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SCN 27th Session

This section of SCN News provides information on our most recent annual session.

The ACC/SCN 27th Session took place in Washington DC in April 2000. Two keynote addresses were given by senior officials of UNICEF and the World Bank. Both speakers provided inspiring messages for all of us working towards nutrition goals. They also reflected on some of the key findings of the SCN’s Fourth Report on the World Nutrition Situation, launched the same day, and committed their agencies to new strategic alliances. The annual Dr Abraham Horwitz Lecture, given by Deepa Bhat, a student at Tufts University, provided new insights into the design of programmes to tackle foetal malnutrition and improve pregnancy outcomes.

Seven of the SCN’s Working Groups were convened, and their reports are summarized here.

The Working Groups are the driving force of the SCN. It is through SCN Working Groups that participating agencies take an active role in the substantive areas of greatest importance.

Kul Gautam

Deputy Executive Director, UNICEF

Mr Chairman and distinguished participants at this meeting - which has so many of the world’s “who’s who” of nutrition - I am afraid that if I speak about nutrition, I will make a fool of myself and reveal my ignorance or superficial knowledge on nutrition. There is an expression in my language that says: “don’t light a candle where there is bright sunshine”. Guided by that advice, I won’t speak on nutrition to this assembly of some of the world’s best and brightest in the area. Instead, I will speak about a safer subject - mobilization - and will raise some questions for us all to ponder and act upon.

Let me assure you that I’m not trying to avoid UNICEF’s responsibility as a member of the SCN to speak on nutrition. We have here a large delegation from UNICEF, and I do have a written statement prepared by my competent colleagues. I have read the SCN’s Fourth Report on the World Nutrition Situation, the final Report to the ACC/SCN of the Commission on the Nutrition Challenges of the 21st Century, the draft Strategic Plan for the SCN, and the fascinating report of last year’s SCN meeting.

What I gather from these reports - and so many others on the subject of nutrition - is the following: that nutrition - and malnutrition in particular - is a subject that has been over-studied and under-acted-upon; and that we now understand quite adequately the problem of malnutrition - its grave and lasting consequences and, on the other hand, the virtuous impact of effective, positive nutrition interventions. Yet the world is not mobilizing enough to end malnutrition as a public health problem.

Instead, even as we speak, a famine of horrific proportions is unfolding in the Horn of Africa. Fifteen years ago, a similar famine aroused the world’s conscience, and a massive response through Live-Aid, Band-Aid, and “We are the Children” campaigns. Today there seems to be compassion fatigue. Although we know better than ever before what needs to be done, what approaches work, and the world’s capacity to respond is so much better now than ever before, it is hard to arouse the world’s compassion for what appear like chronic crises in the Third World. It is even harder to arouse genuine solidarity for long-term development.

We would probably get a lot more media coverage on famine and malnutrition if we could fly in Elian Gonzalez to Ethiopia, than all the excellent reports of the ACC/SCN.

What is to be done? And where have we failed? In 1990, the World Summit for Children endorsed eight nutrition goals. They were all ambitious, but none were unattainable. It is worth reflecting on why we have greater success in achieving some goals than others. Tremendous progress has been made on salt iodization and IDD elimination. Respectable progress has been made towards the reduction of vitamin A deficiency. Good progress has been made on breastfeeding promotion, especially through the Baby-Friendly Hospital Initiative.

Some would argue that, unlike underweight or stunting or basic education, these goals had easy technical fixes, silver bullets, and did not require significant behavioural change. I respectfully disagree.

In all the goals where we have had significant success, the key has been our ability to communicate and articulate the goals in simple, easily understandable ways to decision-makers and leaders; to demonstrate convincingly how the goals are achievable in their political or official lifetime; how the goals can be pursued without emptying the state coffers; what political, tactical, moral benefits it would bring to them, and what international support and recognition can be brought to bear. In some cases, attracting the support of the private sector has been useful. In all cases, invoking publicity by the media has been vital.

In goals where we have faltered, we have failed to articulate them and position them in a convincing manner.

Many of us recall the inspiring manner in which the late Jim Grant of UNICEF used to convince leaders, great or small, to pursue goals that at first seemed impossible, but were made impossible not to pursue. Our incoming SCN chair, Mr. Ngongi, referred to such an example that occurred at a meeting some years ago of Central American presidents for universal salt iodization.

Sometimes, in nutrition, we are more concerned about being scientifically correct than programmatically effective. We wish to do the right thing, but don’t do it right.

Now, ten years after the World Summit for Children, we at UNICEF are embarking on developing a new agenda for children in the next decade. In this new agenda, Early Childhood Care, Survival, Growth and Development, with nutrition as a vital element, will be a core component. I would like to invite the nutrition community to suggest - as you had done ten years ago and as the SCN has done over the past quarter century - a new set of goals, targets and strategies around which we could try to mobilize political leaders, corporate leaders, civil society organizations and the media.

Let me pose a couple of questions on whose feasibility we would appreciate your advice. Yesterday, at a meeting on early childhood care and development, World Bank Vice-President Eduardo Doryan spoke about how child growth might be made a proxy indicator for poverty reduction. For over two decades, we have known the value, the sensitivity of child growth as the best measure of child nutrition. Yet growth monitoring has not quite gone to scale except in a few countries.

Can we now take up this subject and try to nail child growth as the gold standard for measuring the success of development efforts? Both the Fourth Report and the Commission Report emphasize that where child growth has been monitored at community level in combination with guidance and support for parents, child malnutrition rates have declined more rapidly. Can we make child growth monitoring and promotion a new political imperative?

When the World Bank and IMF missions visit countries, they always ask questions about a variety of economic indicators - on GDP growth rates, inflation rates, balance of payments. What if the Bank missions were to make a practice of also asking about the status of GMP - growth monitoring and promotion, or child growth rates?

Richard Jolly has been the architect of the wonderful Human Development Report for some four to five years. But I am not sure that we have ever really made a case that child development is the foundation of human development, that the most important growth indicator is that of growth of the foetus in the womb and of the baby under two years of age. If development is about empowering people, then empowering mothers, families and communities to monitor the most important growth indicator would seem to merit high development priority.

As nothing succeeds like success, can we now envisage double fortification of salt - adding iron to combat anaemia? How wonderful it would be if we could transform our most spectacular failure of the past decade - not making a real dent in the world’s most prevalent micronutrient malnutrition, anaemia - as the new decade’s most spectacular success. Fortification might not be the only answer. Perhaps there are other approaches as well. But surely, this ought to be feasible if we put our minds to it.

I read somewhere an analysis that at current rates, it will take a century to reduce malnutrition to a level at which it would stop being a public health problem. Our challenge ought to be to eliminate malnutrition as a public health problem within a single generation, not in 100 years. My reading of these documents indicates to me that we now have the know-how to make this feasible. What is lacking is vision and bold leadership. We, here at the SCN, we are or can be those leaders. If not us, who? If not now, when?

May I suggest to the development agencies and donors present that we endeavour to double our investment and triple our impact over the next five years on nutrition programmes? That as a minimum, we identify 10 to 15 countries, mostly in South Asia and sub-Saharan Africa, with major problems of malnutrition, where the conditions are ripe for our joint action in new partnership. Let me say without stealing the thunder from Eduardo’s presentation next, that the World Bank as the single largest funder of nutrition could certainly double or triple its investment in nutrition. Can we United Nations agencies and bilateral donors help with good projec t preparation work at the country level, and creation of demand from governments for nutrition loans so that the Bank can triple its investment?

