The 10th Annual Martin J. Forman Memorial Lecture: How are we doing in International Nutrition?

By F. James Levinson

The 10th Annual Martin J. Forman Memorial Lecture was presented by Dr James Levinson at the XVIII IVACG (International Vitamin A Consultative Group) Meeting in Cairo, Egypt, September 1997. The lecture, reproduced below, summarizes the results of a questionnaire, devised by Dr Levinson and completed by 173 individuals working in international nutrition. The purpose of the questionnaire was to compile information - the perceptions and opinions of those asked to complete it - about the field of international nutrition and the people who work in it. The views expressed in the lecture are those of Dr Levinson, and as he himself points out, this is not a comprehensive stocktaking. Nevertheless, some important, and no doubt contentious and controversial issues are raised - issues and views that we hope will generate positive discussion and reflection amongst those involved or interested in the field of international nutrition.

I am honored to have been selected to deliver the 10th Annual Martin J. Forman Memorial Lecture. Many was a friend, a colleague and a teacher. He was a mentor during my early years in India and during our fledgling efforts at MIT to make some sense of multi-sectoral nutrition planning. And now we also have lost Lainie Forman. Lainie, as most of you know, was actively involved in a host of worthy endeavors, wholly unrelated to her connection with Marty, but she also was a driving force behind these lectures.

During the past year I was visited by a graduate student in international nutrition at Tufts who wanted to talk with me about her future. She wondered about the field of international nutrition. She was anxious about her job prospects. And she also wanted to know about the field as a whole, and about the people in it. What do they do? What are they like? What do they stand for?

I rarely find myself hesitating very long when asked about international nutrition, but these questions, asked with such sincerity, gave me pause. What could I say about this field which would be wholly honest, but at the same time encouraging to this young woman thinking about throwing in her lot with us?

I promised her a letter, and then began thinking about the subject seriously and talking about it with colleagues. It became clear that the subject is serious and deserving of discussion on what can be considered (depending on how we count), the 50th anniversary of sustained, large-scale international efforts, initiated after the end of World War II, to address malnutrition in developing countries.

Accordingly, it struck me that rather than speaking about assessments of program constraints, multisectoral planning, dynamic models, cost effectiveness, or any of the other topics that I teach to graduate students, I would utilize this 10th Forman Lecture, and this 50th anniversary occasion, for a stocktaking of the field of international nutrition itself, and a response to this young woman's questions¹.

¹A proper stocktaking might have three components: (1) perceptions of persons working in international nutrition, (2) perceptions of our field by others in the broader international development community and by those we are seeking to serve, and (3) an objective assessment of what we've accomplished. The last of these is, of course, the most difficult, given our frequent difficulty in isolating the effects of what we do even on nutritional outcomes, All are important. This discussion addresses only the first.

Dr F. James Levinson, Director, International Food and Nutrition Center, School of Nutrition Science and Policy, Trufts University. Medford MA. 02155, U.S.A. Tel: 617 627 3223 Ext. 2284 Fax: 617 627 3887 Email: JLEVINSO@EMERALD.TRUFTS.EDU

Of the 350 questionnaires sent, 49% (173) were returned. Of these, 52% of the respondents indicated primary responsibilities in operational programmes or policy (referred to in the tables as OPP), 39% work primarily in research, teaching or training (RTT), and the small remainder indicated responsibilities divided between the two².

²This OPP/RTT distinction was selected as an organizing principle in our analysis, although one might have legitimately chosen others, e.g. those who work on PEM vs. micronutrients, or those who focus on nutrition as an input vs. those who are concerned primarily with its role as output indicator.

September 1997

Dear Erica,

In trying to respond fairly and honestly to the important questions you asked me last year, I've collected information from colleagues in the international nutrition community around the world. Let me share with you some of their responses.

First the good news. Fully, 88% of the respondents to the questionnaire indicated that they would definitely or probably recommend the field of international nutrition as a career to students today (Table 1). Eighty percent believe that, on balance, the field is healthier than it was 10 years ago - an assessment particularly significant at a time when most of the major international donors are cutting back on nutrition-related funding, staff or both.

