 43 yuan per year in 1981 to 414 yuan per person in 1984."

(Source: WHO, June 1990).

In relation to IDD control measures, the results of successful application of a new method developed by French scientists to prevent environmental iodine deficiency have recently been released. In several villages in Mali, where the project was carried out, inhabitants were provided with iodinated drinking water. Both humans and animals consuming such water showed physiological levels of iodine in their blood and urine samples.

The method is based on continuous diffusion of iodine from silicon polymer iodine containers to water in wells and boreholes.

The Rhone-Poulenc Foundation, which collaborated in this project, has estimated that with the help of various organizations and on a non-profit basis, IDD eradication using this measure may cost one French Franc per person per year. From 1993, the Foundation can provide 100,000 of these containers per year in order to prevent IDD in around 50 million people. It is interesting to note that the method can be adapted so that other nutrients like vitamin A, iron or products to kill larvae may, similarly, be added to water resources.

(Source: Le Monde, 31 May 1990. For more information contact Dr Robert Sebbag, Delegue General de la Foundation Rhone-Poulenc Sante, 20 Avenue Raymond Aron, 92165 Antony Cedex, France)

The North-South Round Table of Nations held a two-day conference on the Economics of Peace in Costa Rica, on 4-5 January 1990. A statement by the Chairman of the meeting, Richard Jolly, UNICEF's deputy executive director, reflected the main ideas expressed by 25 high level policy makers and scholars from 12 countries participating in the meeting.

"We are now at a unique moment in world history. The reduction of East-West tension and the surge of democracy in Eastern Europe, and in parts of Asia and Latin America, provides the sudden opportunity for a breakthrough into a new way of ordering world relationships. It is now quite possible that human beings in the 21st century can settle conflicts through negotiation and the rule of law, without the use of military violence.

"....We must seize the new opportunity. We must develop a new vision of the world after the Cold War. It has to be a vision in which security is achieved not through reliance on armed forces and external defence but through negotiations to settle outstanding conflicts and through global efforts to tackle the roots of violent conflict - poverty, environmental degradation, injustice and inequity.

"The most urgent security need is a re-definition of the concept of security. Instead of one-sided national security, we need an international security system based on the rule of law. And in order to guarantee the rule of law, we need the active participation of non-governmental groups, movements, associations and institutions, and the mobilization of an international public opinion. In short, we need to aim for an international civil society.

* "Every minute 15 children in the world die for want of essential food and inexpensive vaccines, and every minute the world's military machine takes another $1,900,000 from the public treasury." * "In the 1980s, two governments in three have spent more to defend their citizens against military attack than against everyday hazards of disease, accidents, and ill health; one in three spent more on military power than on education and health care combined." * "....Since 1960 developing countries have increased their military expenditures more than twice as fast as living standards, measured by per capita income." (Quoted from: "World Military and Social Expenditures", 13th edition, by Ruth Leger Sivard)

"Military spending currently amounts to over $1,000 billion a year. It is rising fastest in the Third World. Even so, over half of world military spending is devoted to the confrontation in Europe. The end of the Cold War could free the resources necessary to meet the real and ever growing threats to human existence. It would only cost, for example, $2-3 billion a year - one day's military expenditure - to tackle the readily preventable causes of child mortality worldwide and thereby reduce by half the 14 million under-five children dying unnecessarily each year.

"....In drawing up this declaration, we have been inspired by the example of Costa Rica, where our meeting is held. Costa Rica abolished its army in 1948. An active civil society has ensured that resources released by the elimination of military spending have been devoted to human development and to environment. Costa Rica has shown how a small country can make a powerful contribution to peace both in its own region and in the world. The voice of Costa Rica is respected because it is not a military power. This is the new realism."

(Source: Press release, North-South Round Table Conference on Economics of Peace. San Jose, Costa Rica, 4-5 January 1990)

Preparations for the International Conference on Nutrition, co-sponsored by FAO and WHO, are proceeding. The date has been decided as December 1992, and the venue will be Rome. The Conference will be inter-governmental, involving all member governments - some 167 countries. It will be organized by WHO and FAO in close cooperation with other U.N. agencies, as appropriate through the ACC/SCN. Roles are foreseen for non-governmental organizations, scientific institutions, and industry. Already, the Conference has been discussed at all the FAO regional conferences, with presentations and participation by WHO. An extra session (the 17th) of the SCN is being held at the end of July, to involve all the U.N. agencies and bilateral donor representatives, review documents in preparation, and contribute to planning the next steps in the preparation.

Nutrition - One of Five Priorities in WHO's New Programme

"Every WHO programme is a contributor and a partner in advocacy for health through peace, equity and social justice" said WHO Director General Dr. Hiroshi Nakajima in the opening meeting of the 85th Session of the WHO Executive Board in Geneva on 15 January 1990. He however listed five areas which will be particularly emphasized in the implementation of WHO's general programme of work. One of these priority areas is nutrition. He went on to say that in spite of improvement and gains in agriculture and health technology in many countries, the fact that there is still widespread malnutrition and improper nutritional practice is "an unacceptable situation", and is affecting human resources development, which is fundamental to the infrastructure for overall development. WHO Director General announced to the Board that with FAO and other concerned parties an international conference of nutrition will be organized in 1992. Other priority areas to be emphasized are: relationships between world economy and health developments; environment and health; integrated approach to disease control and communication.

(Source: WHO Press Release WHOM, 15 January 1990)

A flurry of such headlines appeared over press articles recently. The trigger was the launch of the World Watch Institute's "State of the World 1990", led by Lester Brown. Here is an example.

"Our careless misuse of the planet's resources threatens much more than our air, our water and our climate - it is now posing a serious and very real threat to future food supplies, according to a disturbing new report".

"With the world's population spiralling out of control, the planet's capacity to provide enough food is fast running out. Every week, the population swells by about 1.7 million people, all of whom need to share limited food. "We'll be facing a food emergency in a few years" says Lester Brown... "we now have barely sixty days of emergency stocks left. Just one more summer in the United States like we had in 1988, and that will be the planet's Pearl Harbour, when it will wake up to reality"."

What is the reality?

Trends in the 1980s of per caput food availability showed slow rises in the developing world, except Africa - as for example shown in the SCN's First Report on the World Nutrition Situation. Most projections, for example FAO's "Agriculture towards the Year 2000" predict a continued slow overall rise in per caput food availability. Here again Africa is of particular concern. Sustainable development and environmental degradation are major concerns - however imminent global starvation is not generally considered to be the issue.

Making some enquiries and examining "State of the World 1990" gives the impression that a useful and timely debate may be stimulated. Some factors arguing for great uncertainty for the future are, for example, the direction in which biotechnology will go (notably animals or plants), the effects of economic and political developments, how prices will respond, etc. A major point made by World Watch is, however, that growth in grain yields are nearing their limits. But the supply-driven view is only one dimension. Physical availability of food is in principle not critical in global terms: World Watch's figures themselves (which are however not interpreted in this way) estimate current per capita grain availability as 316 kilograms, declining to 295 kilograms by 2000. Recalling that as much as 2000 calories/caput from grain per day (more than is normally eaten) equals around 210 kilograms per caput per year illustrates other dimensions. One is that substantial amounts of grain are used for animal feed. Another is that sheer global physical lack of grain is not the primary issue. Demand for food, its distribution, mechanisms for shifting in and out of different uses, and many other complex factors need to be fed into the equation.

At the same time, the figures quoted by World Watch should also be seen in proportional terms. For example, the quoted 18 million MT shortfall in grain in 1989 needs to be seen in the light of their overall projected consumption of 1,685 million MT - i.e. around 1%. This is serious, and should not be minimized, but needs to be seen in proportion. Equally, the World Watch estimates of loss of grain output due to environmental degradation are only given in millions of tons - which are difficult to conceive of. Their figures give a grain output loss from soil erosion of 9 million MT (which is 0.5% of total production) and from air pollution - including from ground level ozone - of 1 million tons; this is serious, but needs perhaps to be seen as a 0.05% loss.

Maybe viewing the figures in this way gives the perspective that World Watch's position is an early, perhaps timely, warning. No one doubts that environmental degradation and population pressure are among the most serious issues of our time. In a complex and integrating world, simplification gets attention, but can obscure the many facets of the concern.

(Sources: State of the World 1990, World Watch. Evening Press, Dublin, 9 June 1990.)

Education for All - A Renewed Commitment

A global consensus on a World Declaration and Framework for Action to achieve Education for All was reached during the World Conference on Education for All, which was held in Jomtien, Thailand, from 5 to 9 March 1990.

The Declaration documents the persisting realities that "more than 100 million children, including at least 60 million girls have no access to primary schooling; that more than 960 million adults, 2/3 of whom are women, are illiterate, and functional illiteracy is a significant problem in all countries, industrialized and developing; that more than 1/3 of the world's adults have no access to the printed knowledge, new skills and technologies that could improve the quality of their lives and help them shape, and adapt to, social and cultural changes; and that more than 100 million children and countless adults fail to complete basic education programmes, millions more satisfy the attendance requirements but do not acquire essential knowledge and skills". The participants in the conference reaffirmed that education is a fundamental right as the Universal Declaration of Human Rights asserted forty years ago. But an expanded vision for meeting basic learning needs is necessary to improve the seriously deficient provision of education and to increase effectiveness of current efforts. The Declaration makes it clear that basic learning needs "comprise both essential tools (such as literacy) and the basic learning content required by human beings".