We at UNICEF are committed to putting a sharp young-child focus on our nutrition efforts - in fact in all our development efforts - to emphasize the dynamic concept of growth and to redouble our outreach and partnership with you all. We believe that UNICEF, with our increasingly human rights and child rights-oriented approach to programming, can play an important advocacy role to position nutrition as a central development concern. If we can join hands to do that, we might have some hope of getting the protesters outside the barricades to join us inside for a common cause.

Thank you.

Eduardo Doryan

Vice President & Head of Human Development Network
The World Bank

It is a professional privilege and personal pleasure to welcome you to the World Bank, and to speak here today at this important meeting, which brings together a large contingent of the global leadership against malnutrition. Since I became Vice President for the Human Development Network here, eight months ago, I have gone through a crash course in ‘What’s What in Nutrition’ and ‘Who is Who in Malnutrition Reduction’. However, since my early youth I remember the work done in my own country to document nutrition issues in particular the well known case, at least at that time of the Puriscal county. Later on in public office both in the Science and Technology portfolio, and particularly in the Education one, nutrition issues where indeed a key element in policy making.

In the Bank, my very first field trip was to Bangladesh, a country where, as you know, as many as 50% of babies are born with low birthweight, and nine out of ten children are not growing adequately in the critical first two years of life. I don’t have to explain to you what this stunting and wasting means in terms of:

· compromised human potential, including physical and mental impairment à reduced learning capacity and educational achievement

· increased vulnerability to illness and premature death, both in early life, but also in later life (as the Barker studies are showing)

· lowered productivity, both economic, social and cultural

· even intergenerational effects

· not to speak of the sheer human suffering, something we can now also see vividly on our television screens that highlight the slow-onset famine in Ethiopia and the Horn of Africa.

Bangladesh is a silent emergency, Ethiopia a loud one, and all this is happening in many countries all over the developing world as we enter the 21st century. There is no doubt: this is a grotesque failure of humanity, a humanitarian disaster that need not happen, that should by now be entirely avoidable. Malnutrition and hunger are an outrage: a human rights violation but also bad politics, as Mr Gautam has said, and, I would add, bad economics as well. I will come back to this point in a minute.

The reports we have before us - especially the Fourth Report, but also the World Development Report 2000/1, UNICEF’s State of the World’s Children Report 1998, the Commission Report, and the World Bank study among 60,000 people called Voices of the Poor - all these reports make clear how enormous the challenge of malnutrition is. Never before have we known so accurately how heavy is the ‘global burden of malnutrition’.

Bad and good news

That is the bad news. But there is also some good news. Because we have now a solid understanding of how to tackle these problems, at the macroeconomic level, at the multi-sectoral level, and at the community level.

Just last week, the World Bank and the Government of Bangladesh successfully negotiated what I think will be one of the world’s largest malnutrition reduction programmes, the National Nutrition Project, the first of a series of three projects over the coming 15 years, with a total price tag of over US$1 billion.

Several of you here today have been involved in the design of this project or its precursor, the Bangladesh Integrated Nutrition Project. These are prime examples of a sharply targeted, highly focused set of interventions aimed at preventing or mitigating malnutrition by focusing on young-child growth monitoring and promotion, and by fostering behavioral change at the household level. Few projects have enjoyed such concentrated attention by so many experts, of different partnering agencies - local, national and international - that we at the World Bank are confident that it represents the first of a new generation of efforts to bring down malnutrition on a large scale, within a generation.

While there may not yet be a full technical consensus among nutritionists, we believe that a pragmatic agreement is emerging on what needs to be done - thanks in no small measure to the work of the ACC/SCN. As you know, the World Bank is the single biggest provider of funds for nutrition, and we have been involved in this field for about 25 years. I think it is not incorrect to say that the World Bank helped put nutrition on the international development agenda.

During recent years there has been an important increase in the portfolio for Human Development (education, health, population, social protection and nutrition), however, there has not been an equal increase for nutrition. Still the Bank’s nutrition portfolio averages around US$120 million a year. In addition to the Bangladesh project, there are also a number of substantial new projects in the pipeline, which would maintain commitments at this level. However, it is useful to rethink what the limitations are and what has to be done to move as fast as the overall Human Development portfolio.

Our constraints have been two fold: 1) we are overstretched in our technical capacity (staff and consultants) to go through the new wave of projects that include policy dialogue, sound sectoral studies, and the whole process of preparing more sound projects while maintaining high quality in the current portfolio, and 2) we deal with a diverse set of stakeholders. Many do not yet recognize the importance of nutrition, or have limited capacity to prepare and implement projects. I will be making some specific recommendations on how we plan to overcome these two limiting factors.

Friends, the world is easily capable of doing much, much more - and so is the World Bank.

And I want to assure you that we are committed to significantly stepping up our efforts in this field, because we are now more than ever convinced that if you reduce malnutrition you will reduce poverty - which is increasingly the focus of all World Bank operations. This is very much at the core of the Comprehensive Development Framework, which brings a more holistic view of development, more balance between macroeconomic, human development and institution building, more country ownership and a more strategic and long term view of development and its outcomes.

Why, what and where?

In the next minutes I would like to touch on three topics:

· why the World Bank considers it important to intensify efforts and increase impact
· what those efforts would entail, and
· where the resources should come from
The World Bank, with its specific mandate, also looks at nutrition through an economic lens. We conclude, from many economic studies, that investments in carefully designed malnutrition control projects give tremendous returns, particularly if they are supported by appropriate macroeconomic policies and multi-sectoral alignment.

This is especially important for low-income countries and societies, because, if we are willing to take a long-term perspective of, say, 20 or 30 years, we can see that malnutrition reduction has powerful and positive impacts on economic growth and human development.

Nutrition today is perhaps the best development bargain available. Some rough estimates show that whereas malnutrition costs the world around US$80 billion each year (due to lowered economic productivity, illness and the cost of treatments, poor performance of the educational system), addressing malnutrition cost-effectively would cost less than US$5 billion per year, with costs borne jointly by governments, donors and consumers.

One of the most remarkable pieces of information I recently came across is that micronutrient malnutrition robs many countries of five percent of their gross domestic product through death and disability, yet countering this problem successfully could be done for as little as 0.3% of GDP. With such favorable benefit-cost ratios few countries can afford not to address micronutrient malnutrition.

Similarly favorable benefit-cost ratios are available for the promotion of breastfeeding and young child growth.

It is now increasingly apparent that adequate nutrition is as much a necessary condition for development as it is a desirable outcome of development.

So we at the World Bank are keen to increase our investments in malnutrition control, especially in countries that need it most. It is our intention to make nutrition an essential part of our dialogue with governments and other stake-holders and partners, particularly in the context of the new Poverty Reduction Strategy. As you are aware, President Wolfensohn has proposed an increased use of the Comprehensive Development Framework as a means to harmonize and synergize all development efforts at country level. I would welcome specific ideas from our partners on how we might collectively proceed against malnutrition, in selected countries, spelling out our respective contributions and accountabilities, in accordance with the comparative strengths that each of the partners bring to the table.