Job prospects in the year 2000 are considered excellent or fairly good by most respondents - the prospects considered better for students from developing countries than for those from industrialized countries (Graph 1).

We don't know whether the 51% who did not participate in the survey would have been as optimistic, and more generally whether the participation factor introduced bias into the results as a whole, and if so, in what direction.

Table 1: Would you recommend the field of international nutrition as a career to students today? (%)

	OPP	RTT	TOTAL
Definitely	56	34	48
Probably	31	50	40
Unlikely	12	15	11
Definitely Not	1	0	1

OPP: respondents with primary responsibilities in operational programmes or policy; RTT: respondents with primary responsibilities in research, teaching or training.

Graph 1: How would you assess the likely job prospects in international nutrition in the year 2000?

There was remarkable unanimity among programme and research/training respondents on the question of the most important advances in international nutrition over the past 10 years. Both groups identified new findings on the effects of micronutrient deficiencies and the benefits of increased micronutrient provision as the most important of these advances. Sixty-four percent of respondents who were asked to check up to four advances from a prescribed list or to add their own, checked off this micronutrient category (Table 2). The next four advances, ordered the same by programme and research/ training respondents, are indicated in Table 2.

Table 2: What do you consider the most important advances in international nutrition over the past 10 years? (%)

New findings relating to micronutrients	64
Better understanding of the causality of malnutrition	42
Greater community involvement in project design and development	41
Better designed and managed nutrition interventions	38
Greater sensitivity to the importance of nutrition counseling	33

(Respondents were asked to check up to four points)

Among research/training respondents, the highest-ranking problem was reduced funding (48%). By contrast, among those involved in programmes, the funding constraint was listed by only 18% and was ranked seventh on a list of 11 possibilities (of which respondents were asked to check 3). Clearly the funding constraints of which we in the academic community are so keenly aware, are not as serious a problem for those more directly involved with programmes. Stated another way, donor agencies faced with tighter budgets, appear to be providing an ever larger proportion of their funds to actual programme operations in developing countries themselves rather than to supporting research, teaching and training, particularly that done outside of the developing countries.

And what did the programme respondents list as primary obstacles, primary negative factors? At the very top of the list (44%) is infighting within the international nutrition community. Next in order, as indicated in Table 3, are (1) the continued common assumption that nutrition programmes mean food programmes, (2) inadequate commitment to nutrition by governments of developing countries, (3) the frequent absence of project evaluation, and (4) bureaucratic problems in getting things done.

Looking at this listing, it is striking to note that, at least from the perspective of those responsible for programmes, the major negative factors faced in international nutrition are not, by and large, intractable structural or financial constraints, but rather problems that the nutrition community and its government and donor counterparts can, to a significant extent, control. None of these is more within our control than infighting. The respondents are not referring here to the honest, above-board dialogue over differences of opinion and perspective - which we must have - but to the more insidious hostilities and rivalries we see today in too many facets of our work, and which so many in the international community find debilitating.

What is upsetting to the respondents is the all too frequent bickering over procedures, the posturing, and the territoriality, which characterizes so many of our international meetings and so much of our inter-institutional dialogue. This not only reduces our credibility to others in the development community, but also genuinely obstructs our ability to get things done. In an increasing number of cases, development agencies have intentionally labeled nutrition activities as something other than nutrition, in order to avoid these very squabbles.

Table 3: What have been the (three) primary disappointments or negative factors you have experienced in international nutrition over the past 10 years? (%)

Operational Programmes or Policy (OPP)		Research, Teaching or Training (RTT)
1. Infighting	44	1. Reduced funding	48
2. Perception that nutrition=food	43	2. Bureaucratic problems	35
3. Absence of valuation	40	3. Inadequate commitment by govts.	32
4. Inadequate commitment by govts.	40	4. Inadequately trained professionals	31
5. Bureaucratic problems	35	5. Infighting	29
6. Inadequate demand for nutr. services	29	6. Absence of evaluation	29
7. Reduced funding	18	7. Perception that nutrition=food	27

(Respondents were asked to check three points)

One of the realities behind a portion of the infighting that we see in nutrition today is the conviction many of us hold that the positions to which we adhere tenaciously are the only positions. Doris Lessing, the British writer, wrote in the introduction to her novel. The Golden Notebook, the following warning that she offers to her own students, "What you are being taught here is an amalgam of current prejudice and the choices of this particular culture. The slightest look at history will show you how impermanent these must be." This is a warning which perhaps ought to be required on all the courses that we teach or nutrition advice that we give.

