Refugees' Nutrition Crisis
Breastfeeding, Birth Spacing, and Nutrition
Community-Based Development - From a Programme Towards a Movement
Micronutrient Intakes, Incomes and Prices
Serious problems are experienced in meeting the nutritional needs of refugees. Why? Article draws on international symposium.
Their faces are familiar, but we seldom meet them. Refugees, trailing in endless lines, loaded with tatty bundles of remaining possessions, exhausted carrying bewildered children. We see them usually -in photos and television pictures - as they become refugees, in crises like the Gulf. We lose sight of them soon, as attention shifts, and as they start their long stays in crowded camps. How long do they stay? They seem innumerable - do we realize that the total number of refugees if they were together would form a nation bigger than most of the countries in Africa? And much poorer than the poorest country in the world.
What happens to them? At their first introduction to us they obviously need water, food, shelter and medical help. Do we fully realize that many continue to starve, some beginning to get deficiency diseases, as they languish in camps neglected by world attention? Outbreaks of scurvy, beri-beri, pellagra, reminiscent of half a century ago and hardly seen since, have now actually reappeared as epidemics amongst refugee camp populations. The situation is a major failing of the world to cope - remembering that this continues after refugees have made it to some access to help; it happens in sight of refugee agencies, it happens while help could be at hand.
Why is there a nutritional crisis among refugees? Surely it should be possible to at least succour those who have made the perilous flight from war and drought seeking safety, food and shelter. Why? Increasing outrage among many with first hand experience of trying to organize relief - in voluntary agencies and the UN system, brought together by the Refugee Studies Programme in Oxford, UK - led to an international symposium entitled "Responding to the Nutrition Crisis Among Refugees: The Need for New Approaches" in March this year. This article draws on the report of the meeting and other recent articles (see sources and boxes).
At least 35 million people in the world have either fled their country as refugees, or been displaced internally due mainly to civil war. Of today's 15-20 million cross-border refugees, about 13 million are in Africa, southwest Asia and the Middle East, and their situation cannot be considered temporary. These numbers have at least doubled during the 1980s. The numbers themselves are not certain - that too is part of the problem.
If we include internally displaced people, the "refugee nation" of 30 to 40 million people would easily be the poorest in the world, ranking as a medium sized country. It has no natural resources, high population density, terrible health and nutrition, and little future - the prospects for development are grim.
Refugees suffer from the same type of diseases as other vulnerable groups in developing countries, only more so, being more vulnerable. Malnutrition, infectious disease and mental imbalances are some of the more common consequences of being uprooted. The main killers of refugees are measles and dehydration caused by diarrhoea - diarrhoea caused by infection with bacteria such as shigella, giardia, salmonella and amoeba - not cholera and typhoid. Underlying the risk of contracting these diseases is malnutrition. Refugees often receive food which is inadequate both in quantity and quality, and if this is prolonged, they not only starve but suffer from debilitating micro-nutrient deficiency diseases. Outbreaks of scurvy, pellagra, beri-beri and other deficiency diseases are now common. These are the symptoms of the nutritional crisis within refugees which not only persist but seems to be worsening.
The immediate cause of the nutritional crisis is simple and obvious. First, not enough food is getting to many refugees. Second, refugees may be largely dependent on the food provided by governments and donors, and be unable to use the diversity of foods that others do; the food rations provided may lack certain essential nutrients, so that after some time bodily reserves (often already low) are exhausted and deficiency diseases break out. Scurvy results from lack of fresh fruit and vegetables to provide vitamin C. Vitamin A deficiency has similar causes in lack of green leafy vegetables. Pellagra breaks out when the staple is maize - deficient in niacin - and the usual complementary sources such as ground nuts are unavailable. Beri-beri - a shadow of earlier times - comes with a polished rice diet lacking thiamine. Anaemia results from lack of iron, usually derived from animal products, and needing vitamin C for absorption. All these are easily prevented by a more diverse diet; and in some cases readily by fortification of rations.
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STARVATION Extract from Symposium Report (see below) "Rations, malnutrition and death rates are closely related. Examining relief operations in Thailand (1979-80) and Sudan (1984-85), suggested that levels of childhood malnutrition and overall death rates tended to follow one another closely in each case, and a much slower drop in malnutrition and death rates in Sudan was noted in association with clearly inadequate ration levels. Indeed, malnutrition and death rates stayed high in Sudan for eight months after the refugee influx began. Significantly, the rapid fall in malnutrition and death rates in Thailand was associated with a ration of around 2500-2600 kilocalories per person per day, while in Sudan the ration never reached 2000 kilocalories at any time in the first five months of the relief operation." [Source: P. Nieburg, B. Person-Karell and M. Toole (Centers for Disease Control, Atlanta): "Malnutrition/mortality relationships among refugees"] "A more recent instance of damaging insufficiency of rations was highlighted in a study of relief to Somali refugees fleeing civil war to eastern Ethiopia. The largest refugee camp, 'Hartisheik A', was established in August 1988. Yet in early 1989, the level of acute protein-energy malnutrition (PEM) among children under five in the camp was actually rising. For the first five months of 1989, it was as high as 23%, with death rates at the camp also peaking at this time. For the first twelve months of the camp's existence, death rates were some 46 per 1000 - about double the normal rate for non-refugee populations in Ethiopia and Somalia. The ration distributed to refugees between February and May 1989 - when malnutrition and mortality were peaking - was only 1463 kilocalories per day, giving insufficient energy for health." [Source: M. Toole: "Somalian refugees in Hartisheik Camp. Eastern Ethiopia"] "Another example of damaging insufficiency of rations was documented in Malawi. Mozambican refugees began to seek asylum in Malawi in late 1986, and in early 1987 a surveillance system was set up to monitor both the refugees' condition and relief efforts. Yet mortality peaked almost twelve months later, reaching nearly 10 per 1000 per month among children under five between December 1987 and February 1988. From April 1987 right through to August 1988, in the camp of Makhokwe (with 40,000 refugees), the ration was consistently below the recommended 1800 kilocalories per person per day. Indeed, in some months the rations was less than half this level. Notwithstanding these failings, death rates among Mozambican refugees in Malawi were still some 3-5 times below those observed in Thailand, Somalia, Uganda or Sudan. Epidemiologic surveillance contributed to this." [Source: A. Moren et al. (Medecins Sans Frontières (MSF), Epicentre, UNHCR and the Malawi Ministry of Health): "Epidemiologic surveillance among Mozambican refugees in Malawi"] "In western Sudan in 1990, a nutritional crisis among refugees was avoided - but not thanks to the level of rations. Rations given to Chadian refugees in western Sudan in early 1990 were only a fraction of those recommended by a previous Food Assessment Mission, which had included representatives of the Sudanese Commission of Refugees, UNHCR and the World Food Programme. In one camp, at Mornei, between January and May 1990, refugees received only 31% of the sorghum that had been recommended, 23% of the oil, and no edible pulses. The refugees' own economic resourcefulness helped maintain nutritional status and health at satisfactory levels, despite these shortfalls." [Source: H. Young: "A case study of the Chadian refugees in Western Sahara"] "Meanwhile in western Africa, there was grave insufficiency of rations among Mauritanian refugees in Senegal. In January 1990, UNHCR had stipulated that general rations be reduced to 1700 kilocalories per person per day, the basis for which decision was unclear. In practice, rations in the Matam area of Senegal (where there were some 27,000 refugees) averaged only 695 kilocalories per person per day between March and June 1990. Again, refugees' own resourcefulness protected them to some extent: they made use of significant income-earning opportunities, including cattle-smuggling. Many local people also shared their stocks of food with refugees. Even so, taking refugees in Matam area together with those in Dagana area, protein-energy malnutrition in May/June 1990 was recorded at 8.2% (less than 80% weight-for-height) - a significant level." [Source: K. Ritmeijer (MSF Holland): "Refugees' food acquisition strategies: Mauretanian refugees in Senegal"] "In northwest Uganda, UNHCR was able to give refugees fleeing