The World Declaration on Education for All adopted by the participants in the conference contains ten Articles addressing the complexity of the challenge. Seven of these elaborate the "Purpose", while the last three describe the necessary "Requirements" for reaching the goal of education for all.

Young or old, it's always a good to learn to read or write.

(Source: Reproduced from 'INTERCOM', UNICEF, April 1989, No. 52.)

Article 6 on enhancing the environment for learning highlights the importance of sound nutrition and health care for improved learning capacity. The Article stresses that "Learning does not take place in isolation. Societies, therefore, must ensure that all learners receive the nutrition, health care, and general physical and emotional support they need in order to participate actively in and benefit from their education".

Developing a supportive policy context, mobilizing resources and strengthening international solidarity (Articles 8-10), are the necessary cited requirements for meeting the basic learning needs of all.

Reallocation of resources between sectors (e.g. a transfer of military expenditures to education sector), as well as special protection of basic education during structural adjustment programmes in particular in countries with high external debts would be urgently necessary. The least developed countries would also need international support both financial and otherwise, in order to meet the basic learning needs of their people.

The conference participants called on governments, concerned organizations and individuals for a renewed commitment towards achieving the goals of education for all.

(Source: Proceedings [preliminary version] of the World Conference on Education for All. Thailand, March 1990)

A thematic Roundtable on School Performance, Nutrition and Health was held during the World Conference on Education for All. It was chaired by the Kenya Minister for Education, Mr. Oloo Aringo.

The theme arose out of increasing experience in many developing countries about the centrality of nutrition and health factors as determinants of learning.

The presenters were Dr. Susan Van der Vynckt (UNESCO), Dr. Cecilia A. Florencio (University of the Philippines), Dr. John A. Nkinyangi (University of California, Los Angeles) and Ms Judit Katona-Apte (WFP). It was noted that not only does the literature underscore the fact that the incidence of malnutrition and poor health are widespread in developing countries but that up until now there has been no recognition among many Third World governments and donor agencies that these problems render children "unteachable". The studies show how highly prevalent nutrition and health conditions such as undernutrition and short-term hunger, lack of essential micronutrients (particularly iron and iodine), infection with intestinal parasites, and schistosomiasis are inhibiting children's learning, thus directly hindering many countries' efforts to provide effective learning opportunities to all their children. It was argued how in many developing countries school attendance in particular is greatly influenced by seasonal food shortages ("temporary hunger"), as well as by endemic diseases and illnesses resulting from poor living conditions.

(Source: Report on Thematic Roundtable No. 9, Bangkok, March 1990)

See also "Food for Thought" in this issue.

Iron deficiency is the most common nutritional disorder in the world, with an estimated 1.3 billion people suffering from anaemia, half of which is due to iron deficiency. Anaemia due to iron deficiency affects around half the pregnant women and pre-school children in many communities, and severe anaemia is a main cause of up to 20% of maternal deaths. Maternal anaemia leads to low birth weight, and iron deficiency in early life is associated with a significant loss of cognitive abilities.

Most national programmes to control and prevent iron deficiency anaemia are based on iron supplementation to achieve short term effects. Such programmes are usually targeted to sub-groups such as pregnant women or to areas where, for example, hookworm is prevalent. While experimentally the efficacy of iron supplementation in raising haemoglobin values in at-risk groups is well demonstrated, large-scale programme effectiveness has often been difficult to obtain.

Despite prevention and treatment being inexpensive, difficulties are still experienced with iron deficiency control programmes. The ACC/SCN organized a workshop to examine operational problems in controlling iron deficiency, on 6-8 June held in Dublin, chaired by Dr J Kevany of the SCN's Advisory Group on Nutrition. A full report of the meeting will be issued shortly, and here we give a brief summary of some of the major recommendations.

Pregnant and lactating women are the highest priority for iron supplementation, and where the deficiency is common, blanket coverage is recommended. The constraints in achieving this range from simply the supply of the supplement and its distribution, which needs to be increased many times; through to counselling by health workers, training, and other factors influencing compliance. Premature and low birth weight infants are another priority group, for whom a simple liquid preparation needs to be developed for administration in the first few months of life. For older preschool children where anaemia is common, screening and supplementation may be important.

Supplementation programmes are the major line of attack for these groups, but for others fortification and modification of diet are likely to be more effective approaches.

The cost of supplementation - which needs to be daily, which is part of the problem - is low, only around US$0.20 per pregnancy. The problems of supply need to be overcome by careful planning, procurement and additional (although relatively minor) financing. Distribution and ensuring compliance through antenatal and other health services requires raised priority, and support to make it succeed.

Preventing iron deficiency will lead to improved health especially in women and children, reduction and infant mortality, and increased productivity and learning capacity.

(Source: From background materials and the report of Workshop on Iron Deficiency, Trinity College, Dublin, 6-8 June 1990)

Some preliminary results from a large international research project on the interrelationships among health, eating habits, environment and social practices within China were quoted in our last issue of the SCN News (No. 4, late 1989, The Cornell-China-Oxford Research Project on Nutrition, Health and Environment). The results of this huge study are now appearing in the press. Jane E. Brody recently reported on some of the early epidemiological findings of this research in The New York Times, May this year.

These reported results are related, mainly, to the variations found in the dietary habits of the Chinese as compared to those of Americans, particularly in respect to animal fat and protein intakes. The study reports that the much larger intakes of fat and protein of animal origins in current American diet may be related to the existing higher risk of cancer, heart diseases and diabetes in this society. A more plant-based eating plan, it is reported, may promote health. This seems to be just a beginning for a chain of articles and reports on the findings of this massive research. The following quote is taken from the New York Times article.

"We are basically a vegetarian species and should be eating a wide variety of plant foods and minimizing our intake of animal foods" says Dr. T. Colin Campbell, a nutritional biochemist from Cornell University. The Chinese have already begun to capitalize on these findings, using them to develop national food and agricultural policies that will promote health. "Usually the first thing a country does in the course of economic development is to introduce a lot of livestock. Our data are showing that this is not a very smart move, and the Chinese are listening. They're realizing that animal-based agriculture in not the way to go."

(Source: Science Times, The New York Times, May, 8, 1990)

An important ruling from the World Bank Legal Department broadens opportunities for nutrition lending by the Bank. Setting a significant precedent for those planning nutrition projects, the Bank's Legal Department has concluded that provision of food supplements under circumstances common in World Bank nutrition projects "constitutes a clear productive purpose", and therefore can now be financed in such projects. This analysis stated that "while the supplements are a kind of food, i.e. enriched and fortified cereals, they are also specialized and are available to a particular group of individuals only under circumstances which are intended to be therapeutic.... These nutritional activities appear to be distinguishable from disbursing general food in a relief situation". Projects may now address food issues directly if analysis points to the limitation of food as the main constraint to achieving a key productive objective. And developing human resources through better nutrition is accepted as a productive objective.

(Source: The World Bank, May, 1990).

The important role of nutrition research in promoting health and development was highlighted in the WHO's Technical Discussions - on the role of health research in the strategy of Health for All by the Year 2000 - during the 43rd World Health Assembly this year. The report from this session emphasized the crucial role of nutrition in health, the importance of establishing national research priorities in nutrition, strengthening research capabilities. Among the points covered in the report were the following.

"...It is evident that there are insufficient centres for nutrition research so WHO has a particularly important role to play in encouraging the initial development of regional centres and subsequently the nurturing of national resources as well as the strengthening of the already existing ones. At least two research institutions in each of the WHO regions should take responsibility for conducting advanced degrees in nutrition. Training in regionally-related institutions should be encouraged.

"These centres should have their priorities set by local needs and by their governments but collaboration and the development of networks to amplify their effectiveness is important...."

"WHO itself needs to change dramatically its approach to nutrition.... given the importance of nutrition to so many health problems, a higher profile and a more systematic approach to promoting nutrition is a prerequisite if national governments are to be encouraged to follow suit."

The background paper prepared for the session assessed the global and regional state of nutrition research and gave suggestions for its development. It stressed that "...Because promoting healthy nutrition and preventing and managing malnutrition offer one of the most direct and effective means of improving the duration and quality of life, research into the interrelationships between food policies, diet and health has much to recommend it."

Dr. Dutra the president of the International Union of Nutrition Sciences (IUNS), in his speech to the 43th World Health Assembly in May, 1990, noted that "there has been a gap between nutrition knowledge and its application. The number of trained persons in nutrition is small, the recognition for their work is far from what would be expected and their brain drain to developed countries, including to international organizations, is going on. Countries and international organizations should stimulate the build up of training, research and countries nutrition centres in the area of nutrition specially in less developed countries. Nutrition has to be seen as a major factor for health and development. Everyone has the need and the right to eat everyday a balanced diet for better nutrition. The International Union of Nutrition Sciences along with governments and other NGO groups are certainly willing to see this goal to come true."