From our side I propose the following:

First, in as many countries as practicable, and as soon as possible, we work together to make child growth another key indicator of the overall development effort, along with the conventional economic growth. The Development Assistance Community (DAC) has already recommended that the world begin to use the anthropometric indicator weight-for-age to measure how we are doing in poverty reduction as we move forward toward the 2015 goal of halving extreme poverty. Young child growth, measured by monthly bodyweight changes, is one of the most sensitive of all outcome indicators, and can be used by parents, community and district leaders, state governors and prime ministers. Growth monitoring data on a nation’s children can provide timely and telling feedback that planners, politicians and donors need, month to month, to see the results of their social and economic policies, and to measure the human development impact of poverty reduction strategies. Growth monitoring and promotion would facilitate sharper targeting, emphasize appropriate behavioral changes, and introduce a preventive thrust in the programme. It could be designed as a routine monthly contact service with children under the age of two, or it can be done as a special statistical effort of nutritional surveillance.

Second, and this relates to what I learnt last week, I propose that we do the ground work to establish a consortium to meet the challenge of low birthweight head on. I am thinking of something like the partnership model we have for immunizations (called GAVI) or the Safe Motherhood Initiative. We must find ways to break the intergenerational transmission of malnutrition and poverty by putting a new focus on reducing the high prevalence of low birthweight - the 30 million babies who begin life with such a poor start. I see this as an important plank in countries' Poverty Reduction Strategy, for all the reasons you, the experts here, know so well. It also fits in well with several other Bank priorities, such as our work on Tobacco and Health, Prevention of Teenage Pregnancies, Safer Motherhood and Reproductive Health, and Girls Education. Globally, we haven’t done well, or enough in reaching adolescent girls and improving their nutritional and overall status, but I believe that we can no longer ignore adolescent girls in our development discourse as we enter the 21st century.

Third, I propose renewed efforts to deal with micronutrient deficiencies, especially through mass fortification and supplementation action. Here the private and the peoples’ sectors can play a far more important role than they have thus far, to complement the public sector. The success of the global salt iodation effort is encouraging, and we would be keen to learn whether the experts now believe the time is ripe to begin planning for double fortification of salt, adding iron.

This, I believe, is an essential minimum package which the World Bank would want to work on together with colleagues in this room. When it comes to poverty reduction, and malnutrition reduction, the World Bank should no longer be regarded as a lender of the last resort, but rather as a proactive partner prepared to promote malnutrition control as a priority investment during Country Assistance Strategy negotiations or in consortia meetings.

But, you may ask, where will the resources come from? Here I propose that we all double our nutrition investment, but also aim to treble our impact! All donors and development institutions should seriously consider doing that over the next three to five years. That would be a minimum, if we are serious about reducing absolute poverty by 2015 by 50%. Can we do it alone? No. Can each of you do it alone? No.

We need your help. You need ours. Preliminary estimates show that an additional US$2-$3 million per year over the next five years in grant funds could leverage some US$500 million extra World Bank investments in malnutrition control in 15 to 20 countries in four regions, in addition to the already planned investments.

This amounts to US$100 million extra per year - roughly doubling our investments in nutrition, ranging from project innovations to large scale investments (of US$25 million and higher), after proper nutrition sector work (such as the example from India, entitled Wasting Away), country-specific analyses of the situation and opportunities, ensuring local capacity building and institutional strengthening, and a strong emphasis on monitoring and evaluation.

We should, as Dr Gautam has proposed, make a start during this week to identify countries with big malnutrition problems where the conditions are ripe for joint action in new partnership, perhaps 10 or 15 countries to begin with, mostly in Sub-Saharan Africa and South and South-East Asia.

We have recently completed this Nutrition Toolkit that summarizes the technical lessons we have learnt in the past two-and-a-half decades. It represents, I am told, state-of-the-art approaches and insights that can now be widely applied, and we are in the process of planning a series of team training courses with clients, partners and staff around this new Toolkit.

Clearly, to achieve these new beginnings, partnerships are not an option, but an imperative. I envisage strategic alliances with different partners, globally and at country level, each bringing their best comparative advantages to the joint endeavor. We have been building a stronger alliance with our friends in UNICEF in this direction.

Ladies and Gentlemen, it should not be too difficult to capture the attention and imagination of the world for such a renewed initiative. Before new images of emaciated and dying children begin to haunt us again, subtly undermining our convictions and resolve, let us come together and agree on the centrality of malnutrition and poverty reduction to the future of many, many countries.

This ACC/SCN 27th Session could well become a turning point in our battle with this age-old problem, provided that the global nutrition leadership here assembled so decides. Although I am new to this field, I believe that the urgency and importance of the task compels us all to find new ways forward, to leapfrog over old obstacles and past resistances. I do not find the problems themselves as frightening as the questions they raise about our capacity to gather our forces and act. That is where we all, individually and organizationally, need to reach deep inside ourselves, and begin to end malnutrition. This is an idea whose time has come - as, surely, apartheid was in the past decade, and colonialism before that.

Thank you.

Fourth Dr Abraham Horwitz Lecture

What makes the difference? Applying the positive deviance approach to improve pregnancy outcomes

Deepa Bhat

I am honored to have been selected to deliver the Fourth Dr Abraham Horwitz Lecture. Dr Horwitz is a legend in the field of nutrition and a role model for many of us in the younger generation. I had the privilege of meeting Dr Horwitz two weeks ago in his home here in Washington. With the kind efforts of Alan Berg, we were able to see the cherry blossoms together. In India, we use the term dar-shan to describe a meeting with an inspirational person. Meeting Dr Horwitz was for me an experience of darshan.

During this Lecture I would like to show how use of the positive deviance concept and methodology can improve pregnancy outcomes. It could be said that wherever this method has been tried, there have been promising and successful results.

First, the concept of positive deviance and its use in developing countries to improve child growth will be introduced. Then the critical importance of the pregnancy period in the nutritional life cycle will be discussed briefly. Finally, the outline of a proposal to utilize positive deviance to reduce intrauterine growth retardation and low birthweight will be presented.

Positive Deviance Based Nutrition Activity to Date

The pioneering work on the application of the positive deviance concept to nutrition was carried out by Professor Marian Zeitlin at Tufts University in the late 80s. The concept of positive deviance draws upon both the importance of behavioral change in nutrition as well as the importance of accentuating the positive. The role of behavioral change was well articulated by Alan Berg, former senior nutrition advisor to the World Bank who wrote in his book, The Nutrition Factor1, “An important part of the nutrition gap is the information gap. Although lack of purchasing power is a major constraint, many nutritional deficiencies would be moderated if people knew how better to use the resources already at hand.” Positive deviance shows people how to accomplish this. Poverty is not necessarily an over-riding constraint when using the positive deviance approach. The positive deviance approach points out that people can succeed nutritionally in low-income communities. The positive deviance approach attempts to show that the resources needed to succeed nutritionally are often available in the community. The “positive deviants” are utilizing these resources effectively.

The importance of stressing the positive was underlined by former Harvard Professor Mark Hegsted in 1967 who advised that “we should pay a great deal more attention to the reasons for nutritional successes rather than nutritional failure.”

Application of the positive deviance approach to nutrition evolved out of the observation that most poor communities include impoverished families with well-nourished children.2 This observation, in turn, raised the question of how do some poor families have well-nourished children when their neighbors do not? That is, what is their “deviant” behavior? Zeitlin suggests that these deviant characteristics may be behavioral, social, psychological or physiological. Most prior research focused on problems. Positive-deviant research centers on solutions. The positive deviance approach works with the surroundings of the citizens and deals with their limitations and also their potential.

