NEWS AND VIEWS

Managing Successful Nutrition Programmes
International Conference on Nutrition set for 1992/93
Nutrition and the Road to Health
Potential Health Effects of Climatic Change
Programmes/Letters/and more

Managing Successful Nutrition Programmes

Effective programme management, for communities and individuals, makes the difference between success and failure, for nutrition programmes as for any others. Success of course also depends on interventions being relevant to causes of malnutrition -requiring research and pilot schemes. But in many countries nutrition programmes have now moved well beyond the pilot testing stage to become large-scale routine activities. With accumulating years of experience, the crucial "nuts-and-bolts" lessons leading to sustained and efficient operations can now be examined. To help in this, the ACC/SCN organized a workshop on "Managing Successful Nutrition Programmes" at the 14th International Congress of Nutrition, held in Seoul, South Korea, 21-25 August 1989. The workshop lasting eight hours spread over three days was attended by some 200 people, participants in the 14th Congress. The presenters were supported by a number of sponsors, including GTZ, ILO, the Netherlands, UNEP, UNICEF, USAID, as well as the ACC/SCN itself.

Sixteen projects provided real-life experience, organized into five themes: targeting, staff issues (selection, supervision, training), community participation, management information systems, and sustainability and replicability. Examples of some of the large scale programmes discussed are given in the box. A report is in preparation by the ACC/SCN, and the topic will be featured in more detail in SCN News No. 5. Some initial impressions are highlighted here.

Programmes that succeed, almost by definition, are those that are sustained by long-term support. For programmes to succeed in the long run they must be clearly perceived as of benefit, both by the communities involved, and by the funders (government and donors) alike. Most of the large scale projects have been in operation for at least five years, indeed many began in the mid '70s. The crucial stage from pilot testing to large scale routine operation has clearly been overcome in these cases.

Continuing operation of such projects over a number of years generally involves simplification and refinement of operational procedures. For example, most projects now target by two criteria: geographical area and then to women and children. Some programmes then select on the basis of individuals status - usually by growth monitoring in children, and for pregnant and nursing women. More complicated targeting procedures (for example by socio-economic status) that have previously been tested have not generally found their way into operations.

A substantial level of intensity of programme activities is required to bring tangible benefits. Factors such as frequency of contact of field workers with house-holds, supervision ratios, and organizational development, are central to successful programmes. Although flawed, one measure for comparison between projects is the expenditure per participant per year, and this seems to fall in the range (where feeding is involved) of some US$10 to US$50 per participant per year; programmes that do not involve feeding are of around half the cost or less, but have a different type of impact.

Examples of large-scale nutrition programmes from ACC/SCN Workshop
Country/Programme	Nutrition Components
Botswana - Drought Relief Programme	Food distribution and feeding through health service. National coverage (500,000 participants in 1987/8). 1982-88, during drought.
Costa Rica - National Nutrition Programme	School feeding, food distribution, nutrition education and child care centres (about 500). Begun in 1974.
Gambia - Health and Nutrition Programme	Food supplements (take-home), nutrition education, growth monitoring. About 100 centres, approx. 80,000 women and children participate. Began in 1981, new phase 1989-94 now starting.
India - Integrated Child Development Services	Supplementary feeding, growth monitoring, nutrition education. Population of some 30 million children covered (early 1989). Began 1975.
India - Tamil Nadu Integrated Nutrition Programme	Selective time-limited supplementary feeding, growth monitoring, nutrition education, micronutrient deficiency control. More than 1 million children and women participate. 1980-9, to be expanded.
Indonesia - Family Nutrition Improvement Programme (UPGK)	Monthly weighing, nutrition education, home gardening, nutritional first aid (iron & vitamin A). National coverage, about 21 million children. Began in 1974.
Philippines - Alternative School Nutrition Programme	Nutrition education, supplementary feeding, food production, income generation; uses revolving fund. Covers over 1000 schools. Began 1983.
Tanzania - WHO/UNICEF Joint Nutrition Support Programme, Iringa	Growth monitoring, maternal and child health, household food security, etc; emphasis on community mobilization. Covered 600 villages in 1987. 1984-1989.
Thailand - National Nutrition Programme	Growth monitoring, nutrition education, supplementation. Covered 2.5 million children in 60,000 villages in 1989. Planned 1982-2001.
Zimbabwe - Supplementary Food Production Programme	Community production of supplementary foods, community mobilization, nutrition education. National, comprising over 6000 local projects in 1989. Began in 1981.
Source: Project summaries prepared by workshop participants

Overall the impression is that there are now a number of models of mature programmes whose future seems relatively assured, and whose impact on nutrition -although this was not evaluated directly - seems likely to continue. Sustainability of such programmes, as summarized at the end of the workshop, can be viewed as both financial (internal and external) and functional, the latter involving both technical and social/political aspects. While political support is necessary, its relation to accountability of decision-makers to the community may be one of the most important factors of all.

- J.B.M.

International Conference on Nutrition set for 1992/93

At the ACC/SCN 15th Session, held at UNICEF Headquarters, New York, February 1989, the United Nations agencies represented on the SCN decided that the time was right to propose an international (or world) conference on nutrition. The objectives put forward were as follows (taken from the official ACC/SCN report):

"The ACC/SCN recommends consideration of a major effort by governments, organizations of the UN system and bilateral agencies, including financial institutions, and non-governmental organizations, to:

- increase awareness of the magnitude, causes and consequences of nutrition problems;

- formulate and adopt strategies, based on available knowledge and technology, to meet nutritional goals;

- mobilize resources for a concerted effort to implement these strategies;

- get momentum behind action for a human nutrition focus for the 1990's Development Decade."

In summary, the ACC stated that it believed that malnutrition and undernutrition, which affect millions of women, men and children are major impediments to social and economic progress, and that the conference will be an important step towards increasing public awareness and obtaining national and international commitments to appropriate strategies and actions to ensure improved nutrition world-wide.

We will keep readers informed of progress in this important effort. Watch this space.

- J.B.M.

Nutrition and the Road to Health

Professor Thomas McKeown, the eminent epidemiologist and former Chairman of a World Health Organization (WHO) advisory group on health research strategy, died on 13 June 1988 aged 75. Essentially, in his most important writings, McKeown - with outstanding gifts of intellectual vigour, erudition and fluent expression - argued that the key to health lay in changes of lifestyle. WHO issued a feature (WHO Features, December 1988, No 131) as a tribute to Professor McKeown - drawn from a statement he prepared a few weeks before his death, for a meeting of the World Health Organization Advisory Committee on Health Research. His views are of such interest in the context of nutrition that we have extracted the article here at some length.