civil war in Sudan cereal rations sufficient for only 29.5 days and pulses for
only 13.5 days - from June 1986. Some additional unknown quantities were
distributed by the Lutheran World Federation. The next 151 days saw UNHCR - now
the only organization distributing - able to provide only 15-17 days of cereal,
21 days of pulses and 19-22 days of cooking oil. These figures are those of
UNHCR itself. [Source: UNHCR/WFP: "The UN response to refugee food
requirements"] |
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DEFICIENCY DISEASES "Refugee rations usually contain either insufficient vitamin A, or none at all. Outbreaks of xerophthalmia, a clear sign of severe vitamin A deficiency, have recently been reported among several groups of refugees, notably in Sudan in 1984-85, when already severely-malnourished refugees were fed a vitamin A-free diet. Since vitamin A requirements rise as the intake of calories rises, providing food without vitamin A to refugees whose malnutrition includes vitamin A deficiency is likely to worsen the deficiency, perhaps causing blindness. Vitamin A deficiency can have fatal consequences. "A lack of vitamin B-1 (associated with a diet of processed rice) created a number of outbreaks of beri-beri in Cambodian refugee camps in Thailand in the early-1980s. Scurvy has been reported in refugee camps in the Horn of Africa, and linked with the absence of vitamin C in the normal refugee ration. Scurvy can be fatal if left untreated. Clinical scurvy was affecting between 1 and 2% of refugees in 'Hartisheik A' camp, Ethiopia in March 1989, attributed to a diet deficient in vitamin C." [Sources: P. Nieburg et al: "Malnutrition/mortality relationships among refugees.": M. Toole: "Somalian refugees in Hartisheik Camp. Eastern Ethiopia"] "Another resurgent disease is pellagra. Common among the corn-eating communities of the American South in the 1930s and among Prisoners of War in the 1930s, it has now re-emerged as a major nutritional problem - notably among the Mozambican refugees in Malawi. There were two significant outbreaks of pellagra among these refugees in the period June 1989 to February 1990. The second was the largest ever documented among refugees in the past two decades. Both outbreaks followed a 5-6 month cessation in groundnut supplies, which had deprived refugees of a vital source of niacin, exposing them to pellagra. One remedy for this kind of situation is food fortification. A visit with SCF support in August 1990 found that food fortification - adding niacin, thiamin and riboflavin to maize flour - was technically feasible in refugee areas of Malawi." [Sources: P. Malfait et al. (Epicentre, Medécins Sans Frontières, Institute National d'Agronomie and UNHCR): "Outbreak of pellagra among Mozambican refugees in 1990."; J. Henry and J. Seaman: "Fortification of refugee rations to alleviate nutritional deficiencies"] "Another medical problem related to rations is anaemia. Anaemia was observed to be a serious clinical problem in all 35 camps for Somali refugees in Ogaden, Ethiopia, in the winter of 1986/87. A serious outbreak of scurvy was seen at a number of the camps. Both outbreaks were linked with serious deficiencies in the rations - a lack of iron and folate (anaemia) and a lack of vitamin C (scurvy)." [Source: B. Hassan and H. Mursal (Somali Ministry of Health): "Anaemia and scurvy in refugee camps in Somalia."] "A 1990 survey of Palestinian refugee camps in Gaza. West Bank, Jordan, Syria and Lebanon, showed that the prevalence of anaemia in non-pregnant women ranges from 23% (Jordan) to 44% (Gaza). Iron deficiency anaemia in children under three and their mothers, indeed, has not fallen in the last 20 years. High consumption of tea (interfering with iron absorption) and high fertility (increasing the strain on iron resources) have boosted people's iron needs. But with the sources of UNRWA flour having been diversified, flour provided to refugees is no longer fortified with iron. Dried milk given to refugees was also not fortified with iron, despite UNRWA pressure on food donors."/Source: R. Cook (Director for Health for the UN Relief and Works Agency): "The evolution of the food and nutrition problems of the Palestinian refugees"] "Shortcomings in the provision of non-food items and services to refugees have been documented. Long delays occurred between detection of epidemics and remedial action among the Mozamibican refugees in Malawi in 1989, in particular a slowness in immunising against measles. Preventable infectious diseases here accounted for 70% of deaths of refugee children under five." [Source: A. Moren et al: "Epidemiologic Surveillance among Mozambican Refugees in Malawi"] Extracted with minor editing from "Summary of Symposium
Papers" by David Keen, in "Responding to the Nutrition Crisis Among Refugees:
The Need for New Approaches". Available from Refugees Studies
Programme, University of Oxford, International Development Centre, Queen
Elizabeth House, 21 St Giles, Oxford OX1 3LA, United Kingdom. |
What then is wrong? Who is actually responsible for avoidable nutrition-related deaths among refugees? This was the main starting point of the recent international symposium. The conclusion: a lack of accountability among organizations responsible for feeding refugees. When things go wrong, everyone blames everyone else, no-one accepts responsibility and mistakes are perpetuated. Host countries claim insufficient resources, UN agencies inadequate mandates, and NGOs a lack of coordination.
Underlying this is an important ethical issue of human rights, indeed potentially of international law. The principle (discussed in Oxford) is that refugees should have a right to assistance, not just a hope of charity.
Not Enough Food
The root cause of the problem is more organizational than technical. What should be done is widely agreed. How to get it done is the issue. Failures to effectively deliver food to refugee populations can be traced to inadequate information on which to base decisions or inadequate policies guiding such decisions, compounded by ill-defined operational roles and responsibilities. Food received may be inadequate because rations ordered were not enough or not sufficiently varied, delivery was hampered by logistical problems, or fair distribution within camps could not be achieved. Usually it is a combination of all these.
What needs to be done? Food adequate in quantity and quality, clean water, good latrines and shelter are what refugees, like anyone else, require. Expensive medical technologies like intravenous drips dispensed by Westerners may be attractive to the media, but are only required by a small minority. Far more people benefit from less-glamorous methods such as oral rehydration and immunization. As the article "International Disaster Relief Efforts: A Mixed Blessing?" in "News and Views" shows, local initiatives in such times of crisis are often more effective than outside intervention. This is not to say that outside help is not required, but it needs to be appropriate and sustained. Measles vaccination is an example of a simple, quick and extremely effective external intervention for reducing the death rates among refugees - though this requires 90-95% coverage of refugee children in crowded camps. Death rates from measles, where immunization was not carried out, or was too late, have been as high as one in three cases in Sudan in 1985.