Utilization of this concept focusing on child growth at the community level has been undertaken with considerable success by the US-based nongovernmental organization Save the Children, with support from various donors including USAID, UNICEF and several corporations and universities. In Save the Children’s own words, “Positive deviance is a developmental approach that is based on the premise that solutions to community problems already exist within the community ”.3

The basic positive deviance model adapted by Save the Children involves growth monitoring promotion (GMP) every two months for every young child. Specific age coverage varies slightly from country to country. Children falling below - 2SD in weight-for-age enter a two-week Nutrition Education and Rehabilitation Program, or NERP session, with their mothers. The NERP session itself is modeled on the “Hearth” model developed by Drs Warren and Gretchen Berggren in which, ideally, positive deviance mothers themselves participate in the counseling of mothers of malnourished (low weight for age) children, and in which mothers bring a portion of the raw food which will be prepared into nutritious meals.

Children who remain moderately or severely malnourished at the conclusion of the NERP session are automatically enrolled in the next session. An average positive deviance project employed by Save the Children might have four GMP sessions and four NERP sessions and continue for a period of one year.4

It is worth noting that this model differs conceptually from those followed in large scale, multi-year nutrition projects in Bangladesh, India, Indonesia, and Tanzania. It differs not only in the use of the positive deviance concept but also in the premise that intensive daily meal-based sessions (usually a complete meal plus counseling lasting two hours) will produce dramatic improvements in a short period of time.

The basic model of GMP and NERP sessions is complemented by additional activities in particular countries. In Vietnam a Nutritional Revolving Loan Program provides credit for poultry activity to the households of children failing to graduate after two NERP cycles. Vietnam is also initiating a project that addresses healthy pregnancies for new mothers similar to that being proposed in this Lecture. In most countries, these efforts are integrated with complementary immunization, disease control, micronutrient, de-worming and family planning activities provided by Save the Children and other organizations.

Finally, positive deviance programs in several countries are experimenting with what is called a “Living University” in which staff and volunteers from project areas train counterparts in new areas to facilitate project expansion. The positive deviance approach is employed currently in 15 countries. Vietnam and Egypt will be used as examples.

The results of these positive deviance-based nutrition projects have been dramatic. The Poverty Alleviation and Nutrition Program (PANP), the project in Vietnam, resulted in a 40% reduction in malnutrition of children under the age of three, and a 68% reduction in the prevalence of severe malnutrition. The pilot program moved 3092 children out of moderate or severe malnutrition to mild malnutrition.4 Now the program has expanded to about 108,000 children.

In Egypt projects of 12 months duration reduced the prevalence of moderate and severe malnutrition from 47% to 13% in one area and to an astonishingly low 1.4% in another.5 Of children “who graduated” from NERP sessions in Egypt, none relapsed during the year of project operations. The pilot program covers about 1000 children. Although data on behavioral change has been limited to date, studies indicate that messages have been disseminated effectively.

In such short duration projects, sustainability is of critical importance. Sustainability here means that once the NERP sessions have ended and the organization leaves the project area, the messages taught are still applied and improved nutritional status is maintained. The results to date have been noteworthy. In Vietnam, an assessment of sustainability found that three years after the termination of project services, the nutritional status of project participants remained higher than that of matched controls. Even more impressive was the finding that siblings of these children, who had never been exposed to the program were also much better nourished than age-and gender-matched controls. The caretakers also fed their children, the younger siblings more meals per day on average than their comparison counterparts. In Egypt, recent data suggests that sustainability may require some minimal follow-up for message reinforcement. Where such follow-up was in place, malnutrition prevalence increased by only 1.6 percentage points in 14 months. Where follow-up was absent, prevalence increased by ten percentage points in less than one year.5

While the annual cost per child, using direct cost data from the Egypt project, is roughly three times higher than World Bank-assisted projects in South India and Bangladesh, the short duration and high impact of positive-deviance projects makes them comparable in terms of overall cost-effectiveness. Comparable projects assisted by World Bank provide supplements only. Positive-deviance projects on the other hand provide full meals and counselling to all enrolled children who are moderately and severely malnourished. The positive-deviance program is considered permanent rehabilitation. This means that because mothers are being educated and behaviors are targeted, improved nutritional status will be maintained and relapse will be infrequent. There are two additional outcomes of this program. In Vietnam, at least one more family member of each child is included as an indirect beneficiary. Also, there is anecdotal evidence that a significant number of deaths are avoided due to the program.6

In Vietnam, PANP provides education through role modeling and hands on experience, enabling women to learn from each other in the community. It reinforces good habits already in existence. PANP is based on the belief that in order for development gains to be sustainable, strategies and solutions to community problems need to be identified by community members themselves.3 The positive deviance model respects the culture, thus making the program more easily accepted in the community. These programs involve the community heavily from the outset. They use existing infrastructure and community health workers, and organize women in focus groups for their mutual support.

In the positive-deviance model, society is paying attention to positive role models and using them to assist others in their own community to reach the next level.

The positive-deviance method has been utilized to rehabilitate malnourished children. It is proposed now to improve pregnancy outcomes; specifically to prevent intrauterine growth retardation and to reduce the number of low birth-weight babies.

The Case for a Positive Deviance Based Pregnancy Intervention

The importance of reducing intrauterine growth retardation (IUGR) and improving pregnancy outcomes hardly needs recounting for those in the international public health arena. Suffice it to say, that low birth weight, a prime result of IUGR, has been closely associated with growth retardation, poor mental performance, morbidity and mortality during childhood7 it may also increase susceptibility to chronic diseases including cardiovascular disease, diabetes mellitus and hypertension, which in turn affects adult productivity and mortality.8

Some 30 million infants born each year in developing countries have experienced intrauterine growth retardation.9 In the developing world as a whole, one in five newborns will be low birthweight. In Sub-Saharan Africa, the figure is one in six. For South Asia, the area of the world contributing the largest number of low birthweight infants, the figure is as high as one in two - in Bangladesh for example.

It is also clear that maternal malnutrition is in large part responsible for IUGR and low birth weight, and poses an enormous risk for reproductive age women themselves in developing countries. Indeed the health-related indicator with the greatest differential between developing and industrialized countries is maternal mortality with rates often 100 times higher in poorer countries. Effective project activity addressing malnutrition before and during pregnancy not only would reduce rates of maternal mortality but would also reduce nutritional depletion that often occurs over the course of successive pregnancies. Dr Roger Shrimpton10 (formerly of UNICEF), in a review of global low birthweight prevention, concludes by saying, “I now see low birthweight prevention as the critical missing link of programs designed to improve both maternal and child survival and development. In many developing countries, there seems to be an obvious relationship between rates of low birthweight and rates of both child malnutrition and maternal mortality."

It is important to note that affecting birthweights through pregnancy interventions is more complex than we once believed and certainly far less linear than the relationship between child nutrition interventions and child growth. Nonetheless there is broad acknowledgement that addressing maternal malnutrition during pregnancy will have positive effects whether they manifest themselves in pregnancy weight gain, birthweight, survival of offspring or growth of offspring.

Because so many of the determinants of IUGR and low birthweight are behavioral, activities oriented towards behavior change, such as the positive deviance-based program of Save the Children, would appear to have a comparative advantage in addressing the problem, at least in countries where maternal malnutrition is not strongly income determined. Among the behavioral factors associated with IUGR are age of first pregnancy, inadequate birth spacing, absence of prenatal care, inadequate energy micronutrient intake prior to and during pregnancy, inadequate daytime rest during pregnancy and smoking or alcohol consumption during this period. These behaviors can all be targeted during the prenatal period.