"With its emphasis on equity, acceptability, self-determination and social justice, the concept of primary health care reflects admirably the spirit of the "health for all" commitment. It is, however, a comprehensive approach which includes all the major developments desirable for health under more or less ideal conditions. In the foreseeable future many Third World countries will be unable to afford all of these developments, and it is therefore necessary to assign priority between them according to their effectiveness.

For this purpose there are two sources of enlightenment to which we can turn, the experience of industrial countries during the last two centuries, and the experience of some developing countries which have made rapid progress during the last few decades. Conclusions from these sources are reasonably consistent particularly on the basic observation that the advances in health were due almost entirely to the decline of mortality from infectious diseases.

In developed countries, the infections declined because of (a) increased resistance brought about by improvement in nutrition and, later to a lesser extent, immunization and (b) reduced exposure, which resulted from hygienic measures (in respect of water, sanitation, food and housing) introduced progressively from the late nineteenth century.

In the developing countries the decline of mortality appears to have been due predominantly to better nutrition, for in some countries which in a few decades have attained Western standards of health there were no substantial advances in the other major influences. However there were some other developments which contributed powerfully if indirectly to health: education, particularly of women; equity of access to health resources; political and social will to improve health; above all, control of fertility, which safeguarded the advances from the effects of rising numbers.

In the light of this assessment of the contribution of different influences, developing countries which do not have the resources needed to provide all the services specified under primary health care - and that is the position in which nearly all are placed - would be well advised to give high priority in research and services to nutrition, immunization and sanitation. And if limited resources prevent the full provision of sanitary services, as they are likely to do, a large advance can be made by increasing resistance to infection.

It is hardly possible to overestimate the significance of the observation that in China and Kerala the advances were due almost entirely to better nutrition; there were no substantial improvements in water, sanitation and personal care, and immunization coverage was low.....

Primary Health Care: an all inclusive approach

The content of primary health care was outlined clearly in the Report of the International Conference at Alma-Ata. "Primary health care should include at least: education concerning prevailing health problems and the methods of identifying, preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water, and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; promotion of mental health; and provision of essential drugs.

Moreover this comprehensive agenda was regarded as a statement of basic requirements, to be supplemented according to the economic and social values of each country and its communities. From this statement it is evident that primary health care, so conceived, covers all the major developments needed for health under more or less ideal conditions. It does not attempt to judge the order in which the developments should be promoted where conditions are far from ideal, as they will be in many countries for a long time to come.

The inevitability of deficiencies, and hence the need for priorities, is well illustrated by two of the influences that are most critical for health: nutrition and sanitation. A recent report on the world nutrition situation ¹ concluded that malnutrition has decreased in Asia and Central America, has remained stable in South America and has increased in much of Africa. Since the population of the world is expected to double before it stabilizes, and the population of Africa will increase about six times, on the basis of present policies it seems inevitable that serious food deficiencies will continue well into the next century. And the WHO report on sanitary progress during the present decade makes it evident that we are not in sight of the time when clean water and adequate sanitation will be generally available in developing countries, particularly in rural areas. ....

¹ ACC/SCN 1987. First Report on the World Nutrition Situation.

In developed countries the improvement in health since the eighteenth century resulted mainly - until 1900 almost wholly - from the decline of mortality from infectious diseases. The direct influences which led to the decline of the infections were as follows:

1. Increased resistance brought about by:

(a) Improved nutrition. It was responsible for the advance in health in the eighteenth and nineteenth centuries where exposure to infection was increasing because of rapid population growth and defective hygiene.

(b) Immunization. It accelerated the decline of mortality in the twentieth century, particularly by reducing the pool of infectious people.

2. Reduced exposure to infection, mainly through hygienic measures applied progressively from the late nineteenth century. The important developments were clean water, improved sanitation and, a little later, advances in the handling of food and improvements in housing. To a limited extent exposure was also reduced by treatment.

Experience of Developing Countries

Fortunately additional evidence is now available from a number of Third World countries which have advanced rapidly in health: Sri Lanka, Costa Rica, India (Kerala State), China, Thailand, Cuba, Jamaica and a few others. The conclusions which follow are based on books, papers and case studies which have examined this experience... and it will be convenient to examine the direct influence under the same headings as in developed countries.

1. Increased resistance to infection. All of the countries which advanced rapidly achieved a substantial improvement in nutrition which led to increased resistance (to infection). Indeed in some countries this was the only important direct influence. It is perhaps surprising that immunization appears to have contributed relatively little to the advances, not of course because it was ineffective, but because the reduction of mortality occurred in a period when vaccine coverage was still low.

2. Reduced exposure. Improvements in water supply and sanitation were important influences in industrial countries, but they do not seem to have been very significant in the Third World countries which have advanced. For example, the coverage of the population by provision of clean water and safe sanitary measures was low in China, Sri Lanka and Kerala - lower indeed than in many other developing countries - although their death rates were well below average levels. It is also clear that treatment of established diseases contributed little to the reduction of exposure, for in several countries there was little improvement in personal care services. ....

The Present Position of the Major Influences on Health in Developing Countries

To anyone who has travelled extensively in the rural areas of the Third World, the common causes of ill-health may seem self evident. Many children are visibly malnourished; sanitary conditions are primitive; drinking-water is unclean, the food displayed in open markets is contaminated; and the number of people competing for the means of life is clearly excessive. Our conclusions concerning the determinants of health can be epitomized by the simple statement that the most elementary requirements are that people must have enough to eat and they must not be poisoned. ..."

Source: WHO Features, Dec. 1988, No. 131. Part of the article is based on "The Origins of Human Disease" (1988) Blackwell, Oxford.