(Source: Report of Technical Discussions, 43rd World Health Assembly, May 1990)

Extensive re-examination of the current strategies and priorities in nutrition research is needed, according to the Nutrition Technical Advisory Committee of the International Development Research Centre (IDRC) of Canada. Examining the global trends in nutrition research over the past forty years, a recent report notes that more attention should be given to the actual situation in communities, including resources and knowledge. Some of the views in this context are reproduced below.

"The IDRC experience in dealing with nutrition has not been unique in its piecemeal approach. This experience parallels the evolution of concepts and knowledge within the greater nutrition research and development community. Research on nutrition has generally reflected views on causes of malnutrition current at the time.

"In the 1950s and 1960s, protein deficiency was considered the major cause of third world nutrition problems and this led to substantial investment in protein technology research. The complete failure of these technologies to make any indent on malnutrition resulted in a radical re-thinking of nutrition policies and priorities in the 1970s, with a new emphasis placed on the socio-economic context of malnutrition and the need for multi-sectoral nutritional planning. Nevertheless, by the 1980s, this new approach had proven to be overly ambitious, expensive, insensitive to the needs and desires of intended beneficiaries, unrealistic in terms of national government capabilities and its expectations for intersectoral collaboration, and too demanding on facilities for data collection, analysis and use.

"Some lessons may be learned from these past experiences in nutrition interventions and these can be applied to new initiatives. The extremes of "magic bullet" technical solutions and unwieldy, bureaucratic multi-sectoral interventions have not had much impact. Although a deeper understanding of the causal factors of malnutrition and their interactions are evolving, practical and analytical work is still required to develop and validate new approaches. A major conclusion is that not enough attention has been paid to the actual situation, resources and knowledge of malnourished people. For example, long-term trends and patterns in food availability and consumption should be understood as they relate to seasonal and demographic changes over a number of years. It is becoming increasingly clear that malnutrition in intimately linked to inequitable access to productive assets, low income, social discrimination and poverty. In many cases, total food production is adequate but the incidence of malnutrition is worsening. The food is there but beyond the reach of the poor. In other cases, however, and particularly in Africa, nutritional improvement may indeed be constrained by food shortages and environmental degradation.

"By focusing most analytical and promotional attention on the large centralized schemes, a whole range of smaller community-based experience and their lessons has been all but ignored. There is much potential for achieving improvements by involving local community members in the identification and analysis of their malnutrition problems. This local analysis can then lead to the choice of interventions, the identification of obstacles which can be addressed by the community members themselves, and those in which specific sectoral agencies and institutions could be effectively involved. NGO's in particular can be important vehicles for nutrition improvement programmes but their past track records and experiences have not been well documented or analyzed. In general, they are closer to communities and can assist in the articulation of local perceptions, needs and priorities. The challenge is to link these groups with national support programmes and to assess the replicability of their approaches."

(Source: Dr. Richard Young, Nutrition Unit, Agriculture, Food and Nutrition Sciences Division, International Development Research Centre (IDRC), P.O. Box 8500, Ottawa, Canada)

Epidemiological evidence is accumulating on the profound effects of vitamin A deficiency on resistance to infection and mortality risk. Basic research results from the laboratory are now beginning to show that vitamin A metabolites may be remarkably important in control of cell differentiation both in embryogenesis and throughout life. These results have far-reaching implications. It may turn out not to be media hype to label vitamin A "the impresario of life". Recent findings have been readably summarized by Natalie Angier in the New York Times, from which the following quotes were taken.

"The question of how a single fertilized egg blossoms into a complete human infant is one of the magnificent puzzles of biology, and scientists are just beginning to pinpoint the key genes and molecules that direct the intricate unfolding. But in a rush of new experiments, researchers have made the surprising discovery that one of those crucial impresario molecules of life is not some exotic or arcane compound, but retinoic acid, a familiar derivative of vitamin A.

"Emerging as a potent controller of development, retinoic acid evidently plays a pivotal role in normal cellular differentiation. It helps determine the shape and pattern of a broad array of the body's organs, including parts of the brain and spinal column, the face, the limbs, the heart, the skeleton, the liver and the skin. The molecule appears to work by nicking on whole groups of genes during key moments of development.... The results indicated that retinoic acid works as a morphogen, a molecule that helps cells to migrate and form patterns characteristic of mature organs. The vitamin derivative operates by entering a cell and somehow arousing one or more of its designated receptors. The receptors then glide over the cell's DNA molecule and flick on a battery of genes. The timing and amount of the retinoic acid that infiltrates the cell seem to help determine which genes become activated.

"These results come largely from studies of chicks and mice, but researchers believe that they are likely to apply to human development as well.

"It is believed that retinoic acid remains important in cell control throughout life, particularly in orchestrating the growth and health of epithelial tissue, which makes up the bulk of the skin, breast and the lining of the lungs, intestines and other organs. This information will be particularly stimulating for those researchers investigating the role of vitamin A in reducing morbidity and mortality, due to acute conditions, in children under five years of age..."

(Source: Science Times, The New York Times. Tuesday 20 March 1990)

The International Vitamin A Consultative Group (IVACG) held its 13th meeting in Kathmandu, Nepal, on 10 November 1989. Global dimensions of vitamin A deficiency, intervention strategies and long-term solutions for its prevention and control as well as new aspects of the vitamin A biology and assessment techniques were the main topics discussed in this largest IVACG meeting so far.

A number of important advances in this field were highlighted in the closing remarks of the IVACG Chairman Dr. A. Horwitz (who is also SCN Chairman). Here are some extracts from his speech.

"We celebrate this year the 76th Anniversary of the discovery of Vitamin A by E.V. McCallum. I had the honor to be his student at the Johns Hopkins School of Hygiene and Public Health, 45 years ago. He taught us nutrition. I remember well how modest he was, despite the greatness of his spirit and the significance of his discoveries for the well-being of the people. With the arrogance of the young, we underestimated the social consequences of the message he was conveying to us, namely, that vitamin A was essential for normal growth, resistance to infection and maintenance of ocular integrity...

"...Out of a complex and diversified agenda, we single out three major issues: vitamin A in morbidity and mortality in children; new assessment techniques; and the reports of country programmes from multilateral, bilateral, and nongovernmental organizations.

"With reference to the impact of vitamin A on morbidity and mortality of children under five, we all came to the IVACG meeting full of hope that the fundamental observations of Sommer and his colleagues in Ache, Indonesia, would be confirmed in other ecological and cultural settings where incidence and prevalence of vitamin A deficiency as well as food availability, eating patterns and health problems, may be different. We expected morbidity and mortality rates to be significantly reduced as compared with placebo controlled groups, linear growth increased, and hemoglobin levels raised.

"At this meeting, additional data which confirmed previous reports was presented from research projects in India, showing that improved vitamin A nutrition of pre-school children reduces mortality. Data from Thailand, Indonesia, and some other countries, suggest that vitamin A deficiency also increases childhood morbidity and that improving vitamin A nutrition of deficient children will reduce their rate of death and blindness.

"In interpreting the sense of the XIII IVACG Meeting, I believe that we can all agree that where vitamin A deficiency constitutes a significant public health problem, governments should initiate and/or extend appropriate programmes for improving vitamin A status, recognizing that deficiency generally exists within an environment of multiple deprivations that also require attention.

"Ongoing intervention trials will better define the level of impact that improved vitamin A nutrition will have in populations with different geographic, socioeconomic, and disease patterns and, thereby, assist government planners in choosing between alternative strategies and allocation of health and nutrition resources. Continuing research is needed to assess the mechanism(s) by which vitamin A exerts its effects, the impact that supplementation may have on less severely deficient populations, and the development of better methods for assessing and improving vitamin A status. In addition, operations research is needed to better identify constraints and barriers to implementation of various interventions as well as to improve the quality of services delivered. Better outputs and outcomes could be obtained with available resources....

"The reports from countries and the international community of agencies show progress in diverse degrees. A common denominator is that better information is available for defining country situations, particularly in Asia.

"The evidence that emerged from this meeting and the outcomes of studies underway should be carefully analyzed by the United Nations Sub-Committee on Nutrition (SCN) and its member Agencies in order to decide on policy implications. The question is, should vitamin A interventions be integrated regularly in the primary health care armamentarium to reduce morbidity and mortality of under fives, due to acute infection? Many of us believe that this should be done. I submit that the best forum for this highly significant decision is the forthcoming International Conference on Nutrition sponsored up to now by WHO and FAO, to be held in 1992. We hope that other major agencies, such as the World Bank, UNICEF, and UNESCO will also join to ensure well planned discussions on the basis of the best scientific evidence available on nutrition problems. IVACG should play a very active role in the planning phase of the conference.

"When all results are put together, this may be seen as a fundamental breakthrough in the history of vitamin A deficiency and public health."

(Source: Dr. A. Horwitz, Director Emeritus, Pan American Health Organization).

Street Foods: Socioeconomic Benefits Versus Potential Health Implications

Street foods have an enormous impact on the urban food supply, economically as well as socially and nutritionally. They also make a very large contribution to the national economy of those countries where they are being sold. Internationally, the financial turn-over of this unofficial industry runs into billions of dollars. For instance the annual sale of street foods in Malaysia is around US$2.2 billion. In the city of Bogor in Indonesia, annual sales of street foods are estimated as US$67 million.