Data collected in March 2000 in Egypt in communities which have participated in Save the Children's positive deviance-based projects geared to children, indicate clearly the opportunities that exist to influence some of the behavioral determinants of low birthweight. While only two to six percent of women reported consuming more food than usual during their last pregnancy, 25-40% reported intentionally consuming less than usual.5 Only one third of these mothers had regular day time rest during their pregnancies, a finding associated with the fact that almost none received assistance from their husbands in relieving their work load. Finally only 46% received any prenatal care and only 39% received any micronutrient supplements.5 Neither, to date, is routinely provided in that part of Egypt and both are usually procured from private practitioners rather than government clinics.

A Positive Deviance Based Pregnancy Education Program

In Vietnam, the Healthy Pregnancy and New Mother Program (HPNMP), implemented by Save the Children, has been able to reach 88% of pregnant women in the villages covered. The program met its objective of bringing about adequate pregnancy weight gain in over 60% of the women reached.

The adaptation of the positive-deviance program to pregnancy proposed in this Lecture would build on this work with pregnant women in Vietnam.

Rather than focussing on specific "positive-deviance food" as is often the case in Save the Children’s child-based projects, this proposal would focus primarily on behaviors. The study question here would be: How do some mothers give birth to healthy babies when other mothers do not? What are they doing in the prenatal stage that makes the difference? Additionally, rather than focussing exclusively on pregnant women themselves as agents of change, my proposal would target mothers-in-law and husbands. The positive deviance program is envisioned to operate in this way. The aim of this study is to determine which behaviors and practices result in a healthy newborn. The objective would be to promote healthy pregnancies and safe deliveries in order to decrease the incidence of low birthweight babies.

Following appropriate village level discussions and volunteer training, the first step would be the positive deviance inquiry. This inquiry would be conducted by a team of interviewers. This would be accomplished by carrying out baseline surveys, in project and control areas, to collect data on body mass index (BMI) of women early in pregnancy, pregnancy weight gain and birthweights and/or the weights of infants under one month of age. Data would also be collected on each of the behaviors discussed earlier, plus information on age, educational level, parity, and socio-economic status of the women. All pregnant women in the community would be weighed and women with low body mass index would be enrolled in the program. Questions on feeding and caring practices, health care seeking behaviors and knowledge of safer motherhood practices would also be asked. Analysis of this data would permit a determination of those positive deviant behaviors associated with adequate pregnancy weight gain and adequate birthweight among low-income women but practiced less often among lower income pregnant women as a whole. This quantitative data collection would be coupled with focus group discussion and key informant interviews and direct observation in homes in an effort to identify inappropriate practices which are unlikely to emerge from the baseline survey itself.

DYNAMIC MODEL OF THE PROGRAM

INPUTS

ASSUMPTIONS OF THE INPUTS

OUTPUTS

ASSUMPTIONS OF THE OUTPUTS

OUTCOMES (BEHAVIORIAL)

IMPACTS

BENEFITS

· PD mothers

· Training of Staff and volunteers

· PD foods

· PD behaviors

· assistance of local health clinics to assure capacity for ante-natal care and supply of micronutrients

· Physical center for activities

· project monitoring system

· There are PD mothers and children

· Staff and volunteers understand concepts and are motivated to apply them

· Local departments of health and clinic staff are receptive to the approach and cooperative

· Pregnant mothers will complete the PEP

· Monthly BMI screening for pregnant and newly married women

· Monthly recording of pregnancy weight gain for women already registered with counseling

· Utilization of ante-natal care and complementary services; supply of micronutrients

· Periodic attendance of mothers-in-laws and fathers at project sessions

· Mothers, mothers-in-law and husbands understand messages and are motivated to change behavior

· Women do not substitute the project meal for food normally consumed at home

· Changes in practices relating to positive deviant behaviors

· Increase in total daily in-take of calories and micronutrients

· Women form continuing mutual support network

· Improved birth weights

· Improved pregnancy weight gain

· Improved growth of offspring

· Decreased maternal and child morbidity

· Decreased maternal and child mortality

· Sustainability of behaviors - mothers will apply to their second pregnancy

· Increased productivity in next generation


The next step would be organizing daily counseling and food provision sessions for women with low BMI plus women who fail to gain 1 kg of weight from one monthly weighing to the next. The name IMPRESS is given to these daily sessions which stands for Improving Pregnancy through Education and Supplementation. These sessions will be lead by a Community Health Facilitator/Volunteer (CHF/V) selected from the local village and trained by the organization. The CHF/V would be a woman from the community - a good role model. The meal itself made in part from ingredients contributed by participants and always in a form easily prepared in the home, would provide an incentive for mothers to attend the sessions and provide needed energy and micronutrients, hopefully increasing daily intakes. Mothers-in-law and husbands would be invited to a specified number of these sessions. Counseling focussing on positive-deviant behaviors, other key nutrition and health information and messages dealing with child care (including the importance of exclusive breastfeeding and the timely introduction of complementary foods) would be done both by local trained volunteers and by positive deviant mothers themselves. Incentives would be provided for the latter. Enrolled women would continue to attend these sessions until delivery. Also, follow up and monitoring of these women would continue after delivery. Birthweight and pregnancy weight gain are the outcomes of interest in this positive-deviance based intervention program.

Given the vital importance of prenatal care and micronutrient provision, steps would also be taken in advance to assure that local health care facilities are capable of providing good care and are fully stocked with micronutrient supplies.

Primiparous or first time mothers are an ideal focus of such activity because first time mothers are new to child rearing and are likely to be open towards new information. It is anticipated that they will be more likely to apply what they have learned during their first pregnancy in their subsequent pregnancies. In fact, given the importance of first pregnancies and pre-pregnancy nutritional status, the daily food provision and counseling sessions would be targeted to any newly married women with low BMI.

Finally this program would try to instill a strong sense of community among reproductive age women in the project area, and an ongoing sense of responsibility on the part of experienced and successful mothers to share their wisdom with younger mothers and those less successful. Even after conclusion of the project per se, a support network of reproductive age women might continue to share wisdom and offer encouragement thereby sustaining gains achieved in the project.

Monitoring and evaluation of the project can be carried out with reference to the project conceptual framework. The monitoring system would focus primarily on inputs and on outputs or service delivery. Project evaluation would compare the pre-post changes in behavior between the project and control areas, and ultimately the changes in impact indicators, specifically in pregnancy weight gain and birth-weights between project and control areas. What would be gained? There would be improvements in birthweight and growth in the offspring. There would also be a higher intake of food energy and increased weight gain during pregnancy. Mothers would be educated about healthy pregnancy behaviors and knowledge of safer motherhood practices would be enhanced. It is not just one baby that would be affected. Succeeding babies would also benefit. An entire generation could be affected. Because of this impact, benefits such as a decrease in maternal and child morbidity and mortality would result. In terms of impact, the analysis would be extended to examine the child growth during their first year of life. Here the positive deviance approach would be used as a preventive measure to prevent unfavorable developmental outcomes whic h so often accompany fetal malnutrition.

Conclusion

The nutrition strategy first articulated by UNICEF in 1990 states that “the shortcoming of most nutrition-oriented programs to date is not the lack of well-documented interventions... It is rather the failure of most programs to explore fully how existing local skills and resources should be mobilized and supported in concert with technical interventions, in order to create an environment and a support structure that is more conducive to improved nutrition."