* * *

Prof McKeown went on to summarize conclusions in relation to four critical influences: food, immunization, drinking water and sanitation, and control of numbers. Here is an excerpt from his conclusions regarding food. "Food A World Bank study of the relation between poverty and hunger quoted an edict by the Emperor Wen in 113 BC: "Why is the food of the people so scarce? ... Where does the blame lie?" The deficiency is even more remarkable today, because in many countries and in the world as a whole food supplies are believed to be adequate. The World Bank Study concluded: "The often predicted Malthusian nightmare of population outstripping food production has never materialized. Instead the world faces a narrower problem; many people do not have enough to eat despite there being food enough for all. This is not a failure of food production, still less of agricultural technology. It is a failure to provide all people with the opportunity to secure enough food - something that is very hard to do in low-income countries." Although one would question the statement that population growth has never outstripped food production, it is an accurate assessment of the position in many countries today. The recent First Report on the World Nutrition Situation (1987) made an appraisal of trends in nutritional indicators from 1960 until the most recent year available, usually 1985. The Report concluded that although nutrition has improved over the last 25 years in most parts of the world, in sub-Saharan Africa there has been declining food availability and increased malnutrition, and in South America there has been no significant improvement. Improvements in living conditions recorded during the 1970s have slowed or halted with the severe economic recession of the early 1980s, and this is affecting child nutrition. In the light of our conclusion concerning the critical role of nutrition, the data for China in this report are of particular interest. Over the past 25 years, China's per capita food production increased 75% and its population by around 60%; dietary energy supply increased by approximately 40% between 1961-63 and 1983-85. There were corresponding increases in birth weight and child growth rates, and infant mortality fell from 200 (per 1000 live births) before 1949 to about 40 in 1980, and to 35 in 1982. As already noted, apart from the improvement in nutrition there were no other major changes which could account for the reduction of mortality. The increased food production during the last 35 years has resulted mainly from technological advances; the use of chemical fertilizers and pesticides; increases in the amount of irrigated land; and the introduction of high yielding disease resistant seeds. As a result of these advances, grain production more than kept pace with the growth of populations, both in the world at large and in developing countries considered as a whole. However, for a number of reasons the practice of equating food resources with the number of people gives a misleading picture of the effects on nutrition... ... it is evident that malnutrition and its sinister effects on health are common in developing countries, and result mainly from international and national policies which prejudice food production and distribution. The international community can contribute in many ways - with resources, with advice and not least by refraining from encouraging or requiring Third World countries to absorb food surpluses (the grain and butter mountains) or to adopt agricultural and economic policies which contribute to their poverty. However, the causes of food insecurity and the resultant ill-health are determined largely by national policies. The chief requirements are (a) to ensure an adequate food supply through policies which promote domestic production (by shifting resources from industry to agriculture, from large to small farms, from capital-intensive to labour-intensive activities) and (b) to give people at risk of food insecurity the opportunity to earn an adequate income. The problem of food deficiency is determined essentially by poverty. "

Potential Health Effects of Climatic Change

Climatic conditions may change. A rise of global mean temperature and an increase in UV radiation is predicted if the present trends of greenhouse gas emissions continue during the next 100 years, or even if they are substantially cut. Climatic changes may affect the world's entire population. The World Health Organization, through its Environmental Health Division, has undertaken to assess health consequences of climatic change. A small group of experts met in WHO, Geneva, from 12-16 June 1989 to discuss the basis for a review of the "Potential Health Effects Associated with Climatic Change".

Many of the changes will affect ecology and influence food production, vector-born and other infectious and non-infectious diseases. The phenomena might trigger migration both from one rural region to another and from rural to urban areas. Notable among potential indirect effects of climatic change on health are those mediated by effects on food production and nutrition requirements.

Adaptive mechanisms depend, among other things, on the soundness of the environment, the strength of economy, and the quality and level of health services.

If these gradually occurring changes are accompanied by an increase in frequency or intensity of natural disasters such as cyclones and floods, their effects on human life become acute, possibly generating large refugee or population displacement problems. Predictions of the potential health effects of the climatic change have to remain very general since the available data are not sufficient for any kind of quantitative projections. Geographical factors, however will determine the population at risk in certain events (e.g. flooding from sea level rise), and affect agriculture, nutrition and household socioeconomic status. Rising temperatures may modify nutritional requirements. More important perhaps, climatic change could have a profound effect on agriculture and hence food production.

According to a preliminary draft report of this meeting, even in the absence of large quantitative effects on agriculture, climatic variations are likely to diminish the variety of crops that subsistence farmers will be able to cultivate, causing a narrowing of the dietary spectrum. Regions at present in a precarious agroeconomic equilibrium due to marginal climatic conditions are of special concern. These are the most vulnerable to even minor changes, thus a small increase in the frequency or length of drought periods for example may be sufficient to make them virtually uninhabitable.

From 'New Scientist', reproduced with permission of David Austin.,

The meeting looked also at the possible public health responses to the adverse effects of climatic change, and gave recommendations for actions to be taken. The full report of this meeting will be available by mid 1990. A WHO Task Group meeting in April 1990 will finalize recommendations concerning health. The UN sponsored Intergovernmental Panel on Climate Change will produce a comprehensive report by end-1990.

(Source: WHO Press Release, 16 June 1989; Environmental Health Division, WHO, Geneva)

- M.L.

The Cornell-China-Oxford Research Project on Nutrition, Health and Environment

This project which started in 1983 is a large international study on the health, eating habits, environment and social practices within the People's Republic of China, designed to investigate interrelationships between food, environment and diseases. The principal investigators are nutritional scientists, physicians and epidemiologists from Cornell University, the Chinese Academies of Preventive Medicine and of Medical Sciences, and the University of Oxford, who work in collaboration with other scientists from the United States, France, Britain, Taiwan and other countries.

A large quantity of survey data and biological samples have been gathered from more than 6000 individuals in 130 rural areas in 24 provinces of China, to provide the most comprehensive data base that exists on the multiple causes of disease.

China was chosen for this health investigations because of its unique characteristics: it has a huge population; it encompasses a wide range of ecological zones, mortality rates for various diseases, and food and other consumption patterns; and a large range of exposure to both industrial and non-industrial carcinogens. In addition China is at a stage of epidemiological transition where diseases of industrialization such as lung cancer and heart disease are becoming more prevalent than diseases of underdevelopment such as infectious diseases. Another remarkable feature of China for epidemiological studies is that there has been little mobility of the population so that life styles and dietary patterns have remained relatively stable in each area. These characteristics lead to clear cut geographic differences in disease patterns from one county to the next. Mortality rates for a specific disease can vary by more than a hundred fold. This provides a level of sensitivity that is unlikely to be produced in other countries. The methods of data collection have been extremely carefully prepared and scrutinized to maximize the reliability of the data set. The information emerging from the relationship of these differences to environmental and dietary factors will have significance not only for China but also internationally.

More than 350 items of information on biochemical indicators, carcinogens and viral exposure, dietary practices, physical and reproductive characteristics, clinical status, smoking and drinking practices and other habits have been recorded. Initial computer analysis carried out at the University of Oxford has produced several thousand statistically significant associations many of which provide interesting insights into possible causal factors but a great deal of work still needs to be done on the interpretation of these findings. Sections of this database have been made available to associated research groups throughout the world for further analysis and interpretation in the expectation that many new insights into the causation and prevention of disease will emerge.