Such facts were brought out in a Consultation on Street Foods convened by FAO in late 1988. Other points from this report (see source) were these. Street foods are an important part of urban life in many countries, playing an increasingly greater role in many others. By the year 2010, almost 40-45% of the population of India, Pakistan and Thailand will be urban. The movement of people from rural areas to urban centres has led to a need for feeding large number of working people on a daily basis. For instance, in Singapore one million street food meals are purchased every day. In Kuala Lumpur, Malaysia, an average of 25% of all household food expenditure goes for street foods. In addition to offering quick meals, to mainly lower income people and students, the vendors are a positive factor in the local economy providing employment. It is estimated that some 100,000 food vendors are employed in Malaysia and a million in China are believed to be involved in various aspects of this business. The numbers in other countries like India, Indonesia, Nigeria, Thailand and Peru must also be substantial. Based on a UNICEF report, 40,000 to 50,000 people were engaged in this informal trade in Senegal in 1979 while modern agribusiness and food industry provided jobs for just 6,800. Studies in Nigeria, Colombia, Peru and some Asian countries show that street food vendors usually earn more than the country's minimum wage and in some countries as much as three to ten times this level.

Street foods are inexpensive, provide variety and include traditional foods, are quickly served, ready to eat immediately, may provide nutritionally balanced meals and are tasty. Yet they have definite potential for serious health hazards due to microbial, and to a lesser extent, chemical contamination. Inadequate hygiene and sanitation in preparation and storage of food, particularly use of contaminated water, often result in various food-borne diseases due to pathogenic bacteria, as well as contamination with unsafe and non-permitted chemicals, colourings and food additives and presence of other adulterants such as road dusts and filth. In addition to fatal and/or various serious food-borne disease consequences, contaminated foods can also cause mild diarrhoeal diseases many of which are of short duration. They frequently are not reported to public health authorities, and almost become an accepted normal event. These have, however, significant economic importance when considering possible work absence, decrease in productivity, etc. In most countries the production and sale of street foods is not regulated by a food control organization.

In collaboration with a number of countries in Africa, Latin America and Asia, activities have been carried out with FAO assistance in reviewing various aspects of street foods as they pertain to their composition, availability and safety. An FAO Expert Consultation on Street Foods met in Yogyakarta, Indonesia from 5 to 9 December 1988. Realizing the socioeconomic and nutritional significance of street foods as well as their potential for health hazards, the Consultation upon reviewing the available information, strongly recommended official recognition of street food vendors, assisting the industry through development measures, and ultimate absorption of the vendors as partners in the urban food supply system and establishment of agencies responsible for providing control and supervision as first steps towards improving the situation. Not only training of vendors on the basic principles of sanitation, manufacturing quality and safety, but also consumer education would be necessary to enable them to evaluate the nutrition and safety value of the foods offered to them. Future studies should explore the feasibility of introducing new, low cost technology and inexpensive and effective fuel resources in the marketing of street foods. The Consultation recommended that FAO continue its efforts to coordinate and assist countries in their efforts to improve the food handling practices of street foods and to develop codes of practices. Appropriate action was suggested to be taken to bring the issues to the attention of national governments and international organizations so as to gain support and assistance.

(Source: Report of a FAO Expert Consultation on Street Foods. FAO Food and Nutrition Paper No. 46, 1989)

Under favourable conditions, a single bacterium can reproduce itself 10 million times within 12 hours,

Food Borne Illnesses

Food-borne diseases are still a major public health problem in the world, both in developed and developing countries. This is true in spite of the fact that food safety has been one of the main objectives of modern technology. While hundreds of thousands of cases of food borne diseases are reported from all over the world annually, WHO estimates that only a small fraction of these diseases is currently recognized and reported as being of food-borne origin. In developing countries, the ratio between real and reported cases may be as high as 100:1, while in developed countries only less than 10% of the total number of actual cases are in fact reported. WHO defines a food-borne disease as "a disease usually either infectious or toxic in nature, caused by agents that enter the body through the ingestion of food". Most food-borne diseases are caused by microbiologically-contaminated food. Such food is responsible for a high proportion of diarrhoeal and other infectious diseases, particularly in the developing world. Diarrhoeal diseases cause an estimated 1300 million episodes in the world annually, and result in some 4 to 5 million deaths among children under five years of age. As much as 70% of diarrhoeal diseases in the developing countries are now believed to be of food-borne origin. Repeated diarrhoea attacks are one of the main causes of malnutrition and account for 30% or more of paediatric hospitalization in many areas of the world.

(Extracted from: In Point of Fact, Health Organization) No. 67. April, 1990, World

A longitudinal study by P.W. Howie et al on 674 pairs of mother-infants in Dundee, Scotland showed beneficial effects of breastfeeding on gastrointestinal and respiratory illness during the first year of life. When the effect of breastfeeding of different durations on gastrointestinal illness was studied, it became evident that even breastfeeding for only 13 weeks may protect the infant against gastrointestinal illnesses up to the 24th month, demonstrating that breastfeeding has benefits long after it stops.

These findings provide yet further evidence on the crucial importance of proper feeding, by breast milk, in infancy.

(Source: British Medical Journal (1990), 300 (6716): 11-16)

Supplementary Feeding Counteracts Effects of Diarrhoea on Growth

Children living in poverty are at risk of malnutrition because of both inadequate food intake and infectious diseases, of which diarrhoea is particularly significant. When diets are limiting in energy and protein, increasing dietary intake is of obvious importance and is a key pathway through which nutritional supplementation is thought to influence nutritional status. The effectiveness of supplementation, however, may vary depending on the increased need for nutrients imposed by diarrhoea. Ascertaining the relative impacts of nutritional supplementation and diarrhoeal disease on growth and their interaction is thus important to clarify the mechanisms and conditions under which supplementation is most effective in improving growth. This was the topic of two recently completed studies that asked the question, "what are the effects of diarrhoea and nutrition supplementation on growth and are these effects additive or interactive?"

One recently completed study (Lutter et al, 1989)¹ has compared child length and diarrhoeal morbidity at 36 months of age for Colombian children supplemented from birth, and unsupplemented. Among unsupplemented children diarrhoea was negatively and significantly associated with body length. Among supplemented children diarrhoea had no effects on length. The more frequent the diarrhoea, the more effect the food supplement had. One way this was shown was to examine the effect of the supplement from 0 to 36 months. The difference in attained length between supplemented and unsupplemented children in the lowest quartile of diarrhoeal disease was small and not significant statistically. The difference became, however, progressively larger and more significant with age, so that in the highest quartile the difference was nearly 5 cm among supplemented and unsupplemented children.

Regression analysis confirmed significant differences in the slopes but not in the intercepts for supplemented versus unsupplemented children (see Fig. 1). Lack of a significant difference between the two intercepts indicates that in the absence of diarrhoea there was no difference in attained length due to the supplement.

The slope for supplemented children did not differ significantly from zero (but significantly differed from that of unsupplemented children), which indicates that among these supplemented children diarrhoea had no effect on attained length. In other words, supplementation completely offset the negative effect of diarrhoea on growth in these children. In contrast, the slope for unsupplemented children was significantly different from zero, showing that each day with diarrhoea was associated with a reduction of 0.03 cm in attained length at age 36 months.

FIG 1. Linear regression model for combined effect of supplementation and diarrhea on attained length. Supplemented (up), Unsupplemented (down).

In a second study, Martorell et al (1989)² also examined growth in length in Guatemalan children between 3 and 36 months, in relation to percent time ill with diarrhoea, and supplemental energy intake from two traditional beverages: one with a high amount of energy and one with lower energy. They found that the negative effect of diarrhoea on length was significantly less among those children who were high consumers of the high energy supplement compared to children who were consuming the low energy one. In contrast to the Colombian study the type of supplement was found to significantly affect length even at low levels of diarrhoea so that such children consuming the low energy supplement were approximately 1 cm shorter than those consuming the high energy supplement.

Results from both studies are consistent with a biological model, which predicts that the effect on attained length of a given level of nutritional supplementation will depend on both the prevalence of diarrhoea and the energy content of the home diet. The relationship between inadequate energy intake and diarrhoea is thus synergistic, and affects growth in a manner far greater than the simple additive effects of diarrhoea or inadequate intake alone would predict. Previous analyses, which did not consider the effect of diarrhoea, have shown the cumulative effect of nutritional supplementation on attained length at 36 months to be only 2 cm for these same Colombian and Guatemalan children. In contrast, Lutter et al have shown that among the Colombian children studied those in the highest diarrhoeal disease quartile the difference between supplemented and unsupplemented groups was nearly 5 cm.

The differences that were found between the two studies (in Colombia and Guatemala) are not the result of differences in the underlying biological model, but the result of vastly different amounts of energy available in the home diet in the absence of supplementation. While the percent time ill with diarrhoea was similar in both populations, unsupplemented Colombian children consumed almost twice as much energy as Guatemalan children (1329 versus 778 Kcal/day). The net increase in energy intake among supplemented Colombian children averaged 120 Kcal per day, and among Guatemalan children consuming high amounts of the high energy supplement, 124 Kcal per day. Thus, the finding in Guatemala of a supplement effect across high energy supplement categories even in children without diarrhoea can be attributed to the larger energy deficit in their home diets. This is not the case in Colombia where supplementation did not contribute to improved growth in the absence of diarrhoea, presumably because home diets were adequate.