Just as food is seen as an economic, not purely nutritional, resource by recipients, so should it be perceived by donors. Refugees should be viewed as being resourceful, not only dependent, and their ability to engage in self-sustaining economic activities maximized. Where their non-food needs (e.g. for fuel, water, shelter, clothes) are not met, they barter or sell rations. Often rations may be sold to acquire a more varied nutritionally-rich diet. This means that whole livelihoods, rather than simply calorie needs, need to be taken into account in an appropriate aid disbursement strategy, and such "informal monetiz-ation" permitted.
In many cases, providing people have access to markets it can be more efficient to sell the food aid and supply refugees with cash to buy it. Market access, transport systems and other factors affecting trade will determine whether this is a viable strategy.
Where food rations are provided, allocations should be based on need, rather than the immediately available resources of donors. The need should be determined by both macro- and micronutrient requirements, in the light of food acquisition strategies and physiological needs. In recent draft guidelines for calculating food rations for refugees, UNHCR and WFP stress the need for a food basket to be provided consisting of basic and complementary foods. Basic items include cereals, oil, and protein sources e.g. pulses, while complementary foods include meat or fish, vegetables, fruit, fortified cereal blends, sugar, condiments, salts, spices. Foodstuffs should be culturally acceptable and safe.
The total food intake from all sources (including external) should be no less than an absolute minimum of 1,900 kilocalories per day - as recommended at the ACC/SCN "Nutrition in Times of Disaster" conference in Geneva, September, 1988. This basic food ration may however be increased or decreased depending on prevailing circumstances of the population. Increased requirements may be indicated by a population's particular age/sex composition, nutritional and physiological status and energy output, while climatic variations and household-level food processing losses need also to be taken into account. Decreased requirements, on the other hand, may be indicated where a population has access to additional foods or opportunities for earning incomes or trading foods.
A correct dietary mix is all the more important, as micronutrient requirements will rise as calorie intake rises. In extreme cases, providing, for example, adequate energy in vitamin A deficient diets to populations already vitamin A deficient can hasten the onset of blindness in many people. Reliance on processed rice led to outbreaks of beri-beri among Cambodian refugees in Thailand in the early 1980s. In March 1989, clinical scurvy due to a lack of vitamin C affected 1-2% Somalian refugees in one Ethiopian camp. while as many as one in four of the 80,000 refugees in camps in Sudan in 1990 were showing scurvy symptoms at one time. In 1990, 18,000 Mozambican refugees in Malawi developed pellagra -which begins with skin rashes and diarrhoea and can lead to dementia and death. This was caused by a 5-6 month cessation of groundnut supplies, their main source of niacin, while the main staple was maize. The response to this outbreak was poor, although eventually a group of aid agencies identified and bought a supply of groundnuts from South Africa. Anaemia due to iron deficiency is also a very common and debilitating problem among refugees.
Where other options are not feasible for achieving an adequate micronutrient intake, food fortification can be considered. Following the Malawi pellagra outbreak, for example, fortification of maize with niacin, thiamine and riboflavine was subsequently found to be feasible. Selective feeding programmes are only warranted in emergency situations where rates of malnutrition are particularly high, or for specific target groups with special needs.
Turkey-Iraq border/Iraqi refugees/Cicirca camp, Hakkari Privince/Shelter.
Malnutrition has health- as well as food-related causes. The high incidence of diarrhoeal diseases among refugees and associated high mortality rates, argues for priority to be attached to the provision of clean water. During 1989, Somalian refugees in Ethiopia received only 3-5 litres of water per person per day, compared with the 15-20 litres recommended by UNHCR. Sanitation and adequate shelter are also of obvious importance.
Simple data on mortality and morbidity collected regularly (initially once a week) and made available to local health workers is crucial for assessing the situation and responding. Anthropometric measures of undernutrition, if possible, should be routinely recorded. The risk of dying in refugee camps has been found to be linked to changes in the prevalence of undernutrition. If the indicator of undernutrition is the prevalence of the population wasted - below 80% of the WHO standard weight-for-height - on average for the general population in sub-Saharan Africa, less than 5% will be so classified. The mortality rate in refugee camps has been observed to double as wasting prevalences rise to between 5% and 10%, and more than quadruple with rises of between 10% and 20%. Recent reports (reported in New Scientist, 3 August 1991) from Kenya, for example, put the prevalence of wasting among Somalian refugees now at 29%.
What Next?
The Oxford symposium came forward with several recommendations regarding the organizational problem in making adequate food available to refugees. Some of these, taken from the report, are summarized here.
Appropriate information should also be regularly fed back from the camps to decision-makers. In fact, all channels of communication need to be opened -between UN field staff and headquarters, between UN agencies and NGOs, and between agencies and the host government. Refugees should be both consulted and informed. Agencies and governments should be made accountable, and health and nutrition-related data fed back so that donors can see the effects of their actions, and respond accordingly.
Governments should re-affirm the right to food as a basic human right, and establish new mechanisms for upholding such rights among refugees and displaced persons. Within the UN system, the coordinating role of UNHCR should be strengthened, and cooperation in international relief with competent NGOs, facilitated. Refugees should not be treated as a political tool, they should not be labelled and stereotyped, nor manipulated through the use of food. Both UNHCR and WFP need regular, predictable funding to cover each protracted refugee situation. This will require donor commitment to provide funds in advance without political strings. Where possible, programmes should be oriented to benefit both refugees and host populations in an integrated fashion. Development initiatives such as improving the health infrastructure and supporting agricultural schemes in border zones, are investments now requiring higher priority by donors.
-S.R.G./J.B.M.
SOURCES
Responding to the Nutrition Crisis among Refugees: The Need for
New Approaches. Report of the International Symposium, Oxford, 17-20 March 1991 (available from the Refugee Studies Programme, International Development Centre, Queen Elizabeth House, 21, St
Giles, Oxford OX1 3LA, United Kingdom). How Refugees Survive by Phyllida Brown, New Scientist, 3, August 1991, pp. 21-26.
ACC/SCN (1989) Report of the "Nutrition in Times of Disaster" Symposium, held in September, 1988, Geneva (mimeo; awaiting publication).
Draft WFP/UNHCR Guidelines for Calculating Food Rations for Refugees.
These are closely linked; support to breastfeeding can integrate programmes in nutrition and population.
Population growth has vital consequences for nutrition - ranging for instance from more mouths to feed from finite resources, to environmental degradation from intensive and inappropriate land use to meet nutritional needs. The food-people-resources balance, now and in the future, is a critical determinant of the quality of life. At the same time, programmes in family planning, health and nutrition are widely pursued to improve maternal and child health, with expected longer-term demographic effects.