Based on the full analysis of only a small part of the data, a number of associations and hypotheses on causal relationships between food, environment and diseases are beginning to emerge. Some findings are, however, more fully developed of which only few examples are given in what follows.

At the low plasma cholesterol levels found in China the quantitative relationship between plasma total cholesterol and coronary heart disease (including myocardial infarction plus coronary heart disease) mortality is that which would be expected from a linear extrapolation of the relationship previously observed for several Western populations in which mean plasma cholesterol levels are much higher. This observation suggests that there is no threshold of plasma cholesterol below which coronary heart disease mortality remains constant. However, within the low ranges of plasma cholesterol and coronary heart disease mortality in China, no significant association was found.

On the same theme, in the absence of any association found between red blood cell (RBC) oleic acid and plasma cholesterol, the study was able to provide an alternative hypothesis to explain the observed beneficial effects of oleic acid on reducing cardiovascular disease. It was found that in the phosphatidyl fraction of the RBC membrane, the oleic acid concentration was significantly negatively correlated with its arachidonic acid concentration. Assuming that the same is true for the platelet membrane and considering that thromboxanes (potent inducers of platelet aggregation and platelet release reactions and also a vasoconstrictor) derived from arachidonic acid increase platelet aggregation, the potential for aggregation may be reduced by oleic acid displacing arachidonic acid in the membrane. In other word, beneficial effect of oleic acid may relate to reducing clot formation, rather than to effects on plaque deposition.

Contrary to the recently postulated relationship between low plasma cholesterol levels and higher total cancer rates, no evidence of such association was found in this study and if anything the opposite trend was indicated. The study provided support for the hypothesis that at least part of the geographic variation in esophageal cancer is diet related, suggesting low levels of vitamin C to be possibly involved. Esophageal cancer mortality was found to be significantly higher in areas of low plasma vitamin C and low fruit consumption. Most non cancer disease mortalities are inversely related to both socioeconomic and general nutritional status, except for coronary and hypertensive heart diseases and stroke which are negatively associated with socioeconomic status but positively associated with the general nutritional status. Salt intakes may account for part of this observation. In the case of mortalities from most cancers (including leukemia, lung, breast and lower bowel cancers) there are strong positive associations with both socioeconomic and general nutritional status. Esophageal, stomach and cervical cancers were, however, positively related to the general nutritional status and inversely to socioeconomic status.

The monograph presenting the original data and a preliminary data processing is expected to be published in January 1990 by Chen J., Campbell T. C., Li J. and Peto R. under the title: Diet, Lifestyle and Mortality in China. A study of the characteristics of 65 counties. Oxford University Press. Further enquiries on the project should be directed to Dr Thierry Brun, Coordinator of the China-Oxford Project on Nutrition, Health and Environment, MVR. Division of Nutritional Sciences, Cornell University, Ithaca, N.Y. 14850, USA.

(Source: Thierry Brun and Catherine Geissler, Division of Nutritional Sciences, Cornell University, Ithaca, N.Y., USA.)

Dried skim milk is still used for feeding programmes in refugee camps, despite well-known cautions expressed by nutritionists and others, over many years now. Do the benefits outweigh the risks? At the request of UNHCR a meeting was organized by the ACC/SCN on April 7 in Geneva to consider the issue of using dried skim milk (DSM) in relief programmes, and to discuss a policy proposed by UNHCR to regulate the distribution and use of milk products in refugee camps.

The following basic principles and guidelines for DSM use in refugee camps were agreed:

(i) Distribution of DSM, when not pre-mixed with other commodities such as cereals, should be avoided wherever possible in take-home rations, due to the risk of use as reconstituted milk which is readily contaminated, and of its being used as a breast milk substitute. Where sufficient supplies of beans, tinned fish or other suitable protein foods are available, as well as enough fuel for cooking, such items are preferred to DSM for general rations where distributed in dry, take-home form.

(ii) Where sufficient supplies of beans or other suitable protein foods are not available, and/or cooking fuel is scarce, DSM for general rations should be premixed centrally, away from the distribution point, for example with cereals. When pre-mixing centrally cannot be assured, then the possibility of local pre-mixing should be looked into, but avoided if leakage and misuse of DSM is likely.

Source: Reproducted from 'My Name is Today' (1986). Fig. 161. D. Morley & H. Lovel. TALC, P.O. Box 49, St Alabans, Herts, AL1 4AX, U.K.

For further information, please contact:

Ms Angela Berry, UNHCR, Palais de Nations, 1211 Geneva 10.

(Source: Report of the meeting on DSM, 7 April 1989, ACC/SCN.)

- S.G.

Commercialization Benefits for the Malnourished Poor

"Increased income of the poor that results from commercialization of agriculture goes a long way towards providing solutions to the hunger problem" according to a Commentary by Joachim Von Braun, published in the International Food Policy Research Institute (IFPRI) Report in April 1989.

The report describes recently completed long-term research on commercialization of agriculture in the Gambia, Guatemala, Kenya, the Philippines and Rwanda, where there has been a recent change from semi-subsistence staple food production to increased production of crops for sale in the market in some of the farm households. The findings were presented and discussed at an international workshop in Guatemala in March 1989. The outcome of this workshop suggest the general conclusion that agricultural commercialization raises the income of the rural poor, thus improving their food security. Moreover, no adverse effect on nutrition was found by agricultural commercialization under any of the study settings. (See also "Does Cash Cropping Affect Nutrition?", SCN News No. 3).

Effective policies and programme design required to deal with the limited negative factors and side effects of cash cropping are often debated - if benefits are to be captured by the malnourished poor. For instance, agricultural policy can support the combined cropping of subsistence food production and cash crops, by the small land holders through the promotion of better production technology for staple foods.

Further, since the problem of malnutrition is due to the complex interaction between food inadequacy and morbidity, health and sanitation in rural areas have to be promoted together with agricultural development. Based on the data provided by these studies, in the poorest households (at a per capita income level of under $100 per year) a 10% increase in income resulted in improvement in children's nutritional status (using weight-for age) of 1.1% (Guatemala and Philippines), 1.9% (Gambia) and 2.5% (Rwanda). In the Kenyan example, with a particularly bad health situation, however, income had no significant effect. While generally significant and positive, the nutrition improvement effects relating to increased income were found to be small. In the authors' view these results point to the fact that "the positive impact of increased income on alleviation of the food deficit constraints is overshadowed by health and sanitation constraints in determining child malnutrition".