Two mechanisms through which supplementation and diarrhoea interact to affect growth are possible: 1) if supplementation results in increased dietary intake during the illness episode, the immediate negative effect of diarrhoea on nutritional status may be offset; 2) if supplementation leads to increased dietary intake immediately after an illness episode, catch-up growth may occur. The latter pathway may be particularly important if intake cannot be increased during a diarrhoeal episode because of anorexia and if catch-up is constrained during convalescence for lack of nutrients. The two mechanisms, increased intake during diarrhoea versus during convalescence, are not mutually exclusive and both may be operating.

The results presented in both studies were based on the effect of supplementary feeding. Similar results might be expected from any nutrition programme that leads to increased dietary intake. Thus one important strategy to reduce the nutritional deficits and growth retardation associated with diarrhoea is to encourage continued feeding during the diarrhoeal episode and increased feeding during the convalescence period. Combining nutrition programmes with diarrhoeal treatment programmes should encourage maternal compliance with this strategy. Combining nutrition supplementation programmes with diarrhoeal disease control programmes would also provide a highly targeted setting in which to provide nutritional supplementation and, thus, should increase its effectiveness in preventing growth retardation associated with diarrhoeal disease.

(Source: Based on article provided by Dr Lutter and "Nutritional supplementation: effects on child stunting because of diarrhoea." American Journal of Clinical Nutrition, 1989, 50:1-8)

1) Lutter, C.K. et al (1989). Am. J. Clin. Nut. 50, 1-8.

2) Martorell et al (1989) In: Breastfeeding, Nutrition, Infection and Infant Growth in Developed and Emerging Countries, SA Atkinson et al (eds) ARTS Biomedical Publishers and Distributors, St. John's, Newfoundland, Canada. 1989)

An informal group of officials and consultants from WHO, UNICEF, USAID and SIDA, known as the Interagency Group for Action on Breastfeeding (IGAB), has been meeting periodically to consider strategies to protect, promote and support breastfeeding. The Group agreed that breastfeeding can be viewed as both a goal and a strategy: it is a key strategy for the attainment of so many goals, relating to the survival and development of children, child nutrition, control of diarrhoeal diseases, birth spacing, and mothers' health and well-being, that it is expedient to regard it as a legitimate goal in itself. The strategy to achieve those goals is to create an environment of awareness and support such that those women who choose to exercise their right to breastfeed are able to do so. Mothers should be empowered to practice exclusive breastfeeding through the first four to six months of life and to continue breastfeeding with complementary foods well into the second year - or longer.

On the following critical areas reviews and workshops have been, or are being, conducted: Current status and trends of breastfeeding and modern knowledge of its benefits; practices of health services relating to breastfeeding; education and training in lactation management; women, work and breastfeeding; linkages with other primary health care programmes (notably control of diarrhoeal diseases), information, education and communication; and marketing of breastmilk substitutes.

A technical meeting organized by WHO from 25 to 28 June in Geneva reviewed the results of these exercises. The outcome of this was then considered at a meeting for senior policy makers from governments and agencies held at the International Child Development Centre in Florence, Italy from 30 July to 1 August this year, in order to reach consensus on a strategy to increase prevalence and duration of breastfeeding, and mechanisms to implement it as part of overall efforts to improve infant and young child health and welfare. Recommendations from this meeting will be presented to the World Summit for Children (29-30 September 1990).

(Source: UNICEF, CF/Prog/HN/1990/002).

"The first two years of life are the most critical for the child, for it is during this period that the pattern of its future growth and development is established. Thus, the only way to reduce the prevalence of stunting is to take preventive action, ideally monitoring growth from birth, creating an environment of awareness and support such that mothers are enabled to breastfeed their children exclusively for the first four to six months of life, and ensuring that complementary foods in addition to breastmilk are provided thereafter. Such foods need to be of appropriate quality and provided in appropriate quantity and at appropriate frequency.

"Growth and activity are dependent on the intake of nutrients from the diet (and perhaps from nutritional supplements), but are also influenced by exposure to infection, which affects intake and the utilization of nutrients by the body. Therefore each household or family must be able to enjoy food security meaning assurance of foods to meet the needs of all its members throughout each season of the year, and also health security, meaning access to appropriate health services, in a healthy environment. But in addition a third component is essential, which may be termed caring capacity, encompassing knowledge and understanding of the mother - and other members of the family - about the dietary, health and social, psychological and cognitive needs of the infant or young child, coupled with the ability to provide child care. These characteristics are much influenced by attributes such as literacy, education, independent source of income and - notably -sufficient time.

"Although these three components of food, health and care are each necessary, in a sense the greatest of them is care, for whatever foods and health services may be available they are unlikely to benefit the child below two years of age if care and developmentally sensitive interaction are lacking; while if care and commitment to the child are abundant then, even if food and health security are marginal, resources can more readily be mobilized in favour of the child. Moreover, developmentally sensitive interaction - interaction that includes early stimulation and satisfies a child's need to grow socially, psychologically and cognitively - has a direct and measurable impact on the health and nutritional status of the young child. Effective and sustainable programmes to improve the nutritional status of infants and young children must address simultaneously, therefore, all three needs: for food security, health security and developmentally sensitive care."

(An excerpt from the Foreword, by Mr James P. Grant. Executive Director of UNICEF to the forthcoming book "Infant and Child Nutrition Worldwide: Issues and Perspectives", edited by Frank Falkner, M.D., F.R.C.P., Professor Emeritus, Maternal and Child Health Programme, University of California, Berkeley, to be published by The Telford Press, New Jersey, in Mid-1990.)

Safe Water 2000

By the end of this year, the International Drinking Water Supply and Sanitation Decade launched by the UN 10 years ago - as a tool for promoting the goal of water and sanitation for all - will be over. While 600 million new users now have safe water and 250 million people are now supplied with proper latrines installed for better health and hygiene, much still remains to be done.

"Urban water supply and sanitation is improving. In rural areas, water supply coverage has risen from 30% to almost 50% in the past ten years, but only 17% of the rural population has access to appropriate means of sanitation. Everywhere, the world is facing pollution and loss of natural resources - water, land, air, vegetation and even genetic diversity - with many unknown adverse consequences for human health." (From the statement made by Dr. H. Nakajima, Director General of WHO to the World Health Assembly and the Executive Board. WHO, January 1990)

Ladies and gentlemen, this is the last bottle of unpolluted water in the world. China Daily cartoon by Zhang Yaoning

A Global Consultation on Safe Water and Sanitation for the 1990s (Safe Water 2000) will be held in New Delhi, 10-13 September this year, to provide a forum for the exchange of experience and planning, in which the governments of developing countries and external support agencies will participate. The Consultation is expected to arrive at strategies, built on the world-wide experience during the past years, which could be supported by the international community. The results of the consultation will be brought to the attention of the United Nations General Assembly at its 45th session, in November 1990.

For more information contact: Ms Eirah Gorre-Dale, Information Co-ordinator. Global Consultation on Safe Water and Sanitation for the 1990s. UNDP, 16 Avenue Jean-Trembley, Petit-Saconnex. CH-1209 Geneva, Switzerland. Telex: 415464 udp.

(Source: UNDP Newsletter; January 1990)

The objective of sustainability should benefit employment by substituting employment for scarce physical resources. Views on "New strategies and successful examples for sustainable development in the Third World" were presented by Michael Lipton at a hearing on "Sustainable Development and Economic Growth in the Third World" which was held, on June 20, 1989, by the Joint Economic Committee of the US Congress, Subcommittee on Technology and National Security. He concluded his paper by the following remarks.

"....Whether intensive or marginal cultivation is emphasized, we all - in rich and poor countries and in education, research, or technology transfer - need to recall a central issue. What needs to be "sustainable" is not a particular form of farming, nor a particular use of this or that piece of land. What has to be sustained is the capacity of people, countries, and the world to support decent livelihoods. An important implication of this becomes clear when we consider that a growing majority of the world's poor derive their sustenance not from farming their own land, but from working for other farmers as employees. How are their livelihoods, and the soil and water that support them, to be sustained? Patterns of farming that are labor-intensive yet resource sparing need to be extended, transferred, or (sometimes) invented. Examples are using more labor but increasing the productivity of small amounts of nutrient by placing slow-release or mudball fertilizers in the root zone, thus substituting employment for chemicals; and intensive management (for example, by cross bunding) of irrigation and drainage, substituting employment for water. Such inputs as tractors, threshers, and weedicides - which substitute cash purchases for employment, and at the same time may require more skillful management to sustain the environment - are sometimes desirable in Third World agricultures. But if our perspective is that of sustainable livelihoods, there is always a strong presumption against any subsidy to such inputs, or to research on them."

(Source: IFPRI Reprint No. 170)

When computers were first used for health data analysis, their speed compared to manual methods felt like old dreams coming true. Soon the main drawback of these devices became apparent: their dependence on mains power supply and the fact that they were not portable, restricted their value for field data collection. Furthermore, data collection had to first be made by filling in recording forms, which occupy storage space in extensive field surveys and often get damaged or misplaced if insufficient care is exercised.