Looking back on my own 33 years in this field, I can identify more than a few cases where I crusaded with some zeal for the wrong solution. In the 1960's I was a believer, I regret to admit, in lysine fortification. In the 70's I was a devoted believer in multisectoral nutrition planning as a panacea. And more recently, in one African country, I insisted on targeting in a credit scheme with such tight eligibility requirements that recipients did not, in the end, have the resources to repay the loans.

A 1994 article entitled "Conceptualizing Hunger in Contemporary African Policymaking" by Barrett and Csete, on which I provided perhaps, too harsh a commentary, listed some of the approaches we have followed in this field over the years. The point in the case of each of these approaches is not that they didn't represent our best thinking at the time, but rather that in each case, we were so sure that we were right. The same may be true even of the lofty and presently popular but possibly simplistic notion that communities around the world, or more accurately, those who make decisions within them, are willing to make resource allocation decisions for the benefit of their less privileged, less well nourished residents.

The problems of control, ego and territoriality are perhaps most abundantly in evidence in the frequent inability or unwillingness of agencies to work together, most seriously those within the United Nations. Despite the existence of the ACC/SCN - a U.N. entity established to harmonize nutrition efforts of member organizations and some information sharing procedures - coordination on nutrition within the U.N. system has been poor. Time and again in my work in Africa and Asia I discover remarkably similar projects supported by separate U.N. agencies and functioning wholly in isolation of one another. The idea of agencies thinking strategically together about nutrition with a particular country government is rare.

If I were an official of a developing country, paying dues to the United Nations with the expectation of services, and seeing such wrangling, such unwillingness or inability to work together, I would be disappointed. I would ask whether it is perhaps hypocritical for agencies to be advising my country about the importance of coordination but to be such poor role models themselves. I would ask whether it is acceptable for agencies in the same United Nations system to know so little about the activities being pursued by one another. I would ask whether it is acceptable to see agencies who are assisting our government programs, place a higher premium on getting the credit than on helping to accomplish the task. I would ask whether it is acceptable to see one agency actively undermining the initiative of another at the stage of government negotiation.

At the same time I would be wrong to lay this problem solely at the feet of the U.N. system. Governments and nutrition institutes themselves are replete with power struggles and disharmony. One long time professional in our international nutrition community put it well recently when he said, "Name me a country and I'll name you at least two prominent nutritionists who don't talk to one another." When I reflected on this problem recently at Tufts, one particularly astute observer of human relations noted that infighting is a problem all of us in the international nutrition community are likely to decry. Yet for all of us, the problem resides with others, not with ourselves.

It may be worth adding that today's sophisticated management techniques of mediation, conflict resolution and cooperative decision making, used regularly in the private sector, are almost unknown in the field of nutrition. Would it be so unrealistic as a first step, for the U.N. agencies themselves, and eventually for others, to agree together on a workable code of behaviour, which they would seek to follow, and to which they would also be held accountable? Such codes, stressing common goals, underlining the need for genuinely cooperative working relationships, and specifying norms for behaviour and methods for the resolution of differences, so common in the medieval guilds and more contemporary trade unions, have never been needed more than in our field today.

Is the problem of infighting more serious in international nutrition than in other fields of endeavor? Perhaps not. And yet, somehow, in this field, I expected better.

How well are women represented in decision making positions in international nutrition? Nineteen percent of respondents answered "very well"; 47% answered "moderately," 34% answered, "poorly" (Graph 2). What seems clear, and was well reflected in the margins of these questionnaires, is that while the number of women with professional positions in international nutrition continues to increase, and while their role in decision making has no doubt improved, many important decisions continue to be made by the "old boy networks." Having been a member of many such networks, I can affirm this conclusion.

Graph 2: How well do you believe women are represented in decision making positions in international nutrition?

I found it noteworthy that of the total sample of names listed by respondents as role models, only 11% were women. One would hope that percentage would be very different ten years from now, but this may require better means than thus far employed to encourage not simply the participation of women but their access to major decision making.