(Source: Joachim Von Braun, IFPRI Report, Vol. 11, No. 2, April, 1989)

- M.L.

Consequences of Deforestation for Nutrition

Deforestation - for fuel or for agricultural land -coupled with low agricultural productivity can form a vicious circle, causing further deterioration in forest and land resources. IFPRI (the International Food Policy Research Institute) has studied these issues, in relation to nutrition, in Nepal. The results show that dietary improvement - both quantitative and qualitative - requires not only time spent in production activities, but also increased time for fuel collection and food preparation, all of which are time intensive for women. The study indicates that although income is the primary factor for improving the nutritional status of children in the long run, the degree of deforestation in the area also influences child nutrition. Where deforestation is severe, preschool children do not score as well against standard height and weight measurements of nutritional status. The study shows that not only is the increase in women's work loads in high deforestation areas detrimental to preschool children's nutrition, but a similar effect is seen when older children assume more household labour in the form of increased collection activities and livestock care.

Shubh K. Kumar and David Hotchkiss from IFPRI carried out the study on the Consequences of Deforestation on Women's Time Allocation, Agricultural Production and Nutrition in Hill Areas of Nepal.

Copies may be obtained from: IFPRI, 1776 Massachusetts Avenue, N.W. Washington, D.C., 20036, USA.

(Source: IFPRI Abstract - Research Report 69, October 1988).

- M.L.

Worldwide Immunization Coverage: No Longer a Dream?

The goal of at least 80% coverage of the world's children with all of the EPI vaccines by the end of 1990 appears attainable! The global immunization figures released by the World Health Organization's Expanded Programme on Immunization (EPI) show that immunization coverage of the world has reached 67% for a third dose of polio vaccine for children reaching their first year of life. The third dose coverage for diphtheria, pertussis and tetanus (DPT) stands at 66%, for tuberculosis (BCG), 71% and for measles, 61%. The coverage of pregnant women with a second dose of tetanus toxoid is, however, still only 25%. China succeeded in increasing its national coverage for polio vaccine from 74% in 1987 to 96% in 1988.

In these achievements, the World Health Organization has had the active partnership of UNICEF and the support of other organizations like the World Bank; UNDP; Save the Children Fund; Rotary International; the Rockfeller Foundation and others.

The present two-thirds level of coverage, according to a WHO report, is preventing the death from these diseases of over two million children each year - the lives of four children are being saved from the diseases of measles, whooping cough and tetanus of the newborn with each passing minute. When the programme was initiated by WHO in 1974, immunization coverage for infants in the developing world was below 5%. The world is not now far from eradicating polio by the year 2000 when the coverage with the EPI vaccines should reach over 90%.

With immunization provided as one component of comprehensive child health services, the EPI has set the goals of reducing measles cases by 90% and of eliminating neonatal tetanus by the year 1995.

(Source: International Review, 29 August 1989, World Health Organization)

- M.L.

Is production more worthy than consumption?

"Our country (the US) can spend $20 billion on producing surpluses which then go to waste, while simultaneously professing it difficult to find $2 billion to put purchasing power into the hands of those people and countries that experience desperate hunger problems". This view was put by S Reutlinger, of the World Bank, in a colloquium on "Science, Ethics, and Food", convened by the Smithsonian Institution. In a discussion of a paper by Amartya Sen on 'Food Entitlements and the Economic Chain', Reutlinger expressed views on common failures with food policies. He saw the problem as two-fold: on the one hand, too little is done to enhance the ability of the hungry to produce or acquire more food; on the other, resources are squandered to pay all farmers to produce in excess of what markets will absorb, instead of providing direct adjustment assistance to those farmers unable to earn adequate incomes when food prices decline.

"Public opinion favours subsidizing production over consumption. The former is perceived as just, the latter as relief for the unworthy. A large part of the problem thus lies in our pervasive outdated beliefs of what is right and wrong."

A further point of discussion concerned market mechanisms - in the context of the role of private (rather than governmental) charitable organizations in alleviating problems of maldistribution and hunger. Sen observed that "the only way you can get the market mechanism to move food from those who have it to those who don't have it, is to give those who don't have it more purchasing power than they have, so that they can attract food". He continued that influence on market mechanisms is more feasible for governments.

(Source: "Science, Ethics and Food", Papers and Proceedings of a Colloquium organized by the Smithsonian Institution, edited by Brian W. J. LeMay, Washington Smithsonian Institution Press.)

- S.G.

Structural Adjustment: for health as for finance

An interview with Mr T. Cullen, World Bank spokesman based in Paris, in July this year contained the following points (extracted with permission). These seemed interesting - especially coming from a banking viewpoint - and relevant to health and nutrition issues in the context of structural adjustment. Essentially Mr Cullen points out the need for increasing efficiency of both productive and social sectors. In past times of austerity, emphasis has often been placed on prioritisation and more efficient use of limited funds within the social sector. On the other hand, inefficient companies and enterprises within the productive sector have often been able to survive as a result of soft loans. The parallel is drawn between productive and social sectors here.

"We have recently conducted a major study of the roles of the national (financial) institutions in developing countries. One of the things that came out very clearly from this is that in the years after independence developing countries in many cases nationalized existing banks... they felt that the banks, that were there largely for trade purposes in the ports and in the capital cities, were not really the right vehicles for promoting the sort of industrialization that many countries thought they would like to undertake. In many cases they directed banks - whether they were state-owned or privately-owned - to whom to lend and at what interest rate. So very often the allocation of financial resources became really quite distorted, and it became rather easy for inefficient companies - and very often inefficient state-owned enterprises - to survive, because they continued to be financed by these rather low interest loans that the government was telling the banks to finance. Very often potentially productive companies that were not receiving this largesse could not obtain funds at competitive rates. What has now happened is that resources are much tighter. As countries are now trying to reform their economies they are discovering that a lot of these banks are in quite serious trouble. Now the banks themselves are in need of reforming and governments have to determine who carries the loss...

"... the guts of a lot of adjustment programmes is the whole concept of recognizing that there is a shortage of money, and that the funds that are available have to be used in the most effective way possible. When we embark on an adjustment programme the country undertakes a major review of its investments. We help the country review all its investments, to try to cut down on those that are not really effective and are not really going to help the country regenerate economic growth. But as part of that process, and as part of the austerity which is often involved, cuts obviously have to be made in public expenditure. One of the concerns which is raised is that in the past cuts have sometimes come in areas such as education, health care, and so on. Now one of the things that we are trying to address while designing these programmes is the importance that the government should attach to trying to protect the health budget and the education budget; but also within that budget reallocating the way the money is spent.