The use of hand-held computers (HHC) for health data collection is reported to solve many of these problems. HHCs are portable, battery-operated computers about the size of a pocket calculator, with the ability to capture and retain data which can subsequently be uploaded directly to a host computer locally or transmitted accurately to a host computer from a remote site over standard telephone lines. Electronic versions of the recording form can be generated on HHC directly or on a microcomputer then downloaded to the HHC. Operational time is between 10 to 15 hours for fully charged nickel-cadmium batteries. The batteries can be recharged overnight ready for field operations the next day.

A collaborative project between WHO's Division of Information System Support (ISS) and the Department of Community, Occupational and Family Medicine of the National University of Singapore on the use of HHC for health data collection started in July 1987 and ended in May 1988. In this study three models of HHC were tested and evaluated and the results from field trials demonstrated the advantages over the use of recording forms.

The models tested (Telxon, Epson, Hunter) were 64K to 144K machines costing $600 to $2000. The potential applications of these new devices could be enormous. They can be adapted to a diverse range of activities in which desk type computers are inappropriate and may change the way health (and other) statistics are collected.

For more information, please contact Dr. S.H. Mandil, Director of Information Systems Support (ISS), WHO, 20 Avenue Appia, 1211 Geneva. Telex: 415 416.

(Source: World Health, September/August 1989)

The so-called infant formula controversy became once again a matter of public debate when in October 1988 Action for Corporate Accountability launched another boycott of Nestle products, for alleged violations of the International Code of Marketing of Breast-Milk Substitutes. This time the boycott included the major manufacturers of breastmilk substitutes in a country, as well as Nestle. The issue of chief concern was the continued provision of free supplies of breastmilk substitutes to hospitals.

UNICEF had facilitated discussions between the International Nestle Boycott Committee and Nestle which had led to the ending of the first Nestle boycott, after seven years. The boycott was ended on the understanding that this issue of free supplies would be clarified and addressed.

Because of its earlier involvement UNICEF last year received hundreds of letters from the media, individuals and organizations enquiring about its position. This led to the formulation by UNICEF of a concise statement setting out its position on infant feeding. This statement (dated 10 July 1989) is reproduced in the box opposite.

The statement clarifies UNICEF's stand regarding the issue of free supplies, reaffirms support for the World Health Assembly resolutions, and confirms UNICEF's continued commitment to the protection, promotion and support of breastfeeding.

State-of-the-Code

IBFAN monitors compliance with the International Code of Marketing of Breast-Milk Substitute. 1988 State of the Code by Country - a survey of measures taken by governments to implement the provisions of the International Code of Marketing of Breast-Milk Substitutes - shown on margin (see opposite).

UNICEF POSITION ON INFANT FEEDING IBFAN SCALE - The code in 168 countries 1. Every effort should be made to promote and ensure the initiation and maintenance of breast-feeding, beginning at birth. UNICEF believes this to be the right of all newborn infants and their mothers. 2. In May 1989 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) published a joint statement on the protection, promotion and support of breastfeeding, with special reference to the role of maternity services1. This statement describes in detail activities that every facility providing maternity services and care for newborn infants should undertake to encourage the initiation and maintenance of breastfeeding, and summarizes them as "ten steps to successful breast-feeding". 3. UNICEF urges each concerned party referred to in the International Code of Marketing of Breast-Milk Substitutes2 (adopted by the World Health Assembly (WHA) in 1981) to implement and monitor its provisions. The parties include Governments and United Nations agencies (Articles 11.1 and 11.2), manufacturers and distributors of products within the scope of the Code (Article 11.3), and non-governmental organizations and individuals (Article 11.4). 4. Since the adoption of the Code, Article 6.6 has received much attention. This article states that "Donations or low-price sales to institutions or organizations... of supplies of infant formula... may be made. Such supplies should only be used... for infants who have to be fed on breast-milk substitutes. (They) should not be used by manufacturers or distributors as a sales inducement". It is important to recall that the reference to "institutions or organizations" was intended to ensure that institutions, specifically orphanages and social welfare agencies, caring for deprived children, could obtain donations to meet the legitimate needs of children in their care. In making this provision for free supplies, the drafters of the Code did not intend to include direct health care providers such as maternity hospitals. 5. UNICEF endorses subsequent resolutions of the WHA on infant and child feeding, especially resolution 39.283 which clarifies Article 6.6. Resolution 39.28 noted that "only small quantities of breast-milk substitutes are ordinarily required to meet the needs of a minority of infants (in maternity wards and hospitals) and they should only be made available in ways that do not interfere with the protection and promotion of breast-feeding for the majority". Para 2.6 urged Governments "to ensure that the small amounts of breast-milk substitutes needed for the minority of infants who require them in maternity wards and hospitals are made available through normal procurement channels and not through free or subsidized supplies". 6. Virtually all women can lactate; genuine physiopathological reasons for not being able to breastfeed are rare1. Health care providers should help to ensure that women who choose not to breastfeed fully understand the financial implications of their decision. 7. It has been shown that the ready availability of breastmilk substitutes can undermine the successful initiation of breastfeeding and because the quantities really needed by maternity wards and hospitals are so small, UNICEF advocates that these small quantities should be purchased. However, in institutions such as orphanages where the genuine need for breastmilk substitutes may be substantial, UNICEF supports the donation of free supplies, as provided for in Article 6.6. of the Code. Furthermore, UNICEF urges that donors as well as institutions bear in mind their responsibility to ensure that supplies, when distributed through institutions, are continued as long as the infants concerned need them, as provided for in Article 6.7. 8. UNICEF's mandate is to protect children and promote their optimal survival, growth and development. UNICEF appreciates the work of the many organizations monitoring and aiding in the implementation of the Code. UNICEF is always concerned at any evidence that the Code is being violated. 9. UNICEF reaffirms that all infants should be exclusively breastfed for the first four to six months of life, and that women should receive the support they need to enable them to do this. Thereafter foods complementary to breastmilk need to be introduced, but breastfeeding should continue well into the second year of a child's life and for longer if possible. Specially formulated milks (so-called "follow-up milks") are not necessary. Complementary foods should be prepared at home from foods available to the family. Industrially prepared foods, which are suitable as part of a mixed diet to complement breastmilk, may be a convenience under certain circumstances. They provide an option for some mothers who have both the means to buy them and the knowledge and facilities to prepare and feed them safely to their children. But they are not nutritionally indispensable. 10. UNICEF, as part of its programmes of country cooperation, will continue to support national efforts to implement the International Code of Marketing of Breast-Milk Substitutes, WHA 39.28, other WHA resolutions and all other activities aimed at improving infant and young child feeding. Because of the continuing decline in breastfeeding, UNICEF is accelerating its efforts in this area in order to enhance the gains made over the past decade in other areas of child survival and development. (Sources: Dr J. P. Greaves; UNICEF document 10 July 1989) NOTES (1) Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement, WHO, Geneva, 1989. (2) International Code of Marketing of Breastmilk Substitutes, WHO, Geneva. 1981. (3) Infant and Young Child Feeding, WHA Resolution 39.28, WHO, Geneva. 1986.

Commission on Health Research for Development Reports

Global disparities in health are the result of uneven progress in health and development. Health interdependence in our world is increasing, paradoxically, when the economic gap between poor and rich is widening. By the beginning of the last decade of the 20th century, advancing health status of the poorer countries has proved to be much more complex than previously thought. An under-recognized and neglected yet powerful tool to aid in this and to overcome these hindrances is research. Wise policy and management decisions in health and development depend on the results of research. But while research results are needed urgently to empower those who must accomplish more with fewer resources, "there is a gross mismatch between the burden of illness, which is overwhelmingly in the Third World, and investment in health research which is overwhelmingly focused on the health problems of the industrialized countries".

A comprehensive analysis of global health status, key problems and obstacles to its betterment, and proposed strategies to use research in order to overcome health disparities and accelerate development and health improvements worldwide, has recently been reported by the Commission on Health Research for Development. This is an independent international initiative to strengthen worldwide research on the health problems of developing nations, formed in 1987. It is supported by 16 funders from North America, Europe, Asia and Latin America. The Commission's mandate was to survey current health research worldwide, identify strengths and weaknesses, and propose improvements. Health research includes any scientifically based research that is aimed at improving health and health systems.

The report - "Health Research, Essential Link to Equity in Development" - was released at the Nobel Conference on Health Research held in Sweden, 22-23 February this year. It has been the result of two-year extensive worldwide research, country case-studies, commissioned special papers and consultations with world leaders, policy makers and health and development experts around the world. The report thus represents the ideas and experience of many people. It makes a strong case for research as a powerful tool to bring about health and development equity throughout our globe.

The results of a survey, the first of its kind, of global research on the health problems of developing countries plus a study of the main resource flows to supporting it has produced a range of useful basic information on the present state of health research. For example, it is estimated that worldwide annual investment for research on health is about US$30 billion, but only about 5% is devoted to the health problems of developing countries, which account for 93% of the years of potential life lost in the world.

The book, published by Oxford University Press, has three main parts. In the first, profound global inequities in health are reviewed. On the relationship between health and development, it is argued that health is not only a beneficiary of development but a driving force for it as well.