The positive-deviance concept as it has been applied to children and as it hopefully will now be applied on a larger scale to pregnancy outcomes, represents a prime means of doing just that - of utilizing skills, wisdom and life management techniques and approaches which have proven successful in a local context.

There is reason to believe that, as with the interventions geared to children, a positive deviance-based pregnancy intervention would be effective and if effective and sustainable with low levels of follow-up message reinforcement. The results could provide major benefit both to these mothers and to their offspring, improving their health and, in some instances protecting their lives. The next step for us is to encourage programs that focus on women, especially females of reproductive age.

In closing, the main message is, “positive deviance is an approach that would be able to improve pregnancy outcomes and thus reduce low birthweight babies.” It is an activity worthy of Dr Horwitz and one worthy of this institution. It is our turn to make the difference.

References:

1. Berg A (1993) The Nutrition Factor. The Brookings Institution, Wash ington D.C.

2. Zeitlin M, Ghassemi H, Mohamed M (1990) Positive Deviance in Child Nutrition, with Emphasis on Psychosocial and Behaviourial Aspects and Implications for Development. United Nations University, Tokyo.

3. Sternin M,J, Marsh D (1998) Developing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach - A Field Guide. Save the Children.

4. Berggren G (1995)Nutritional Education and Rehabilitation Program: A Save the Children Project in Vietnam. Save the Children.

5. Levinson J, Ahrari M (2000) Quantitative and Qualitative Assess ments of Positive Deviance-Based Nutrition Interventions in Minia Governate, Egypt. Save the Children.

6. Sternin M (2000) Personal Communication.

7. Allen SJ, Raiko A, O'Donnell A, et al. (1998) Causes of preterm delivery and intrauterine growth retardation in a malaria endemic region of Papua New Guinea. Archives of Disease in Childhood Fetal & Neonatal Edition 79(2):135F-140F.

8. Martorell R, Ramakrishnan U, Schroeder DG et al. (1998)Intrauterine Growth retardation, body size, body composition and physical performance in adolescence. European Journal of Clinical Nutrition 52:S1, S43-52.

9. ACC/SCN (2000) Fourth Report on the World Nutrition Situation. ACC/SCN, Geneva.

10.Shrimpton R (1999) Low birth weight prevention: A review of global programme experience. UNICEF, New York.

Additional References:

Andersson R, Bergstrom S (1997) Maternal nutrition and socioeconomic status as determinants of birthweight in chronically malnourished African women. Tropical Medicine & International Health 2 (11):1080-1087.

Ashworth A (1998) Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. European Journal of Clinical Nutrition 52:S1,S34-42.

Berggren G, Tuan T (1995) Evaluation of the Save the Children Foundation (SCF) Poverty Alleviation/Nutrition Program (PANP). Than Hoa Province, Vietnam: Save the Children Foundation.

de Onis M, Blossner M, Villar J (1998) Levels and patterns of intrauterine growth retardation in developing countries. European Journal of Clinical Nutrition 1998; 52:S1, S5-15.

de Zoysa I, Habicht J-P, Pelto G et al. (1998) Research steps in the development and evaluation of public health interventions. Bulletin of the World Health Organization 76 (2): 127-133.El-Sayed N (1999) Assignment Report on Evaluation of Positive Deviance: A Pilot Nutrition Intervention in Minia Governorate. UNICEF and Save the Children.

Hack M, Nancy K, Taylor GH (1995) Long Term Developmental Outcomes of Low Birth Weight Infants, The Future of Children 5:1.

Hack M (1998) Effects of intrauterine growth retardation on mental performance and behavior, outcomes during adolescence and adulthood. European Journal of Clinical Nutrition 52:S1, S67-S71.

Kramer MS, Haas J, Kelly A (1998) Maternal anthropometry-based screening and pregnancy outcome: a decision analysis. Tropical Medicine & International Health 3(6):447-453.

http://www.unu.edu/unupress/unupress/unupbooks/80697e/80697E08. htm, accessed 3/2/00, 7:25 PM

Marsh D, Schroeder D, Dearden K (1999) Improving Breastfeeding and Complementary Feeding Practices Using the Positive Deviance Approach in Vietnam. LINKAGES Project.

Positive Deviance Pilot Project, Nutrition Program, Gomphy, Zhemgang (1998)Bhutan Program, Himalayan Field Office, Save the Children, USA.

Trinh AU, Marsh D, Schroeder DG (2000) Sustainable Positive Deviant Child Care Practices in Vietnam. Emory University.

The author wishes to thank two people who were especially helpful throughout the preparation of this Lecture: James Levinson and David Marsh. Thanks are also extended to Jerry Sternin and David Claussenius of Save the Children.

Lucy Thairu, Graduate Student in International Nutrition, Cornell University, will present the Dr Abraham Horwitz Memorial Lecture during the SCN 28th Session in Nairobi, Kenya, on

Infant Feeding Options for Mothers with HIV:
Using Women’s Insights to Guide Policies


ACC/SCN Working Groups

Full reports are available upon request from the SCN Secretariat, or on our website: http//:acc.unsystem.org/scn/

Prevention of Foetal and Infant Malnutrition

(Formerly: Life Cycle Consequences of Foetal and Infant Malnutrition)

The Working Group Chair summarized the growing evidence that from conception onwards nutritional factors affect future health. Folate and iodine deficiencies in early pregnancy and iron deficiency in infancy are well documented examples. Several important events over the past year have helped to clarify how to go about designing large-scale programmes. A meeting on the prevention of low birthweight held in Bangladesh in June 1999 concluded that prevention of low birthweight requires a package of interventions, including better nutrition, control of infectious disease, and a reduced physical workload for pregnant women. Further, the UNICEF Care Initiative can serve as a basis for developing an integrated programme. A technic al consultation on low birthweight held in the USA in March 2000 was organized to develop a broad coalition of researchers, organizations and donors working together to move the low birthweight agenda forward. This consultation recognized that low birthweight needs to be addressed through interventions focusing on female adolescents and prepregnant women. A series of studies showing strong associations between low birthweight and stunting at one year of age and chronic disease in adult life (the Barker studies or foetal origins of disease hypothesis) are now being replicated and expanded in the US. The Working Group noted that there are contradictions in the interpretation of the Barker findings and possible mechanisms are poorly understood. Finally UNICEF presented their 11-country low birthweight pilot programme.

The Working Group will report on the following issues in 2001:

· Achievements of a secretariat to be established at the Institute for Child Health in London. The secretariat will collect, summarize and disseminate new knowledge concerning low birthweight prevention.

· Achievements of an IDECG Task Force to critically review the Barker hypothesis and make recommendations for replication studies.

· Guidelines to assist in the monitoring and evaluation of low birthweight prevention programmes.

· Guidelines for programmes to evaluate the efficacy and effectiveness of a multiple micronutrient supplement for use during pregnancy.

· Programmatic experience and communication strategies for promoting nutritional improvement and weight gain during pregnancy.