"So if you have got a certain amount of money for health - even if you may be having slightly to reduce the money - (we are) making the point that if you build a big elaborate hospital which will solve the needs of a few hundred people, with dialysis and cardiac units and so forth, the cost to the economy year after year of maintaining that hospital may take up half the annual health budget. Now it may be much better for your population and particularly for the poor if you forego that big fancy hospital and go for more modest clinics which can serve the needs of more people. Go for smaller health centres, go for oral rehydration kits which will stop children from dying of diarrhoea, go for preventive vaccination programmes and so on ... (support) all of the sort of very good work that organizations like UNICEF are doing to ensure that children really have a chance in life, by being assured of a certain degree of decent health in the early years. That we feel is the sort of way we would like to see health budgets being allocated."

Obituary - Dr John Rivers

John Rivers made enormous contributions to nutrition, and will be known to many. Most recently he helped the SCN in its conference on "Nutrition in Times of Disaster". His death is a tragic loss for his numerous friends and colleagues, and for the cause of nutrition. We reprint here an obituary written by Dr John Seaman:

"John Peter William Rivers
born 7 November 1945
died 2 December 1989

"Professionally, he made important contributions to comparative nutrition through the better understanding of the requirements of different species for essential fatty acids and human essential amino acid requirements. But he will be chiefly remembered for his work for the practice of famine and disaster relief. These were to put disaster relief on a rational basis and, as important, to provoke and challenge constantly what he saw as entrenched academic and institutional attitudes.

"In 1971, during the East Pakistan refugee crises, John and some friends, of their own volition, went to help. What they saw of the relief effort convinced them that it could be much better done. An organization for the scientific study of disasters was founded, funds raised, and at Rivers' suggestion a conference was held. As he pointed out, a new subject needed an international conference, even if, on a shoe-string budget, only one Belgian and a resident American could be invited. A journal, Disasters, was launched at his instigation. These initiatives have had much to do with the fundamental changes which have since occurred in international relief policy.

"John contributed and lobbied consistently for improvements in international famine and refugee relief. His most recent exertions were to try to secure better food supplies for refugees in Africa who have been consistently badly served, suffering starvation and massive outbreaks of pellagra which the international aid donors have been slow to remedy. He would have been pleased to know that in the last few weeks of his life, the problem has at last been officially acknowledged.

"John's intelligence, clarity of thought, and acerbic style often brought him into conflict with the nutrition establishment in the United Kingdom - for example over the Neuberger report, of which he was an outspoken critic - and with international organizations whose motives and priorities he saw as often less than clearly focused. It also brought him, however, a devoted following of colleagues and students who will remember him as an inspiring teacher and an unstinting source of scientific ideas, support, and courage."

(Source: The Guardian, 5 Dec 1989)

The Hunger Project's "Africa Prize for Leadership for the Sustainable End of Hunger" was awarded, recently - jointly to Dr. Quett K. J. Masire, President of the Republic of Botswana, and Dr. Bernard Ledea Quedraogo, founder and president of Africa's largest grass-roots movements for self-reliance. The co-winners shared a cash award of US$100,000.

Dr. Masire was recommended for the prize by the Director of the Pan American Health Organization, Dr. C. Guerra de Macedo, and by Dr. A. Horwitz, the Director Emeritus of PAHO and Chairman of the ACC/SCN, in recognition of his leadership in the critical situation facing Botswana during the 1980s. Botswana demonstrated that malnutrition can be controlled, even during a severe drought, at a fairly low cost.

In his address to an audience of more than a thousand diplomats, world leaders and members of development groups, Dr. Masire described in detail the steps taken in Botswana to cope successfully with the six-year drought that ravaged most of Africa in the early 1980s. The drought-relief programme, including nutritional surveillance and an early warning system, ensured that adequate food supplies were distributed across the country. Botswana actually emerged from the drought with no more (possibly less) malnutrition than in pre-drought years. Key components of the successful handling of the drought, Masire said, were "preparedness, planning and willingness to act" plus government commitment. "It was this commitment, rather than our current favorable foreign exchange reserves and budget surplus, that saw us through this patch in our development and saved lives that would otherwise have perished."

(Source: World Development Forum, 15 October 1989, Volume 7, No. 18; and PAHO).

- M.L.

ACCIS Register of the UN Development Activities

Following five years of intensive efforts, the first edition of the Register of the UN System Development Activities has finally became available by ACCIS.

The great value of this effort is that it has brought together what previously was stored in many different reporting systems. This first volume gives a comprehensive coverage of all UN project operational in 1987 and has information on over 20,000 social and economic development activities of the various UN Organizations. The Register for 1988 has now just been published.

For more information please see publications section of this issue of the SCN News.

FOODBASE - International Food Consumption Survey Data

We were asked to draw attention to the following:

"Technical Assessment Systems, Inc (TAS) is working with the US National Cancer Institute (NCI) on a three year project to collect international food consumption survey data and to enter summary data into an IBM-PC compatible data management and analysis system called FOODBASE. FOODBASE will be a powerful but straightforward tool for nutritionists, epidemiologists, medical researchers, and other health professionals for assessing the intake of foods and food constituents by people throughout the world. NCI will use FOODBASE to investigate relationships between diet and cancer incidence, although the system will be equally useful for investigation of other diet-disease relationships and for endeavours such as chemical exposure assessment, nutrition education, nutritional anthropology, and food industry research. TAS hopes that the many people around the world with expertise in food consumption or food disappearance will provide assistance and thus minimize the difficulty of this project. Their ultimate goal is to make the information gathered and the tools developed available to as many countries and institutions as possible. FOODBASE data contributors will be reimbursed for expenses and will receive a copy of the database. For further information, or to contribute data, please contact Dr Barbara Petersen, Judi Douglass, or Dr Kathryn Fleming, TAS Inc, 1000 Potomac St, NW, Washington, DC 20007, USA (Telephone: 202-337-2625)."