The essentiality of research, a systematic process to generate new knowledge, in order to improve Third World health and its links to equity in development is brought to light. Part two is devoted to the Commission's findings from surveys and country studies. These relate to the financing research on developing-country health problems, where it is done and how it is promoted. Conclusions and recommendations form the third part of this report.

A set of strategies is proposed. Suggestions are based on envisaging a pluralistic worldwide health research system that will nurture productive national scientific research groups linked together in transnational networks to address both national and global health problems. The Commissions major recommendations are the following:

* All countries should vigorously undertake essential national health research to accelerate health action in diverse national and community settings and ensure that resources available for the health sector achieve maximum results. Research should not be limited only to the health sector but should include the health impact of development in other interacting sectors. At present the most urgent need in virtually all countries is for a rapid enlargement of capacity for country-specific health research. It is suggested that at least 2% of national health expenditures should be devoted to essential national health research.

* World scientific capacity should be mobilized and focussed, through international partnerships, on the highest-priority health problems.

* Larger and more sustained financial support for research from international sources should be mobilized to supplement investments by developing countries.

* An international mechanism should be established, as a forum for review and advocacy, to monitor progress and to promote financial and technical support for research on health problems of developing countries.

(Source: Report of the Commission on Health Research for Development "Health Research, Essential Link to Equity in Development", 1990)

M.L.

Professor Tandon Honoured at WHO

Professor B.N. Tandon of the All India Institute of Medical Research, was awarded the Sasakawa Health prize for 1990, at a ceremony during the World Health Assembly in May. His acceptance speech included the following.

"Our National Children's Board is the first body to lay down the policies for child welfare. It has always been chaired by the Prime Minister. Several programmes for children have been launched in the country. We are very happy that today we have the largest national programme for child development in the world. It is neither a pilot project nor a demonstration project, but a national programme which covers about 50% of my large country. The programme has been on the ground for 15 years. It has been gradually 40 expanding with the goal of covering the whole country by the year 2000. It is neither dependent on foreign aid nor on loans, so it can be sustained by national resources. We have given it the name of Integrated Child Development Services (ICDS). The major component of this programme includes the essential components of primary health care, education and psychosocial development. I state with all humility that this programme has achieved substantial success."

(Source: Provisional Verbatim Record of the Sixth Plenary Meeting, World Health Assembly, May, 9, 1990)

The University of Agriculture and Forestry in Thu-Duc, Ho-Chi-Minh City - jointly with the Nutrition Unit, Institute National Agronomique in Paris - is organizing a workshop on nutrition training at postgraduate level for students in Agriculture and Health Sciences from South-East Asian countries.

The workshop will be held at Thu-Duc, August, 27-31, 1990. For further information please contact: Dr. J.C. Dillon, Institute National Agronomique, 78850, Grignon, France. Fax: 33-1-30549454.

Rapid Assessment Procedures

An International Conference on Rapid Assessment Methodologies for Planning and Evaluation of Health Related Programmes will take place from 12 to 15, November, 1990, in PAHO Headquarters, Washington, D.C. Please see notes under UNU, in the Programme News section of this issue for more details.

Course on Agricultural Policies and Structural Adjustments Analysis - Montpellier

The International Center for Higher Studies of the Mediterranean Agronomic Institute in Montpellier, France, has arranged the above course to take place from 14 January to 8 March 1991. The main objectives of the course are to provide information and training on structural adjustment modalities and their differential impacts on the national food and agricultural complex, to enable participants to understand the elements of the economic and political debate on the subject, and to identify methods for information analysis and decision making. The tuition fee is 8000 French Francs.

For more information please contact: Directeur, Institute Agronomique Mediterranean, 3191, route de Mende. BP 5056, 34044 Montpellier Cedex 1, France. Telex: 480783 F.

Symposium on Refugees' Nutritional Crisis -Oxford

Starvation and nutrient deficiency diseases have often been associated with the quality and quantity of food provided to refugees. The extent and causes of such deficiencies in relief must be more widely recognized if they are not to recur. We were asked to publish the following announcement.

An international symposium on "Responding to the Nutritional Crisis of Refugees: The Need for New Approaches" will be held from 17 to 20 March 1991, at the University of Oxford. The objective of this symposium is to establish the dimensions of the nutrition-related problems of refugees in developing countries (with a focus on Africa where the problems have the most serious consequences). On the basis of the review of the existing system of food (and other service) provision, and of the current international system of responsibilities, the symposium will seek to recommend practical and solution-oriented proposals to alleviate the problems identified in refugee relief programmes.

The symposium is being organized by a Steering Committee comprising the Refugee Studies Programme, University of Oxford, with the Department of Human Nutrition, London School of Hygiene and Tropical Medicine; International Rescue Committee (USA): Medecins Sans Frontieres (Belgium, France, The Netherlands); Oxfam (UK); Save the Children Fund (UK); UNHCR and WFP.

More information from Refugee Studies Programme, University of Oxford. International Development Centre, Queen Elizabeth House, 21 St. Giles, Oxford, 0X1 3LA. Telex: 83147 QEH/RSP.

European Nutrition Conference

The 6th European Nutrition Conference is being organized from 26 to 28 May 1991 in Athens by the Greek Society of Nutrition and Foods under the sponsorship of the Federation of European Nutrition Societies (FENS). The Conference will include plenary sessions, posters, workshops and short papers. The followings are the main topics to be covered: current perspectives on diet and disease; factors determining individual eating behaviour; biotechnology and the future of agriculture; novel foods; and a European nutrition policy.

More information from: Sixth FENS European Nutrition Conference, c/o Department of Nutrition and Biochemistry, Athens School of Public Health, 196, Alexandras Avenue, GR-115 21 Athens, Greece. Telefax (301) 6436536.

Also as noted in SCN News No. 3, the First European Conference on Food and Nutrition Policy will be held in Budapest from 1 to 5 October 1990. For information please contact Dr. Elizabeth Helsing, Nutrition Unit, WHO Regional Office for Europe, 8, Scherfigsvej, 2100 Copenhagen 0, Denmark.

Food Security in Sub-saharan Africa: Policy, Planning and Interventions - IDS, UK

Despite nearly two decades of food planning, increasing numbers of people in Africa face seasonal or permanent food insecurity. The situation has been further aggravated by an overall deterioration in living standards in many African countries throughout the 1980s and by unfavourable macro-economic and international conditions.

Poverty, vulnerability, drought and unemployment make food security a major concern of most African governments. Aid donors are also urgently seeking new and more effective ways of supporting national food plans, especially in the aftermath of emergency famine relief programmes in the mid-1980s.

The Institute of Development Studies (IDS) having a long experience of research and operational work on food security and related issues, will be offering a new 8 week course, from 28 May to 20 July 1991, on food security planning in Sub-Saharan Africa. The course is designed for food security planners, policy makers and practitioners from the region as well as NGOs and donor agency personnel working in the area of food security, and combines analysis of policy issues with practical training in planning skills. All participants are expected to bring material with them pertaining to their own country and areas of interest which will feed into this case study work. Course fees, accommodation (including breakfast) and all field study visits will be 4126 English pounds. Applicants are advised to seek funding as early as possible.

Further information on IDS courses from: The Chairman, Teaching Area, Institute of Development Studies at the University of Sussex, Falmer, Brighton BN1 9RE England. Telex 877997 IDSBTN G.

Congress of Nutrition in Puerto Rico

The Latin American Society of Nutrition (SLAN) is planning to hold a scientific meeting, as part of the commemoration for its 25th Anniversary, with the purpose of strengthening scientific exchanges among the participants as well as distributing information on the work during its 25 years of existence. This IX Latin American Nutrition Congress and the First Iberian-Pan American Nutrition Congress will be taken place from 22-26 September 1991, in San Juan, Puerto Rico. The SCN will be among the sponsors.

More information from Professor Jaime Ariza, Nutrition Programme, Graduate School of Public Health, Medical Sciences Building, University of Puerto Rico, G.P.O. Box 2156. San Juan, Puerto Rico, 00936. Tel: 809-758 2525, Ext. 1433 and 1460. Fax: 809 759 6719.

Asian Congress of Nutrition

The sixth Asian Congress of Nutrition will be held in Kuala Lumpur, Malaysia, between September 16 to 19, 1991. Information on this congress can be requested from Dr. Aree Valyasevi, The United Nations University, Institute of Nutrition, Mahidol University, Nakornchaisri, Nakornpathom, 73170, Thailand. Telex: 84770, UNIMAHI TH.

International Nutrition Course in UC, Davis

The University of California, Davis has established a new interdepartmental Programme in International Nutrition (PIN). The Programme coordinates educational, research and service activities of faculty members from several departments in the College of Agriculture and Environmental Sciences (Departments of Nutrition, Applied Behavioural Sciences, Agricultural Economics) and the School of Medicine.

The educational curriculum will offer graduate level courses and seminars in international nutrition, including training in basic biological, behavioural and social sciences as well as instruction in the planning, implementation and evaluation of nutrition programmes at the community and national levels. The programme will emphasize an interdisciplinary approach to the solution of nutrition problems.