Micronutrients

This Working Group brought together a large body of work in three main areas: vitamin A and iodine deficiencies and iron deficiency anaemia. A consolidated report of activities in the vitamin A area covered current status of programming, coverage, the work of partners, and future actions and perspectives. The difficulty in arriving at a reliable estimate of vitamin A deficiency was discussed. Estimates ranging from 125 million (MI/UNICEF/Tulane) to 250 million (WHO) preschool children affected are currently published. A report on iron deficiency touched upon research and programming activities including evidence on the permanent cognitive impairment of young children who suffer from anaemia, new micronutrient supplements for young children and increased international support for wheat flour fortification with iron. Some constraints noted included the need for better data on iron status, assessment methods and research on the causal relationship between iron deficiency and health outcomes; and the importance of integrating interventions such as iron supplementation, food fortification and education for dietary change; and of linking these interventions to other public health and nutrition activities, i.e., reproductive health and nutrition, malaria control and integrated management of childhood illness. A consolidated report of the agencies’ work in the area of IDD elimination through salt iodization including the Salt 2000 Conference was presented. Remaining challenges to IDD elimination include low coverage rates in parts of Eastern Europe and Sub-Saharan Africa and the process of sustaining universal salt iodization while phasing out external assistance to salt producers.

The Working Group agreed to report on the following five issues in 2001:

· Progress in advocating for new and expanded programmes to prevent and control iron deficiency anemia; as well as progress in gathering evidence for the effectiveness of large scale programmes. On vitamin A, the Group will report back on efforts to produce reliable prevalence estimates. UNU offered to act as the secretariat for iron.

· Recommendations on improving public health approaches to iron deficiency, including dosage, supplement and enrichment mix formulation, and methods for preventing iron deficiency in children less than two years of age.

· Stronger consensus on methods to establish the efficacy, effectiveness and impact of food-based approaches, especially for prevention of vitamin A deficiency.

· Situation analysis and possible recommendations on HIV/AIDS in relation to micronutrient deficiency.

· The setting of micronutrient goals for the coming decade and the success of incorporating these goals into those being developed for the 2001 Special UN General Assembly on a Global Agenda for Children.

Breastfeeding and Complementary Feeding

With regards to a Technical Consultation on Infant and Young Child Feeding convened in March 2000 in Geneva, WHO summarized the objectives of the Consultation, presented the rationale for the development of a new strategy and explained the general organization of the Consultation. Nine programmatic themes were discussed in depth at the Consultation, including the impact of globalization on infant feeding and increasing rates of exclusive breastfeeding. Discussion focused on the need to ensure that the new strategy is rights based, and the need for WHO to further review evidence concerning the optimal duration of exclusive breastfeeding. WHO reported that it is currently undertaking a systematic review of all published scientific literature on this issue including infant growth patterns worldwide, nutritional adequacy of breastmilk, health, morbidity and mortality patterns. The results will be available in early 2001. IBFAN reported on the background and development of a training module on infant feeding for humanitarian aid workers. This is a collaborative project of WHO, UNICEF, LINKAGES and IBFAN. IBFAN noted that there are many inconsistencies and gaps in the knowledge of humanitarian aid workers on infant feeding, and consequent inappropriate practices, resulting in poor health outcomes among the most vulnerable age group. Concerning mother-to-child transmission of HIV/AIDS, participants noted that breast-feeding protection, promotion and support, has weakened as a result of concern over the transmission of HIV through breastfeeding. Current messages on infant feeding are perceived as conflicting. UNICEF stressed that there is difficulty in monitoring the growth and health of non-breastfed children in HIV prevalent countries.

The Working Group agreed to report on the following issues in 2001:

· The resolution of technical questions regarding the recommended duration of exclusive breastfeeding.

· In conjunction with the Working Group on Nutrition and Emergencies, the dissemination of pre-service and in-service training on infant feeding issues to all humanitarian aid workers using two modules, one on Key Issues and Recommendations, and another on Basic Technical Knowledge.

· The consistency of messages delivered through national programmes regarding the prevention of mother-to-child transmission of HIV.

· The effectiveness of programmes to support good breastfeeding techniques and exclusive breastfeeding (to prevent mastitis and subclinical mastitis) to reduce mother-to-child transmission of HIV.

· The re-launch and promotion of the three WHO/UNICEF/UNAIDS documents on HIV and infant feeding, given the widespread misunderstanding of their recommendations.

· For those agencies and NGOs involved in the reporting process to the Convention on the Rights of the Child committee, ensuring that country reports address progress on the state of Code implementation and related activities.

· The strengthening of Code implementation, especially in countries with high HIV prevalence.

· The incorporation of infant feeding issues into the discussions of other SCN Working Groups.

· Progress on development of the global strategy on infant and young child feeding.

Nutrition in Emergencies

This Working Group considered three main topics: problems associated with identifying and treating malnourished adults in Burundi and Congo-Brazzaville, recent research on infant feeding in emergencies, and issues associated with infant malnutrition. A presentation on adult malnutrition demonstrated the difficulty of determining the admission criteria for entry into feeding programmes for adults, the problems of dealing with chronic diseases in feeding centers, and some of the behavioural and social differences which need to be taken into account in the design of programmes for severe adult malnutrition. A discussion of research on infant feeding in emergencies highlighted the lack of coordination, quality and monitoring of infant feeding interventions in the Republic of Macedonia during the Kosovo crisis. There is a need for harmonization and clarification of the responsibilities of UN agencies and others in this area. This would involve a review and clarification of the MOUs between UN agencies. A presentation on infant malnutrition included a discussion of the problems of assessment of infant malnutrition for population surveys as well as for clinical care. Breastfeeding in the context HIV/AIDs and emergencies was also reviewed.

The Working Group agreed to report on the following issues in 2001:

· Achievements in the support of, and advocacy for, interventions addressing adult malnutrition. This will include an update on recent research findings presented at the inter-agency meeting which needs wide dissemination.

· In concert with the Working Group on Breastfeeding and Complementary Feeding, develop guidelines for the training of humanitarian staff on infant feeding issues in emergencies.

· WHO should make their nutrition manuals available on their website for global, low cost dissemination.

· RNIS‘s expanded coverage for one year should include the nutritional situation of selected population groups of more than 100,000 people displaced by natural emergencies.

· Achievements of a secretariat for this Working Group, to be located at the Emergency Nutrition Network.

Nutrition, Ethics and Human Rights

Mainstreaming human rights in nutrition must be the aim of the SCN and this should eventually be reflected in the work of all its working groups. NGOs working with a rights-based approach need the SCN Working Group as a UN focal point that can support and assist them in giving visibility and legitimacy to their rights-based work with food and nutrition issues at country level. It was decided that the Working Group would continue for at least two more years to ensure that human rights principles will be interpreted and operationalized. The potential for this is high given the growing UN and civil society commitment to human rights in general, and with the interest expressed by the UN High Commissioner for Human Rights in pursuing collaboration with the SCN that started with last year’s symposium. Various MOUs developed by UNHCHR and single agencies provide scope for direct collaboration on food and nutrition rights.

The past year has provided a set of new working tools with which such collaboration can now more effectively be put into place, including the General Comment No. 12 on The Right to Adequate Food by the UN Committee on Economic, Social and Cultural Rights. The coming two year period will be a period of particular challenges in consolidating the response by the High Commissioner for Human Rights to the mandate given to her by the World Food Summit: to clarify the content of the right to food and steps needed to implement it. The process ought to come to a close with the marking of WFS + 5 in November 2001. The SCN community must take advantage of that process and be an active partner in it by contributing with its professional expertise and commitment to ending hunger and malnutrition.

The Working Group agreed to report on the following issues in 2001:

· Preparation of a manual on the interpretation and use of General Comment No. 12.