What about the focus of the work we do? Is it too narrow, are we too insular, are we too far removed from the problems we are seeking to address? How well are our organizations doing in serving the field of international nutrition and malnourished populations in developing countries?

In the questionnaire, respondents were asked whether, after the mixed results of multisectoral planning in the mid-1970s (characterized by what I have sometimes referred to as our "nutriocentric" perspective on development), the field of international nutrition has become too narrow in its focus. Have we become, in some sense, guilty of "nutrition isolationism," characterized by less concern with the socio-economic determinants of malnutrition, less interaction with other development sectors, and a disproportionate focus on micronutrient deficiencies as opposed to inadequate caloric or food intake?

Table 4: Some commentators have suggested that after the mid-1970s, the field of international nutrition has become too narrow. Do you agree with this assessment? (%)

	OPP	RTT	TOTAL
Agree Strongly	19	28	23
Agree Generally	36	39	39
Disagree Generally	36	27	31
Disagree Strongly	8	5	7

OPP & RTT definitions: see Table 1.

Table 5: Some commentators have suggested that our various activities related to international nutrition, even those carried out in developing countries, are too far removed, physically and otherwise, from malnourished populations. Do you agree with this assessment? (%)

	OPP	RTT	TOTAL
Agree Strongly	23	17	20
Agree Generally	49	46	49
Disagree Generally	27	35	30
Disagree Strongly	1	2	1

OPP & RTT definitions: see Table 1.

Does nutrition need to maintain its own identity and institutionalization as opposed to being incorporated into larger programmes and institutions addressing health and population, food and agriculture, or poverty alleviation? The problem is compounded by the fact that the role of nutrition in development is complex. Nutrition functions sometimes as both input and output - as in the case of most community-based projects, sometimes as input but not output - as in school nutrition activities designed to increase active learning capacity, and sometimes as output but not input - as in many agricultural and rural development projects where nutrition and consumption should be important impact indicators - where nutrition should be the "conscience" of agriculture.

With respect to the matter of independent identity, respondents were quite evenly divided with roughly a quarter each indicating strong agreement, general agreement, general disagreement and strong disagreement (Table 6). These results reflect our genuine ambivalence on the issue of self-perpetuation. At the conceptual level, nutrition institutionalization separate from these larger contexts may not pass the test of rationality. At the same time, experience - and the struggles now actively encountered in the major agencies - suggest that an independent identity may still be necessary if nutrition is to be taken seriously.

Table 6: Do you agree with the following statement: It is necessary for nutrition to maintain its own identity and institutionalization as opposed to being incorporated into larger programmes? (%)

Agree		Disagree
Strongly	Generally	Strongly	Generally
25	29	25	20

What of the agencies themselves? How well have they, or the nutrition-related programmes within them, served the field of international nutrition and malnourished populations in developing countries over the past 10 years, relative to standards we would have set for them?

Institutions or categories of institutions from this list were ranked by respondents, with 5 being the highest ranking, 1 the lowest, and 3 the mid-point (Table 7). At the top of the list is UNICEF, which has been devoting major attention to nutrition at least since the late 1970s. UNICEF today knows a great deal about the design and implementation of effective nutrition activities, and it has learned this in the best possible way - by doing. There can be no question that UNICEF's commitment and dedication to nutrition has had an enormous impact, most importantly on the children of the world.

Looking at this table, I am concerned about the number of agencies or sets of agencies with rankings of less than 3. I am particularly struck by the low rankings of the U.N. technical agencies, which were held in such esteem, when I entered this field in the 1960s. Do these rankings suggest that agencies are no longer adequately committed to nutrition, or that they are committed but poorly equipped, or that they are committed and adequately equipped but less effective because of some of the territoriality or bureaucracy or infighting just discussed? How much of the problem relates to cutbacks in funding making it progressively more difficult for agencies to be proactive and creative? Are we indeed facing a funding crisis in international nutrition, one which may in time affect even the present optimism of the OPP, as one bilateral agency after another fades out of the nutrition picture, and as the major players. UNICEF and the World Bank, face at least cutbacks in personnel?