The PIN is establishing linkages with research and training institutions in less developed countries to foster collaborative research and to provide opportunities for exchange of faculty and students.

Prospective students interested in participating in the PIN must be accepted into one of the existing graduate programmes at UC, Davis, such as the Graduate Group in Nutrition or the graduate programmes in economics, human development, international agricultural development or epidemiology.

Information regarding admission to these programmes can be obtained by writing to the Office of Graduate Admissions, University of California, Davis, California 95616.

A limited number of fellowships are available through the PIN for students with excellent academic credential and a demonstrated commitment to contribute to the solution of nutrition problems of developing countries - seeking a doctoral degree. Application forms can be obtained from the Director, Programme in International Nutrition, Department of Nutrition, University of California, Davis, California 95616, USA.

The United Nations Calendar of Special Days

While 1990 is designated as International Literacy Year, and September 8 as International Literacy Day in the United Nations calendar of events, the followings are some other special dates to remember for this year.

18 September - International Day of Peace
1 October - International Day for Natural Disaster Reduction
6 October - Universal Children's Day
16 October - World Food Day
24 October - United Nations Day
1 December - World AIDS Day
5 December - International Volunteers Day for Economic and Social Development
10 December - Human Rights Day

(Source: The United Nations Social Agenda, 3)

Dr Abraham Horwitz, Director Emeritus of the Pan American Health Organization (PAHO), was unanimously re-elected as the Chairman of the Sub-Committee on Nutrition (SCN), at the Executive Session on 21 February 1990, for a further period of two years from February this year.

Professor Reynaldo Martorell (Honduras), of Stanford University, USA, was appointed Chairman of the Advisory Group on Nutrition (AGN). He takes over from Prof. J. Kevany (Ireland), AGN Chairman for the last two years, who remains an AGN member.

Studies on Iron and Zinc Bioavailability by Isotopes

A new Co-ordinated Research Programme (CRP) will be started by the International Atomic Energy Agency, Nutritional and Health-Related Environmental Studies section, later this year. 12 to 15 institutes, mainly in developing countries will participate in a core programme in which mainly iron but also zinc nutrition will be studied according to an agreed protocol. Isotope-aided studies will be carried out to assess the bioavailability of iron and zinc from human diets. While in some developing countries research on these areas has already been carried out, more needs to be known about the factors affecting bioavailability and the means to improve it. The first Research Coordinating Meeting tentatively scheduled for late 1990 or early 1991, will work out the details concerning the work to be done. Studies in developing countries relating to the planning and/or support of appropriate local intervention programmes for the alleviation of iron deficiency will be given high priority. Please see notes under IAEA in the Programme News section of this issue of SCN NEWS for more details.

(Source: Dr. Parr, Section of Nutritional and Health-Related Environmental Studies, IAEA, Austria)

The IAEA, with the participation of the Commission of the European Communities (CEC), the Food and Agriculture Organization (FAO), the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), and the World Health Organization (WHO), is organizing a major project in which a team of independent international experts will assess the radiological consequences in the USSR of the Chernobyl accident. The survey will include the health and environmental effects, and will evaluate the protective measures taken by the Soviet authorities. The IAEA will publish these findings and arrange for open meetings in which the results of the study can be examined.

The project follows a request made in October 1989 by the Government of the USSR to the IAEA to organize an assessment by international experts of "the concept which the USSR has evolved to enable the population to live safely in areas affected by radioactive contamination following the Chernobyl accident, and an evaluation of the effectiveness of the steps taken in these areas to safeguard the health of the population."

A preliminary meeting between officials of the USSR, the Ukrainian SSR and the Byelorussian SSR and of the IAEA was held in Moscow on 7-9 February 1990 to outline a plan of action to carry out an assessment.

An International Experts' Preparatory Mission was subsequently organized by the IAEA to identify the major assessment to be made. The experts visited the affected areas of the Byelorussian SSR, the Ukrainian SSR and the Russian FSSR from 25 to 30 March 1990 and drafted a proposed work plan for the project based on the information collected. The mission included experts from Austria, Japan, the United Kingdom, the United States of America and from the CEC, the FAO, and WHO as well as the IAEA Secretariat.

They were accompanied by two members of the USSR Parliament and visited villages of Polesskoje and Ovrue in the Ukrainian SSR, Bragin, Veprin and Korma in the Byelorussian SSR, and Novozybkov and Ziynka in the Russian Federation, all of them located in contaminated areas. The experts reviewed information provided by scientific organizations, hospitals, clinics and agricultural centres, both in the affected areas and in the Republics' capitals. They also held meetings with the local population in the villages, its political representatives, and nongovernmental organizations.

The results of this preparatory mission were presented to an International Advisory Committee, chaired by Dr. Itsuzo Shigematsu, Director of the Radiation Effects Research Foundation, Hiroshima, Japan. The Committee met in Kiev and Minsk from 23-27 April 1990. The Committee included experts from Austria, the Byelorussian SSR, Canada, Finland, France. Japan, the Ukrainian SSR, the United Kingdom, the USA and the USSR, and from the CEC, the FAO, UNSCEAR, the WHO and the IAEA Secretariat. The Committee's expertise encompasses various specialities, including medical, radiopathology, psychology, epidemiology, radioecology, nutrition, dosimetry and radiation protection. The Ukrainian and Byelorussian members are the vice presidents of the Republics' respective Academies of Sciences.

The Committee approved the work plan to be implemented, which includes the corroboration of data to be provided by the USSR as well as an evaluation of the protective measures that were taken. It further envisages making recommendations as to future actions in the affected regions. It is expected that approximately one hundred international experts will be involved in the implementation phase of the project that was scheduled to begin in May 1990.

After the completion of the project, scheduled for late 1990, an authoritative report is to be prepared by the International Advisory Committee and published by the IAEA. This will form the basis for subsequent follow up studies.

Finally, meetings are envisaged in Kiev and Minsk in which the findings of the studies will be open to broad discussion.

(Source: IAEA Press Release, 7 May 1990)

A five-year project was recently launched by USAID to help solve problems of maternal and neonatal health and nutrition. The project is called "MotherCare". The following was extracted from their announcement.

Each year half a million women die from complications of pregnancy and childbirth. Ninety-nine percent of these deaths are in developing countries. Of the 14 million infant and child deaths that occur in developing countries each year, nearly half take place during the first month of life. These deaths are due primarily to the poor health and nutritional status of the mother and the conditions of the birth itself. Many births are not assisted by a trained attendant.

In most developing countries, pregnancy and childbirth are seen as familiar, natural and safe events. Yet the statistics show that this is often not the case. Pregnancy and childbirth frequently end in tragedy, particularly for the poor, uneducated woman and her baby. This woman faces a lifetime risk of dying from pregnancy-related causes of about 1 in 33 compared to 1 in approximately 6,000 in the United States.

The reasons for such inequities are clear. Women in developing countries do not have access to the information and services they need to ensure a healthy pregnancy and a safe delivery. This is particularly disturbing in light of estimates that up to 80% of maternal deaths could be avoided. Assuring that women receive quality health care, an adequate diet and appropriate information is long overdue. "MotherCare" was created to assist countries, communities and individuals to identify and implement solutions to the widespread problems affecting maternal and neonatal health and nutrition.

Improving health and nutritional status of women is a high priority. First, women need information that enables them to recognize problems and seek care. At the same time, the quality of the health care services available to women must be improved to provide an effective response. MotherCare activities for women are: prevention and treatment of maternal anaemia; improved maternal nutrition, particularly weight gain during pregnancy; prevention and treatment of infections, especially sexually transmitted diseases; integration of maternity care with family planning; improved life-saving services, specifically for the delivery.

Survival of the newborn is inextricably linked to the health of the mother and to birth practices. An undernourished woman has a much greater chance of delivering a low birth weight infant, one who is more likely to die young. Unhygienic birth practices result in the death of three quarters of a million neonates from tetanus. MotherCare activities for the newborn are: prevention of neonatal tetanus; promotion of clean and safe deliveries; prevention of hypothermia; early initiation of exclusive breastfeeding; early recognition and appropriate care of sick neonates.

From policy makers to traditional birth attendants to family members, MotherCare aims to target the attitudes and behaviours of key individuals who have an impact of the health of women and newborns. Project activities are designed to influence: national maternal and neonatal health and nutrition policies; quality of health care providers' interactions with women; case management, screening, referral, and lifesaving skills of health workers; family and community awareness of the problems and solutions.

MotherCare will conduct country assessment visits and provide support for maternal and neonatal health and nutrition activities through: long-term projects; short-term technical assistance and training; applied research; planning; enhancing maternal and neonatal services; reaching women with information and policy.

How to request MotherCare assistance: MotherCare is funded by the U.S. Agency for International Development, Office of Health, Bureau for Science and Technology. As a centrally-funded project, MotherCare may work in any country at the request of the local USAID Mission. For additional information, please contact: MotherCare Project Officer, S&T/Health, U.S. Agency for International Development, Washington, D.C. 20523-1817, Tel: (703) 875-4663, Fax: (703) 875-5490, or MotherCare Project Director, John Snow, Inc. 1100 Wilson Blvd. 9th Floor, Arlington, Virginia 22209, Tel: (703) 528-7474, Fax: (703) 528-7480.