The WHO Collaborating Centre (WHO-CC) for Nutrition in Rome is organizing an International Meeting on "Food and Nutrition Policies in the Southern European Region". The Meeting will be held in Rome in March 1990 under the sponsorship of the Italian Ministry of Agriculture and the National Institute of Nutrition. Representatives from 7 Southern European Countries will participate as well as from Scandinavian and Eastern European Countries. Representatives from the EEC, FAO and the public and private sectors involved in food and nutrition have been invited. This Meeting is a step towards preparation for the First European Conference on Food and Nutrition Policy which is to be organized by the WHO Regional Office for Europe in Budapest on October 1-5, 1990. For information on the Rome meeting please contact Prof. A. Ferro-Luzzi, WHO-CC for Nutrition, via Ardeatina, 546, 00178 Rome, Italy, Tel. 5042677, Telefax 5031592.

NIAN: Nutrition in Agriculture Network

Inserting consideration of nutritional effects into agricultural development has long been regarded as a key factor in improving nutrition for the rural poor. Now the University of Arizona and the University of Kentucky, with the Nutrition Economic Group (NEG), Office of International Cooperation and Development, United States Department of Agriculture, have begun a network (Nutrition in Agriculture Network, NIAN) to assist developing countries in this. The main objective is to provide technical and research support to assist developing countries to improve the food consumption and nutritional consequences of their agricultural projects. One of the activities is the formation of a Nutrition in Agriculture Network (NIAN) for disseminating information on programme activities and products.

The network is planning to circulate periodic updates of ongoing research focusing on nutrition/consumption issues relating to agriculture. Contributions are welcome (send a 1-2 page summary of related research activity). For materials, information, publications, contributions of information or requests for inclusion on the NIAN mailing list contact: Dr. Timothy Frankenberger, Office of Arid Lands Studies, College of Agriculture, University of Arizona, 845 N. Park Avenue, Tucson, Arizona 85719, USA. Tel: 602 621 1955.

- M.L.

The Pacific Basin Maternal and Child Health Resource Centre

The Pacific Basin Maternal and Child Health Resource Centre (PBMCHRC) is a regional resource centre with a primary focus on maternal and child health. The Centre is responsible for providing culturally relevant educational services, information and technical assistance to the health professionals in the Pacific Basin jurisdiction. It serves as an important link between the sources of information services and the professionals in the various health and educational settings providing maternal and child health. The Centre produces regular publications and provides information and use of its resource materials in response to requests.

Established in 1984, PBMCHRC is located in the University of Guam and is funded by the Bureau of Maternal and Child Health and Resources Development, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services. The Centre seeks to establish contact with various public and private organizations at the local, regional, national and international levels who are engaged in community health development activities. Please address your enquiries to: PBMCHRC, PO Box 5143, UOG Station, Mangilao, Guam 96923, USA, Telephone: 671-734-4717.

-M.L.

The Centre to Prevent Childhood Malnutrition

As an independent, non-profit organization, affiliated with the Department of International Health, School of Hygiene and Public Health of the Johns Hopkins University, the Centre to Prevent Childhood Malnutrition works to improve child nutrition worldwide by supporting communities in their efforts to eliminate hunger. The Centre has field offices in Ghana, Peru and the United States. Funded in part by a matching grant from the Rockfeller Foundation, the Centre supports small-scale, self-help projects that communities themselves design. "Unlike many other organizations that work to treat malnutrition, the Centre effectively reaches children before illness begins" says Dr. Robert Black, Chairman of the Department of International Health, Johns Hopkins University.

The Centre funds a range of projects. Some of these help communities work together to enhance children's diet; some create opportunities for women to earn incomes so they can better feed their children; and others improve child care so that children are kept in a safe and healthy environment when their mothers work to earn money needed for their children's survival. Dr. A. Horwitz, Director Emeritus of Pan American Heath Organization believes that "the Centre to Prevent Childhood Malnutrition brings several new approaches to the field that are not common....the Centre's focus is community based. Its work is a process of strengthening the natural motivation of people to improve their lot".

The work of the Centre shows that successes are possible if nutrition training is combined with supported self-help projects in communities. More information on the Centre's activities from: Dr. Sandra L. Huffman, President, The Centre to Prevent Childhood Malnutrition, 7200 Wisconsin Avenue, Suite 204. Bethesda, Maryland 20814 USA. Tel: 301 986 5777.

- M.L.

International Decade for Natural Disaster Reduction

The United Nations General Assembly in 1987, adopted the 1990s as the International Decade for Natural Disaster Reduction. The over-riding objective is to reduce loss of life, property damage and social and economic disruption caused by natural disasters, especially in developing countries with the following specific goals:

Improving countries' capacity to mitigate the effects of natural disasters; devising appropriate guidelines for application of existing knowledge; fostering scientific and engineering endeavors to close gaps in knowledge; disseminating new and existing information on assessment, prediction, prevention and mitigation; implementing and evaluating programmes of technical assistance, technology transfer and training.

(Source: Disaster Preparedness in the Americas Newsletter. January 1989, issue no. 37)

- M.L.

Pan-African Centre for Emergency Preparedness and Response

In relation to natural disaster reduction, the birth of a new centre is of special interest: The WHO Panafrican Centre for Emergency Preparedness and Response, in Addis Ababa, Ethiopia, set up to give service to African people living in disaster prone areas. This centre has been established to provide the necessary inputs to WHO services in Africa in terms of training programmes, health operational research, policy analysis and research activities to address disaster and food crisis situations. The new Centre organizes workshops or seminars on issues relevant to health disaster management and training sessions based on long term health and developmental perspectives. Epidemiological studies, operational research including field evaluations and assessments are also among the services provided by the Centre. Further information from: Dr. Sandro Calvani, Director, Panafrican Centre for Emergency Preparedness and Response, UN, ECA Building. P.O. Box 3050, Addis Ababa, Ethiopia.

(Source: Health for All When a Disaster Strikes, WHO)

- M.L.

Nutrition in Development Workshop

The International Health Programmes of the University of California at Berkeley and at Los Angeles are holding a workshop on "Nutrition in Development" from July 9 to 27, 1990, at Santa Cruz in California.

The workshop is designed to provide non-nutritionists involved in international development with the knowledge, skills and competence to collect relevant information, to define problems, to select and design project components and to implement, monitor and evaluate their impact within broader socioeconomic development projects and programmes. The conceptual framework and principles for integrating nutrition into development planning is another area of emphasis in this workshop.

Enquiries should be addressed to: Dr. R. L. Minnis, Director, International Health Programmes, 210 High Street, Santa Cruz, CA, 95060, USA.

- M.L.

ECSA Training Programme

A project consisting of in-service food and nutrition training courses is being implemented at the University of Zimbabwe, Harare, under the regional Food and Nutrition Cooperation Programme, in the Eastern, Central and Southern African (ECSA) countries. Scientific, educational and technical assistance is provided by the International Course in Food Science and Nutrition. Senior food and nutrition staff from the ECSA region collectively provide the expertise for holding the training courses.