· Development of benchmarks and indicators for food and nutrition rights programming and monitoring.

· Recommendations made at the 26th session, several of which have been partially or fully completed.

Household Food Security

Dr Namanga Ngongi presented reactions to the consolidated agency report. He noted that: (a) an enormous amount of work is currently ongoing in the household food security area; (b) research reports are becoming more operational in nature, for example work on women’s status and its effect on child nutrition status; (c) the steady shift of poverty and malnutrition to urban areas is a growing concern; (d) there is a profusion of databases on food and nutrition security and a need to harmonize indicators across databases; (e) there is a large number of publications available and downloadable from various websites; and (f) partnerships are growing and playing an important role in the household food security area. FAO presented information on the state of food insecurity in the world showing progress in some areas and declines in others, mostly in Sub-Saharan Africa. A presentation by the World Bank showed that even unprecedented income growth would only get us half way towards the target of halving undernutrition rates by 2020. The critical role of direct nutrition programmes was highlighted. Implications for targeted poverty programmes, the impacts of redistribution of income, and the extent to which findings can be generalized, particularly in the household and community levels, were discussed.

The FIVIMS project was presented and three proposals were put to the Group: (1) that the FIVIMS inter-agency working group play a major role in supporting the SCN’s efforts in disseminating information on food insecurity; (2) that FIVIMS works closely through UN reform processes such as UNDAF and CCA; (3) that FIVIMS forms the basis of a new SCN working group on information systems. A discussion followed on how FIVIMS could help countries to strengthen their information systems. A question was also posed as to the feasibility of improving FAO’s method for estimating the numbers of food insecure people. Several examples provided from the floor of new programming initiatives in urban areas, included those from CARE, FAO, GTZ, and ADB. WHO presented its multicountry study, currently underway in six countries, aimed at examining factors that relate to household food and nutrition security in vulnerable population groups. The next segment focused on ways in which agriculture and other food-based approaches could enhance their impact on malnutrition. Plant breeding approaches to increasing the micronutrient density of staple grains were discussed.

The Working Group will select one or several of the following suggested topics for their report in 2001:

· A review of programme activity in food-based approaches to improving nutrition (including food aid supported interventions) and an assessment of their effectiveness.

· A review of the impact of HIV/AIDS on household food security.

· A review of the role of the public sector in generating biotechnology for low income consumers and producers.

Nutrition of School-Aged Children

This Working Group heard three presentations on: the latest research on nutritional status of the school-aged child and programme impacts, results of a survey of partners and donors in school-based nutrition interventions, and efforts at the Bank to harmonize policies on school health and nutrition. A number of documents had been distributed which included recent results relevant specifically to school feeding programmes. This indicated that targetting school feeding to all grades may be inefficient from a student retention point of view. Another article on the cost-benefit of school feeding vs improved learning materials showed that school feeding had no effect on dropouts, had little impact on test scores, and was expensive. Participants were divided in their support for “universal” school feeding programmes. Some argued that cash incentives to increase school attendance could be more cost effective and need rigorous evaluation. The International Center for Research on Women presented some of the results of multiple programmes they have implemented for adolescents, including nutrition, HIV/AIDS, reproductive health and adolescent livelihoods.

The Working Group agreed to report back at the 29th Session (2002) on one task. The World Bank, WFP and FAO will work together on this task:

An inventory of school feeding programmes will be made, with a special effort to collect impact evaluations and with explicit attention to community-based school feeding programmes. This will assist in harmonizing school feeding policies among agencies.

The next issue of SCN News (#22) will provide a summary of the ACC/SCN 28th Session which will take place in Nairobi, Kenya
2-6 April 2001

- an outline of the programme can be found on page 49
- registration details are available from the SCN

Secretariat by Email: accscnwho.int or on our website: http://acc.unsystem.org/scn/


James Olson

James Allen Olson, Distinguished Professor, Iowa State University, died unexpectedly on September 22, 2000, just eighteen days before his 76th birthday. He will be remembered worldwide as a respected biochemist whose work contributed immensely to knowledge of retinoid and carotenoid biochemistry and metabolism, which is documented in over 400 publications. Jim also will be remembered for his public health pursuits toward development of methods to identify deficient populations and control the preventable health consequences of vitamin A deficiency. He was a teacher who guided over 90 graduate students, a gracious mentor to many international colleagues, and a sought-after speaker for his lucid, insightful and balanced presentations. His critical evaluations, expressed with respect for those with differing views, provided balance on controversial issues based on good science. An international symposium, "Functions and Actions of Retinoids and Carotenoids: Building on the Visions of James Allen Olson" will be held 21-24 June 2001 in Ames, Iowa, USA. More information is available by contacting the Symposium Committee, Department of Biochemistry, Biophysics and Molecular Biology, Iowa State University, Ames, Iowa, or on their website: http://molebio.iastate.edu/~gfst/oslonsymp.htlm

Barbara A Underwood, Scholar-in-Residence, Food and Nutrition Board, President, International Union of Nutritional Sciences (IUNS), Institute of Medicine, NAS, USA

The ACC/SCN 28th Session

will take place in Nairobi, Kenya

Monday 2 through Friday 6 April 2001

hosted by the World Food Programe

Registration details and agendas are available on the SCN website: http://acc.unsystem.org/scn/

Joint working sessions of UN Agencies, Bilaterals and NGOs will take place on Monday 2 and Friday 6 April - ideas for the Fifth Report on the World Nutrition Situation, amongst other items, will be discussed. A public Symposium on Nutrition and HIV/AIDS* will take place on Tuesday 3 April. Meetings of the ACC/SCN Working Groups on Capacity Strengthening for Food and Nutrition; Micronutrients; Nutrition, Ethics and Human Rights; Breastfeeding and Complementary Feeding; Nutrition in Emergencies; the Prevention of Foetal and Infant Malnutrition; and Household Food Security, will be held on Wednesday 4 and Thursday 5 April. Working Group meetings are open to all interested persons.

*Symposium participants will be welcomed by Dr Sam Ongeri, Minister for Public Health, Kenya. Dr Peter Piot, Executive Director UNAIDS, will provide a keynote address on The magnitude of the HIV/AIDS epidemic in Africa and current challenges. Dr Oliver Saasa, Head Institute of Economic and Social Research, Zambia will discuss Nutrition, HIV/AIDS and development; Dr Stuart Gillespie, IFPRI, Washington DC, will discuss Weathering the storm - the impact of HIV/AIDS on livelihoods, food security and Nutrition and Dr P K Dlamini, Minister for Health and Social Welfare, Swaziland, will discuss Nutrition and the Care Package. A panel discussion on implications for programmes will follow - and should promote lively discussion. The panel will comprise: Mrs Sofia Mukasa Monico, Director of The AIDS Support Organization (TASO), Uganda; Dr Ruth Nduati, Department of Paediatrics, Kenyatta National Hospital, Kenya and Dr Margaret Gachara, Kenya National AIDS Control Council. Ms Lucy Thairu, Graduate Student in International Nutrition, Cornell University, will present the Dr Abraham Horwitz Memorial Lecture: Infant Feeding Options for Mothers with HIV: Using women’s insights to guide policies. A two-hour concluding session of the Symposium will be held on Wednesday 4 April, during which Dr Badara Samb, Chair of the ACC/SCN Working Group on Nutrition and HIV/AIDS will provide a synthesis of conclusions and next steps.


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