The ACC/SCN decided to hold its annual symposium for 1991 on "Nutrition and Population". Following views of the SCN's Advisory Group on Nutrition, it was decided to focus on questions of direct relevance to programmes. This in turn came to concentrate on the triangle of breastfeeding, birth spacing, and infant nutrition and maternal health. The importance of macro-level issues of food-population-resources remain well-recognized, but such a crucial topic required more time and resources than were available. Considerations relating to programmes were felt to be more immediately applicable by the UN and donor agencies.
The Symposium on "Nutrition and Population" was hosted by UNFPA at their Headquarters in New York, in February this year. The Symposium was chaired by Ms K. Trone, Head of the UNFPA Regional Office for Latin America. Three papers were presented. Dr Sandra Huffman, Center to Prevent Childhood Malnutrition, Bethesda, presented a paper on "Nutrition and Family Planning Linkages: What More Can Be Done?" Issues on "Breastfeeding, Fertility and Population Growth" were introduced by Professor Roger Short, Monash University, Melbourne. The effects of repeated cycles of reproduction were discussed in a paper on "Reproductive Stress and Women's Nutrition", by Professor Reynaldo Martorell, (at the time of Stanford University and now at Cornell, USA) and Dr Kathleen Merchant (Cornell). The discussion on Dr Huffman's paper was by introduced Dr Charlotte Gardiner, Director of Maternal and Child Health, Ghana; for the paper by Martorell and Merchant, Professor Barry Popkin (North Carolina) introduced the discussion; Dr Solidad Diaz (Chile) introduced the comments on Dr Short's paper. A general discussion at the end of the Symposium was led by Dr Miriam
Fig. 1
Labbok (Georgetown), Dr Beverley Winikoff (Population Council), and Dr Barry Edmonston (Urban Institute, Washington DC), who contributed to formulating the conclusions of the meeting, as discussed later. The Symposium papers, discussions and related literature form the basis for this article.
Breastfeeding, Birth Spacing and Nutrition
Breastfeeding exclusively for four to six months from birth is of well-known importance for infants' nutrition. Breastfeeding delays the return of fertility in the mother, thus contributing to longer birth intervals. Birth spacing allows continuation of breastfeeding for the child's benefit and has other advantages to mother and child. Better nutrition promotes infant and child survival, which in turn tends to increase birth intervals. And all these processes benefit the health and well-being of the mother. This triangle is illustrated in Figure 1.
The interactions are finely-tuned, developed as part of human evolution. They are worth understanding -some only recently worked out and still being researched - and are discussed in more detail below. The triangle in Figure 1 is elaborated in Figure 2.
Fig. 2. Interactions of breastfeeding, birth spacing and nutrition.
A practical message emerged from the Symposium, at which the different disciplines present found (to their slight surprise) they were talking much the same language about the same conclusions from different starting points: support to breastfeeding should be part of population and nutrition and health programmes. Indeed these could be better integrated. As Dr Huffman pointed out "... instead of spending another 20 years justifying the link between family planning and nutrition activities, we may have more success if we start with an intervention that integrates both nutrition and population issues: breastfeeding promotion".
Breastfeeding for Infant Health and Nutrition
The benefits of breastfeeding are constantly becoming better understood. Breastfeeding reduces exposure to pathogens in the environment, gives protection by immunization, provides anti-bacterial and anti-viral substances, and supplies the correct mix and density of nutrients; it also has very little direct cost. Bottle feeding, which is the usual alternative in early life, tends to be contaminated, non-ideal in terms of nutrients, and not affordable to many families in poor societies.
The newborn infant's needs and the mother's ability to provide for them, not only to nourish but to protect1, are closely linked. A continuity has evolved to bridge the gap between the safety of the womb and the shock of post-natal life, when the gut suddenly replaces the placenta as an interface with the world. The immature infant gut is adapted to the nutrition and protection of breast milk. Antibodies from colostrum and breast milk protect the gut and provide some immunity against other infections. Antibiotic activity in breast milk proteins is being shown to be selective against precisely certain of the harmful bacteria that cause infantile diarrhoea. The protein of breast milk is tailor-made to the infant's needs, and is quite innocuous unlike many non-human proteins. The hazards of sudden exposure of the fragile gut to foreign materials is now being realized. The gut matures in the first few months - the recommendation for 4 - 6 months' exclusive breastfeeding is no accident. "It is still true to say that the artificial feeding of our infants has been the largest uncontrolled clinical experiment in human history2."
1. For a recent review see: "Infant Feeding: the Physiological Basis". Suppl. to Bull. WHO 67, 1989, edited by J. Akre; reviewed in SCN News No. 6 pp. 56-57.2. Minchin, M. Birth 14, 25-34 (1987).
Data collected during the 1970s by the World Fertility Survey show an overall historical decline in breast-feeding both in terms of its initiation and duration. In fact, a steady decrease had been observed by the early twentieth century. In Sweden, reduction in the rate of babies being exclusively breastfed at 2 months from 85% in 1944 to only 35% by 1970 was one example of this continued downward trend. Similar statistics are available for other developed and some urban areas of developing countries through the WHO Collaborative Study (Contemporary Patterns of Breastfeeding, WHO, 19813). This changing pattern of infant feeding has been attributed to "the demands of modern life" and industrialization, as alternative means of feeding became available to public. According to Dr Short at the SCN Symposium "with the advent of Industrial Revolution, the artificial feeding of infants with paps and gruels became commonplace throughout Europe, and this was given an added boost by the growing availability of cow's and goat's milk and the development of feeding bottles with rubber teats". But breastfeeding decline and increased use of artificial feeding did not immediately result in population increase. "The potential upsurge in fertility that this increase in artificial feeding might have created" in Dr Short's view "was largely counteracted by the staggering increase in infant mortality resulting from these practices". He notes that, for example, in London during the late 18th century almost 50% of children had died by the age of 2, and in Dublin during the same period artificial feeding resulted in the death of 99.6% of over 10,000 children admitted to the Foundling Hospital, mainly as a result of diarrhoea. In Dr Short's opinion by improving formulation and hygienic aspects of artificial feeding, mortality in most developed countries decreased, but left a high potential for fertility in women who had abandoned breastfeeding.
3. WHO (1981). Contemporary Patterns of Breast-Feeding. Report on the WHO Collaborative Study on Breast-feeding.
But is breastfeeding decline an inevitable result of modernization? The WHO Collaborative Study while confirming earlier results on breastfeeding's declining trend (particularly in cities and urban slums), found some notable exceptions. Thanks to efforts to encourage breastfeeding through health services, education and supportive measures to mothers, the number of Swedish mothers initiating breastfeeding actually increased in 1976 to 93%, and 50% were still breastfeeding at 4 months although with regular supplements. This and other examples from Australia, Eastern Europe, Scandinavia and the USA shows that the decline in breastfeeding is not an unavoidable result of industrialization if the necessary measures for its promotion and support are taken. In most cases, breastfeeding decline accompanied the society's modernization, as noted by Berg and Brems4, "at a time when breastfeeding was not advocated in either medical or patient education".