Some commentators have argued that international nutrition has had its day, that it is no longer in fashion, that it is no longer cutting edge, that the conditions which gave rise to its major growth spurt in resource availability in the late 80s and early 90s - namely a desire to protect the needy against the effects of structural adjustment - are no longer in place, that public health is taking over nutrition.

I find the argument at its core unconvincing. Whether one calls what we do nutrition, or health, or poverty alleviation, or human resources development, there always will be a compelling case to be made for improving the well-being of a child who, even if only moderately malnourished, is six times more likely to die in childhood than her well nourished neighbour. There always will be a compelling case to be made for improving the food consumption and ante-natal care of pregnant women in countries where over 50 percent of newborn infants weigh less than 2.5 kilograms. There always will be a compelling case to be made for assisting seriously food insecure households where caloric consumption during pre-harvest seasons can be less than two thirds of RDAs. There always will be a compelling case to be made for providing Vitamin A supplements to children, leading to mortality reductions of up to a third in areas of clinical deficiency. The world Turns its back on problems like these at peril of its very humanity. There is an abundance of work for us to do.

Table 7: How well do you believe the nutrition-related programs of the following have served the field of international nutrition and malnourished populations over the past 10 years, relative to standards you would have set for them? (5 = Extremely Well; 1 = Poorly)

UNICEF	3.83
Micronutrient Initiative	3.40
ACC/SCN Secretariat	3.29
International NGOs	3.24
IFPRI	3.23
PAMM	3.07
ACC/SCN	2.94
World Bank	2.92
Indigenous NGOs	2.92
Bilateral Agencies	2,79
Academic Institutions (industrialized)	2.76
Academic Institutions (developing)	2.73
Private Foundations	2.63
WHO	2.49
Private Consulting Organizations	2.37
FAO	2.28

What can we conclude from all this? I think this. The international nutrition community is relatively confident about the work in which we are engaged and optimistic about our ability to make a difference. There is optimism about job prospects, particularly for those from low income countries. It is likely that an ever-increasing proportion of activity in international nutrition will be taking place in developing countries and in the policy and programme arena. But, as I've mentioned, there are problems - some of them quite serious.

If, on balance, this field of international nutrition is of sufficient appeal, my hope for you and your colleagues is that, by the time you are full-fledged professionals, some of what I've described to you will be different and some of you will indeed be instruments of change that will permit the following:

· working relations that bring out the best in all of us rather than undermining the work we do;

· processes that allow the most qualified individuals among us, regardless of gender, to make the decisions that count in our institutions;

· revitalized institutions that regain our confidence;

· reassessed national and international priorities based less on greed and narrow, self serving and short sighted self interest, and more on a spirit of mutual global responsibility.

One person who rarely lost sight of why he was in international nutrition was Marty Forman himself. How many of you know the story about Marty's participation in an interagency meeting on child feeding in Brazil sponsored by Operation Ninos in the mid 1960s? The meeting was dreadful. Day after day Marty sat there listening to talk about political constraints and the listing of bureaucratic reasons why the interagency initiative discussed at the meeting couldn't be launched. Marty became more and more frustrated.

As the time approached for Marty's own presentation, he excused himself, went outside to one of the neighbouring favelas, and came back holding the hand of a 5 or 6 year old visibly malnourished little gin. She was dressed in rags, wide-eyed, expressionless. Marty began to speak to the little girl at the podium, explaining that these good people gathered in the room would like to provide food for her and her brothers and sisters, that the food and money did exist in the world to make that possible, but that the bureaucratic problems and financial obligation problems of the particular agencies, and the government's political agenda would not make this possible for at least one more year.

Marty continued talking like this for 20 minutes with the rapt attention of everyone in the room, more than a few visibly moved. By the time the girl had returned to her favela, no doubt with a story her family would find difficult to believe, the tone of the meeting had changed, and ways were found to move the programme more quickly.

My hope for the upcoming generation of the international nutrition community is that amidst the agendas and career advancement, and the balancing of professional and family lives, the malnourished - the children, the mothers, the poor - will not be lost, but will find some room on centre stage. And I hope, in turn, that the upcoming generation will experience in some direct way, the effects of their efforts on people's lives.