The focus of the fourth ECSA course is on the theme of maternal and child nutrition. Supported by the Dutch Government, UNICEF, and SIDA, the objective of holding this course is to update knowledge and to improve the multisectoral functioning of participants in solving nutritional problems of mothers and children specific to the region. The 6-week course (22 January - 3 March 1990) will be held in English, at the University of Zimbabwe, Harare. Topics included in the course curriculum are assessment of nutritional status; data collection and analysis; programme planning and evaluation. The course programme includes a mixture of activities consisting of class work group projects, individual presentations, seminars and field projects. Further information from: Dr. R. G. Choto, Director, ECSA - Food and Nutrition Training Programme, University of Zimbabwe. P.O. Box A178. Avondale, Harare, Zimbabwe. Telex: 24152 univz zw. Or from: International Courses in Food Science and Nutrition, Attn. Prof. Dr. J. G. A. J. Haut-vast, Lawickse Allee, 6701 AN WAGENINGEN, the Netherlands. Telex: 45888 intas nl.

- M.L.

Programmes/Letters/and more

Sir,

In a recent issue of The Lancet (17 June 1989, p. 1392), we commented on the need for those responsible for refugee feeding to consider more closely the nutritional needs of such populations. It is appalling and inexcusable, in the twentieth century, to read repeated reports (such as that in SCN News No. 3) of scurvy, anemia, and vitamin A deficiency amongst refugees who are receiving food aid. All these deficiency diseases are to be expected so long as the present assemblance of commodities which make up the "food basket" are limited to providing mainly macro-nutrients, expecting that refugees will be able to supplement their micro-nutrient needs from the environment. Although in some instances this may be possible, refugees who lack access to land or markets have apparently received no special consideration as has been demonstrated by the increasing number of reports of nutritional-deficiency diseases.

Amongst the three deficiency diseases reported, scurvy is the major killer. The clinical symptoms of simple gum bleeding - which is one of the easily recognized symptoms of vitamin C deficiency - have apparently been ignored even though it is well-known that a patient at this stage, if untreated, will be dead within a few months. Either agency personnel are untrained to recognize such symptoms or are unaware of the high levels of mortality which this disease afflicts.

Amongst the various strategies to provide vitamin C to refugee populations, we believe that in short term, fortification of cereals or oil may be the only solution. The technology for fortification has been available for a number of years. Fortification of foods to provide necessary micro-nutrients to various populations has proved to be a successful means of preventing nutritional deficiencies (eg iodine and vitamin A deficiencies). Several compounds, for example, ascorbyl palmitate and retinol palmitate which are both fat soluble, may be used to fortify oil.

It is incredible that humanitarian agencies have failed to draft in the appropriate expertise to resolve these problems. Moreover, as far as we are aware, little research has been conducted on the suitable vehicles, appropriate compounds for fortification, or on the stability of these micro-nutrients under field conditions. Apparently in one field situation, where a large number of people had scurvy, it was suggested that vitamin C should be added to the water being transported in iron barrels. It is well known than vitamin C is an extremely unstable nutrient and when in contact with iron and stored at the ambient temperature encountered in the semi-arid regions where this disaster was taking place, little or no vitamin C will remain after a few hours. Whilst this attempt to cure scurvy is encouraging, it also demonstrated the acute need for a more scientific approach to resolving micro-nutrient deficiencies in the "food basket" provided to populations who are totally dependent on outside assistance. We urgently recommend that a more concerted effort is made by agencies, food manufacturers and scientists to address these problems to avoid the unnecessary high levels of mortality which are currently seen.

Dr B. E. Harrell-Bond
Director
Refugee Studies Programme
University of Oxford

Dr Jeya Henry, Msc., Ph.D.
Senior Lecturer in Nutrition
Oxford Polytechnic
and
Research Associate
Refugee Studies Programme
University of Oxford

* * *

Sir,

The ACC/SCN Report "Update on the Nutrition Situation - Recent Trends in Nutrition in 33 Countries" Jan/Feb. 1989, contains information for ready reference, and the graphic presentations enable a study of the trends related to the nutrition situation in the countries dealt with. I do wish that India had also featured in this report.

If such similar recent information is available on India in any of the ACC/SCN reports, I would thank you for copies of the same.

You have also made a mention of ten-year programmes on two major deficiencies i.e. Vitamin A and Iodine.

I would greatly appreciate some further information on these programmes as they are related to two of the major problems in India.

Dilnawaz Mahanti, Senior Project Officer, Voluntary Health Association of India, New Delhi.

Replies are:

On data on nutrition in India

The SCN's "Update" report aimed to present trends in nutrition indicators, mainly for the 1980s. The data compilation was completed by July 1988. For India, the latest nutritional data available to us at that time were for 1979, hence we could not include India in the report. Since then more recent data have been published from the 10-state surveys conducted by the National Nutrition Monitoring Bureau (NNMB - Hyderabad), and in future reports on the world nutrition situation we would certainly hope to include such results. Results that we do have available may be of interest, and some of these are as follows.

Since estimates are made in India using Indian standards, for purposes of comparison it is necessary to recalculate to an international standard, for which the NCHS/WHO standards are now those generally used. The common cut-off for calculating prevalences of underweight children is less than 2 standard deviations below the median. Using these criteria, we calculated prevalences of underweight in pre-school children, from surveys in 1976 and 1979, as 79% and 72% respectively. These results are given in the SCN's "Supplement on Methods and Statistics to the First Report on the World Nutrition Situation" (ACC/SCN, December 1988 - available on request). Using indirect methods (given in the First Report, and in more detail in the Supplement), we estimated equivalent prevalences as approximately: 74% for 1975; 70% for 1980; and 66% for 1984. We would much appreciate hearing of more recent and more detailed information on this.

On vitamin A and iodine programmes

Information on epidemiology and control programmes for iodine deficiency disorders (IDDs) in India (and South East Asia) can be obtained from Dr C. S. Pandav, ICCIDD Regional Coordinator for SE Asia, All India Institute for Medical Sciences, New Delhi 110029. For vitamin A one contact would be Dr M. Gurney, WHO Regional Nutrition Advisor for SE Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110002; and/or Dr J. Lambert, Chief Nutrition Section, UNICEF Regional Office for South Central Asia, UNICEF House, 73 Lodi Estate, New Delhi 110003.