4. Berg, A. and Brems, S. (1989). A Case for Promoting Breastfeeding in Projects to Limit Fertility. World Bank Technical Paper No. 102, The World Bank.
Breastfeeding and Birth Spacing
Breastfeeding directly contributes to increased birth intervals by tending to reduce the resumption of fertility in the mother. This is more pronounced with exclusive breastfeeding. It is related to "lactational amenorrhoea", and has led to new recommendations for decisions by individuals on family planning. The SCN Symposium stressed that lactational amenorrhoea is particularly relevant to providing an opportunity in the first months after birth for counselling women on modern family planning methods, and that it is complementary to these not a substitute.
A major step forward was recently taken when an international group of experts met in Bellagio, Italy, in August 1988 to review the evidence for the contribution of breastfeeding to family planning. The conclusion: "Breastfeeding provides more than 98% protection from another pregnancy in the first six months post partum, if the mother is fully or nearly fully breastfeeding and has not experienced vaginal bleeding after the 56th day post partum". Recent research by Dr Short and associates on a well nourished group of Australian women breastfeeding their babies examined the probability of becoming pregnant over a 24 month period after the birth. This showed that if modern contraception was adopted only after lactational amenorrhoea ceased, the cumulative probability of becoming pregnant over the 24 month period would have been only 13%5.
5. Short, R.V., Lewis, P.R., Renfree, M.B. and Shaw, G. The contraceptive effects of extended periods of lactational amenorrhoea: beyond the Bellagio Consensus. The Lancet, Vol. 337 (8743), 23 March 1991, pp. 715-717.
Lactation delays the resumption of fertility by physiological (neuroendocrine) mechanisms. Briefly, suckling at the breast affects hormone secretion that maintains the production of milk (prolactin) and, probably through other pathways, depresses the hormone levels necessary for fertility (inhibiting ovulation and producing amenorrhoea). The frequency of suckling is important, increasing milk synthesis and secretion and decreasing chances of fertility. An inhibitory peptide is secreted by the mammary alveoli to stop further milk synthesis if the alveoli are not emptied regularly. This, as Dr Short puts it, makes the breast a "supply meets demand organ", and explains why exclusive, and not so much partial, breastfeeding has the potential to reduce fertility and increase birth intervals and child spacing. The six month period after birth is crucial both for mother and infant, and illustrates the closeness of the mother's and infant's needs.
The WHO Collaborative Study from 1976-78 indicated a consistent and close relationship between the duration of breastfeeding and the duration of post-partum amenorrhoea. About 85% of the total variability in the return of fertility could be attributed to reported differences in breastfeeding duration. The same conclusions were reached in many other studies, e.g. Bongaarts6, who demonstrated that the duration of breastfeeding explains most of the variation in the duration of post-partum amenorrhoea. Another factor claimed to influence the length of lactational amenorrhoea has been the nutritional status of the mother, with shorter amenorrhoea period in better nourished women. Dr Short, however, reported that in their studies and those of some others, women in developed countries, on an optimal plane of nutrition, still achieve prolonged periods of lactational amenorrhoea.
6. Bongaarts, J. et al., (1983). Fertility, Biology and Behaviour: An Analysis of the Proximate Determinants. New York: Academic Press. Bongaarts, J. and Menken, J. (1983). In: Determinants of Fertility in Developing Countries, Vol. 1 (eds Bulatao, R.A. and Lee, R.D.), Academic Press, pp. 26-70.
Such observations have been used to look at questions like the overall influence of breastfeeding practices on population growth, via its contraceptive effect; and the extent to which breastfeeding offsets contraceptive needs. It has been claimed that lactational amenorrhoea is the single most important variable among the proximate determinants of natural fertility7. A World Bank analysis8 has pointed to the significant effect of breastfeeding in reducing the total possible number of births to a great majority of the couples in developing countries who do not use modern contraceptives. Projections by Family Health International show that a 25% reduction in breast-feeding duration in five African countries would increase total fertility rates by 12%, and that halving the duration of breastfeeding could mean a 26% rise. Corresponding figures for 12 Asian countries are 11% and 23 %9
7. References in Note 6 above.
8. World Development Report, World Bank, 1984.
9. Cited by Berg and Brems, see Note 4 above.
A major step towards reducing the excessive fertility that is currently fuelling the population explosion, concluded Dr Short, would be to persuade both developing and developed countries to do their utmost to support and encourage prolonged breast-feeding. Breastfeeding, thus, in addition to its nutritional and health values needs to be promoted and supported as a child-spacing strategy. Longer birth intervals will reduce total numbers of children per women as well as benefiting both mothers and their children in the other ways described here.
Birth Spacing Benefits Child Nutrition
A delay of two years or more before its mother becomes pregnant again is important for the baby's welfare and indeed survival. One of the earliest observations of malnutrition was of kwashiorkor as the disease of the displaced child - displaced by a new pregnancy. Short birth intervals have often since then been related to malnutrition. They are also related to infant and child mortality - although this operates in both directions, as discussed in the next section. Nonetheless, anything that prevents too-short birth intervals will benefit the youngest child - including family planning programmes directly, and as an additional indirect result of breastfeeding. As Dr Huffman pointed out in her paper, birth intervals of less than two years have frequently been associated with low birth weight, high infant mortality, growth retardation, high morbidity and inferior nutritional status.
The advantage to the child of adequate birth interval goes beyond maintenance of breastfeeding. The burdens of time and stress on the mother tell on her ability to nurture the family, and these are worsened by too-close pregnancies. Her health itself may suffer, as discussed later - a serious blow particularly to poor families with many children.
This stresses another way in which too-short birth intervals are disadvantageous - through family economics: more mouths to feed with the same resources, or probably less as the mother contributes in cash or kind into the family income. Part of the motivation for short birth intervals, ironically, may itself have an economic perspective, in ensuring for old age, encouraging rapid births to reach large desired family size. In a sense this contributes to a vicious circle, as more births will be wanted when mortality is high: reductions in child mortality are needed to motivate birth spacing.
Short birth intervals thus are to no one's advantage: the future infant, the current infant, or the mother herself. "Adequate child spacing can mean the difference between complete recuperation of the mother and depletion of her physical resources. It can also mean the difference between adequate care of the preceding child, including its continued breast-feeding, and early abrupt weaning from the breast due to a new pregnancy and hence the deprivation of maternal attention"10.
10. WHO/UNICEF (1981). Infant and Young Child Feeding, Current Issues. WHO, Geneva.
The health impact of family planning will clearly be greater if it has a specific effect on birth intervals. But a considerable number of the births prevented by family planning programmes are due to sterilization. "While family planning programmes have been more successful in reducing higher parity births, and terminating births through sterilization, they are not generally associated with increasing birth intervals" says Huffman. "Worldwide, over one third of effective modern contraceptive use is through sterilization. This, while preventing any further birth, is usually not associated with adequate birth intervals for the preceding pregnancies."
Child Survival Affects Birth Spacing
A feedback is shown in Figure 2 from infant/child nutrition, through child survival, to birth spacing. This is important in the long-run, as part of the motivation for smaller family size, hence eventually reduced population growth rates. The link of nutrition to survival or mortality is clear. The effect of child mortality on birth spacing can act in several ways. As implied earlier, the death of a breastfed infant will tend to lead biologically to resumption of fertility. But conscious decisions may be made to replace the child as soon as possible - perhaps before the mother has recovered from the previous pregnancy. This decision can be based on the family's desire to achieve a certain family size. Indeed the decision to have rapidly-succeeding pregnancies for this reason may be taken without experiencing a child-death in the family, if it is perceived that this risk is high, to insure against possible future deaths and reach the desired family size before the reproductive cycle of the family is complete. This, in turn, may well depend on the overall community perception of risk, influencing the family's decisions.
Here too, we are dealing with a cycle that can benefit from deliberate intervention to break. In this case, for example, promoting infant and child nutrition and survival can gradually establish more motivation for longer birth intervals, hence acceptance of family planning.
Mothers' Health and Nutrition
The consequences of frequent child bearing have been considered more often for the child than for the mother herself. Drs Martorell and Merchant gave evidence in their paper that spacing reproductive events is necessary for maternal recovery. Repeated reproductive cycles have been referred to as "maternal depletion syndrome", but they proposed avoiding this term and regarding effects of reproductive stress on women's health and nutritional status as a continuum. "The question is not whether or not maternal nutrition is affected by reproductive stress, but under what circumstances are effects noted and to what degree and in what aspects."
A substantial proportion of women in developing countries are lactating and pregnant at the same time. This situation - perhaps not widely appreciated - is clearly likely to increase the stress on women's health and nutrition. It is referred to as "overlap" by Martorell and Merchant, defined as two or more weeks of breastfeeding during pregnancy. The phenomenon has been reported to be common among women in a number of poor areas: 30% in Guatemala and Senegal, 40% in Indonesia, and as high as 70% in India (stressed by Dr Ramachandran11 in a paper prepared for the meeting). Although lactation is generally associated with post partum amenorrhoea, partly because of prolonged breastfeeding in many developing countries, perhaps as many as one third of all pregnancies occur in lactating women. This observation clearly has important implications for both family planning and breastfeeding practices, but here we focus on the impact of this phenomenon on women's health and nutrition.
11. Ramachandran, P. (1991). Nutrition and its Influence on Mother-Child Dyad. Indian Council of Medical Research, New Delhi, India.
The effects of reproductive stress on mothers and infants were shown by Drs Martorell and Merchant using the data from an INCAP longitudinal study. They focused on women actively exposed to different degrees of reproductive stress by carefully studying the period of overlap. Overlap was found to occur in 50% of a sample of 504 pregnant women. Two extreme situations were compared: the "least stressed" women (those with a recuperative interval of more than six months) and the "most stressed" ones (those experiencing an overlap duration of more than three months). Despite higher consumption of food supplements available freely to all women, the "most stressed" group had lower fat reserves (more pronounced earlier in pregnancy), and gave birth to lighter infants when compared to the "least stressed" mothers. While the emphasis of the paper was on mothers themselves, their results showed that reproductive stress also adversely affects the infant. It is interesting to note the results of the National Institute of Nutrition, India, in which pregnant and lactating women were under even greater stress: while women were similarly facing overlap of different degrees, they were not supplemented and their food consumption, as usual in poor areas, was similar to non-pregnant subjects (NIN, 1984/85 Annual Report). In reporting the results of these studies Ramachandran concluded that irrespective of the duration of lactation and period of gestation, women who continued lactating during their pregnancy had lower body weights than their non-lactating pregnant counterparts. Here too, the differences were more marked in the small group of those working women becoming pregnant in the first 6 months of lactation. Their babies had also lower birth weights.
These results pointed to the fact that overlap should be prevented and birth intervals need to be adequate. Using the fertility-inhibiting effect of exclusive breast-feeding, later followed by other family planning methods, another pregnancy can be planned at a more appropriate time and with reasonable spacing.
Integrating Nutrition and Family Planning Activities
The mutual benefits of breastfeeding and family planning programmes mean that they will be more successful if they are integrated. Both nutritional support and birth spacing have impacts on mortality reduction and nutritional status improvements. Breastfeeding is now recognized as a child survival strategy. Keeping a child alive is associated with preventing another birth, since the death of an infant is usually followed by another pregnancy. Some reasons for integration are shown in Box 1.
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Box 1 · to increase birth spacing and decrease fertility rate; Why breastfeeding programmes should promote family planning - · to avoid disruption in breastfeeding in a lactating woman who is no longer amenorrheic, due to another unwanted pregnancy; |
12. Rosa, F.W. (1975). Breastfeeding in Family Planning. PAG Bulletin, 5, 5-10.
Even if contraceptive supply and demand are not constrained - as in reality they often are - significant declines in breastfeeding may place greater pressure on family planning services than can, presently, be coped with. In this regard, breastfeeding can help to use scarce family planning resources more efficiently. But to achieve this effect, family planning programmes should take into account the local breast-feeding patterns and beliefs in order to promote and support breastfeeding, to achieve its maximum fertility-inhibiting effect. When the fertility regulating role of lactation is waning over time, or when more security is demanded, breastfeeding can be combined with other contraceptive methods that do not interfere with lactation. This needs to be accompanied by proper advice and encouragement. Nutrition programmes should similarly combine breastfeeding promotion with family planning messages, appropriate counselling and referrals. In other words, services devoted to maternal and child health should be in close coordination with family planning services.
Some examples given by Dr Huffman indicate that integration works well in practice. "In two breast-feeding promotion projects in Honduras and Guatemala, referrals are provided by breastfeeding counselors to family planning. In addition, exclusive breastfeeding is taught as a family planning method, with the signs of return of fertility taught to breast-feeding women... A recent study conducted in Honduras showed that combining the promotion of breastfeeding with the promotion of family planning can lead to increase in both... The project included the creation of combined breastfeeding and family planning clinics, along with training of health pro- fessionals and changes in hospital practices. Along with prenatal, postnatal and post-partum counselling, mothers received a discharge pack with pamphlets reinforcing messages of breastfeeding and family planning... Results of the project showed that exclusive breastfeeding at 3 months increased from 14% to 23% and use of modern methods of contraception increased from 54% to 68% at 6 months post-partum" with substantial increase in duration of amenorrhoea.
Among the World Bank projects in population, health and nutrition, according to Berg and Brems13 "at least four projects have explicitly recognized the value of breastfeeding for birth spacing and four have made specific provision for data collection regarding breastfeeding prevalence, duration or practices". All these have promoted breastfeeding in some way. Yet it appears that there is considerable scope for enhancing both the number and extent of such activities.
13. See Note 4.
One successful linkage between family planning and nutrition over the last 10 years, in Dr Huffman's view, has been the Demographic Health Survey (DHS). Information on morbidity, mortality and nutritional status are added in recent reports of DHS. Among the reasons for inclusion of nutritional issues in the DHS, Dr Huffman explains, has been the need for more data on breastfeeding and amenorrhoea. She notes that when data on both family planning and nutrition needs are available within the same survey, then they are most likely to be used to affect population and nutrition policies.
Challenges Ahead
Reflecting on the important relations between breast-feeding, family planning and nutrition, the Symposium agreed a statement - subsequently endorsed by the ACC - as shown in Box 2. This emphasized the practical steps now needed - the challenges ahead.
How can programmes promoting breastfeeding and those encouraging the use of family planning be more complementary? Although an integrated approach has been stressed, breastfeeding has only infrequently been promoted in population projects. Because of political, religious or cultural sensitivities, nutrition programmes have often been hesitant to promote family planning use. Dr Huffman was of the view that in reality while most developing countries are now stressing the need to develop a more integrated approach "once at a clinic or community level, family planning services are still quite separate from nutrition and health activities, even though their impacts are mutually beneficial", and that few programmes link nutrition and family planning activities. It is no longer a lack of rationale, but programmatic and policy constraints that have continued to prevent more linkages between the two.
One important obstacle preventing more linkages is that the two programmes address different targets -''family planning programmes focus primarily on women while nutrition programmes focus principally on the child". Breastfeeding promotion naturally addresses both the mother and the child, and results in benefits for population and nutrition programmes. The conclusions of the Symposium emphasized four priorities for improving integration. An underlying issue is one of policy: the need for organizing different programmes to be mutually supportive notably in promoting breastfeeding. This would then lead to detailed aspects of implementation, such as providing similar message from different field workers, ensuring appropriate referrals during and after pregnancy, and so on. Importantly leading on from this, the training of health and family planning workers should take account of new efforts for integration. Getting more specific to breastfeeding (in the third point at the end of the statement in Box 2) the very real constraints to breastfeeding experienced in many countries need to be more widely recognized, and tackled. Within this, sensitivity is needed to the competing demands on women's time, including her need for income-earning work outside the home, which impinge on her choice of infant rearing practices, particularly breastfeeding. Finally, all this requires resources, not only for implementation, but also for research and gathering relevant information.
The Symposium thus emphasized the importance of training both health and family planning workers, before they can educate and encourage mothers to take full advantage of breastfeeding potentials. Training and retraining of the medical and health professionals in numerous fields is necessary to support breastfeeding, and to take into account the special needs of lactating women when offering them other contraceptives. In Indonesia, the National Family Planning Coordinating Board has launched a programme to train counsellors and family planning field workers to educate women about the nutritional and contraceptive benefits of breastfeeding. Education is key in promoting the use of breastfeeding for contraception. Research in this area in the Philippines has shown that through appropriate education programmes women can be encouraged to increase the duration and intensity of their breastfeeding behaviour. The participants in the SCN Symposium felt that it is only through training and education that women can make an informed choice, free from the negative influences of the mass media, advertisements and attitudes which may inadvertently raise barriers to breastfeeding. Policy makers, programme managers and health authorities should equally be informed to set priority to relevant policies and practices and to channel necessary resources. A supportive environment should be created in which breastfeeding can be continued and reinforced in harmony with other responsibilities in and out of household.
-M.L./J.B.M. NOTES
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Box 2 NUTRITION AND POPULATION "There are extensive concerns regarding the topic of nutrition and population. A deeper understanding of the dynamic inter-relationships between population growth, food production, environmental sustainability and urbanization will become increasingly important in the future. In this symposium, the primary focus was on nutrition and fertility. " Breastfeeding provides one link between nutrition and family planning with mutually beneficial effects at the level of the individual mother and child. Exclusive breastfeeding for four to six months is advised. Lactational amenorrhoea, prolonged by breastfeeding, is of great benefit through increasing birth intervals. There is an opportunity at this time for counselling on modern family planning methods, in particular those deemed most appropriate for lactating women. "At an individual level, the health and nutritional status of the mother (particularly the adolescent mother) is a fundamental concern, in terms of her nutritional resources, reproductive and productive roles and family planning needs. Increasing the length of birth intervals will reduce the likelihood of cumulative reproductive stress in the mother and improve her ability to benefit from birth spacing and maternal health through more adequate feeding and care practices. "These are major reasons why family planning and nutrition services and information should be integrated. Programmatic considerations as to how to bring this about, in terms of policy formulation, programme planning, training and the support of community level initiatives present several challenges. These include the following: · appropriate training of health and family planning workers; the motivation to support and counsel women should emerge from common goals; |
A consensus is emerging in development policy that the poor are key actors, and human development and poverty alleviation are priorities.
by Urban Jonsson, Senior Adviser (Nutrition) UNICEF, New York (paper presented at XIV IVACG Meeting, Guayaquil, Ecuador, 18-21 June 1991)
The Emergence of a New Development Paradigm
Community development programmes, like all development programmes, reflect the school of thought of governments and organizations involved in the programme. After decades of experimentation, human development and poverty alleviation are increasingly regarded as priorities for development. Recent reports from several agencies (UNDP 19901 and 19912, World Bank 19903, IFAD 19904, UNICEF 19905 and 19916, and ECA 19907) reflect this new priority but they also show a consensus in overall development strategies. A new development paradigm is emerging. This new paradigm reflects two major changes in development thinking:
- A changing view of the role of poor people in poverty eradication and development.
- A much stronger emphasis on normative or moral arguments than before.1. UNDP. 1990. Human Development Report 1990. New York: Oxford University Press.2. UNDP. 1991. Human Development Report 1991. New York: Oxford University Press.
3. World Bank. 1990. World Development Report 1990. New York: Oxford University Press.
4. IFAD. 1990. Report of the Brainstorming Meeting on the State of World Rural Poverty. IFAD Rome, March 27-29 1990.
5. UNICEF. 1990. The State of the World's Children Report. New York: Oxford University Press.
6. UNICEF. 1991. Strategy for Improved Nutrition of Children and Women in Developing Countries: A UNICEF Policy Review. New York: UNICEF.
7. Economic Commission for Africa (ECA). 1990. Rural Progress, Vol. IX, No. 1. Addis Ababa: ECA.
The first change comes from a better understanding of the relationship between poverty eradication and economic growth. Instead of regarding economic growth as the pre-requisite for poverty reduction, poverty reduction is increasingly more regarded as a prerequisite for economic growth.
The second change comes from a renewed interest and commitment to human rights. The recent political detente between East and West, the enormous cost of defence and military expenditure, and the waste of resources on non-important commodities have all contributed to a "global embarrassment". This is translated into global and national commitments to eradicate poverty and its most overt manifestations, such as hunger and malnutrition and preventable diseases. Such a commitment was clearly manifested in the World Summit for Children in September 1990 (see SCN News No. 6, p. 27). The rapid ratification of the Convention for the Rights of the Child is another expression of this new commitment.
Both changes have far-reaching implications for the design and implementation of community-based development programmes. The changing views on the role of poor people in poverty eradication and development have the following implications:
· Poor people are regarded as key actors in poverty eradication and development and are not seen as passive beneficiaries of commodities and services. Local people are the most capable of understanding the local situation and can judge what will work and what will not work. The majority of poor people know what is best for their own development, provided they have access to adequate resources, including information. o Poor people's survival and coping strategies need to be recognized and understood much better. The day-to-day situation for the poor is most often more diverse and complex than for the less poor. Frequent and often unpredictable changes in their physical, economic and social environment demand a constant adaptation, often involving great risks. The poorest, with the least resources, must adapt most often. Many of these coping strategies are very complex, but probably the most efficient strategies, given the scarce resources. The assistance to poverty reduction should therefore support the most efficient coping strategies already developed by the poor themselves. This requires understanding, patience and flexibility of the "outsider" who wants to assist.
· The context in which a community-based development programme is implemented changes in many ways during the period of implementation. Poor people's survival and coping strategies are adaptive processes in a continuously changing environment. An initial problem assessment and analysis can therefore only be a first approximation to an understanding of the problem. Poor people themselves use several information systems, both quantitative and qualitative, to evaluate, re-think and re-orient their strategies. This has been called "self-evaluation" or "reflection-in-action". (Drake, et al. 19808)
8. Drake, William D., Miller, Roy L., and Humphrey, Margaret, 1980. Final Report: Analysis of Community-Level Nutrition Programmes. Office of Nutrition, USAID and Community Systems Foundation, October 1980.
· The strengthening of existing efficient coping strategies and the development of new ones require empowerment of poor people. This means increased availability and control of human, economic and organizational resources by poor people. It means enlargement of choices of the poor. Social groups and gender disparities must be reduced in order to achieve a more equitable resource control. Knowledge and health are two important components for empowerment and self-reliance.
· Community participation is a means to empower, as well as a very important outcome of empowerment. Active participation requires that communities are involved in programme planning, implementation, monitoring and evaluation. This includes assessment of the problem, analysis of the causes of the problem and the decisions regarding appropriate actions. With true empowerment comes a more equal dialogue and partnership. Poor people will become more capable to articulate their demands on society as a whole. This includes the right to reject proposals from outside that do not benefit the people. The notion that "they" should be encouraged to participate with "us" should be replaced by "us" sharing a commitment and showing an attitude that allows "us" to participate with "them".
· Finally, the aspects of sustainability, replicability and costs have received increased attention during the last few years. Thirty years of development aid efforts have resulted in numerous examples of projects that could not be sustained because the requirements of resources for sustainability were far above the resources controlled by communities. In many cases the community has not felt any ownership of the programme. The poor have been pushed to become passive beneficiaries instead of active participants. Participation and empowerment are necessary for the establishment of a community ownership of a programme. Such an ownership, together with a minimum of resources, are necessary conditions for sustainability. Local ownership is best reflected in a preparedness to take risks and to contribute part of their own scarce resources to sustain and expand the programme. Cost-recovery should not be a condition from above, but if voluntary, cost-recovery is an expression of true self-reliance of the community.
The change in emphasis from primarily arguing that improved social conditions are "investments in human capital" that will pay off in higher productivity, better learning capacity, and so on, to a normative argument saying that better social conditions are human rights, is reflected in the following new emphases in development thinking and policy:
· The most important change is the emphasis and unprecedented concurrences on human development goals for the 1990s, Several UN-agencies and NGOs participated in the definition of these goals (see SCN News No. 6, p. 27), which were adopted by the World Summit for Children and are included in the follow-up Plan of Action. Almost all of these goals can be derived from the Convention for the Rights of the Child. Governments and the international agencies have agreed to attain these goals by the year 2000 and have also agreed to establish national and international capabilities to monitor the gradual attainment of them.
· Some aspects of a cross-cutting nature have been brought up as necessary conditions for the attainment of these goals. Reduction of disparities, including gender disparities, is the most important one. This concern is not derived from any scientific analysis or argumentation. It is normative, as was the case, for example, in the anti-slavery campaign in the USA or in the struggle for women's voting rights in Europe.
· All these changes reflect a desire and a belief in the possibility of increased democracy in the world. Democracy includes empowerment, participation and self-reliance. What we see today is the beginning of a global movement for eradication of poverty in a world richer than ever before. The United Nations, once created for peace and human rights, must play a leading role in this movement.
Essential Aspects of Strategies for Community-Based Development Programmes
The emergence of a new development paradigm is primarily a result of learning from failures and successes. Learning from successes probably provides more useful knowledge than learning from mistakes. Below follows a list of aspects or components that have been identified as associated with successful community-based development programmes.
· There is no market for solutions if the problem is not appreciated. This is why, as a first step, political awareness of the problem and political commitment to solve the problem must be assured. Advocacy at all levels of society about the problem, including its effects on human development and its causes must be a first priority. Advocacy requires knowledge about the political economy of development problems and information about the problem. A minimum of problem awareness is required before any information can be obtained, which means that initial advocacy often has to start with incomplete information. The strong commitment to the attainment of the goals for the 1990s offers a new opportunity for strong advo- cacy. This is particularly true at national level, but the need to attain the goals can also be used at community level. "A strategic intent - a powerful, unifying vision that guides the entire strategy" should be created (The Hunger Project, 19919). Long-term political commitment is usually a result of social pressure from below. For the community to exert such a pressure, it must be organized.
9. The Hunger Project. 1991. Planning-in-Action: An Innovative Approach to Human Development. March 1991.
· Development and underdevelopment are results of processes. The context in which a community-based development programme is planned and implemented, therefore, normally changes during the course of implementation. It is almost impossible to prepare in detail a several-year intervention. Any strategy should therefore include a mechanism for modifying the interventions as time passes to accommodate changes required by the changing environment. Instead of promoting a "blue-print" or a pre-set "technical package", a method or an approach should be provided that enables the community to strengthen their own coping strategies or develop new ones.
· The focus should be on what the community is already doing. This requires a fundamental change in the attitudes of most government people and outside "experts". Priorities must be set by the poor people themselves, within the context of their available resources, including their time. External assistance should enhance their capability to assess their situation, analyse the problem and to choose among viable options. "Experts" should thus be replaced by advisers, who know how to listen and how to learn; they must be more culturally sensitive, and more holistic than sectoral; a "new professional" (Chambers 198310).
10. Chambers, Robert. 1983. Rural Development: Putting the Last First. London: Longman.
· The study of paradigms has shown that generally "you find what you look for" (Kuhn 197011). If one does not think that poor people exercise very complex and efficient coping strategies, one would not try to identify them or study their complexity. There is thus a need to develop and use an explicit conceptual framework which recognizes the multi-sectoral and multi-level nature of the causes of underdevelopment. Such a framework should not be a detailed model, but rather a set of the most important determinants and the key relationships among them. It should help the observer in "what to look for". In a given community it may often be possible to reduce the framework to include only the most important parameters of underdevelopment in that particular context. It may gradually be possible to develop a model. It is important that the conceptual framework recognizes the multi-sectoral nature of the problem of under- development and that it is easy to explain and communicate.
11. Kuhn, Thomas, 1970. The Structure of Scientific Revolutions. Chicago: The University of Chicago Press (2nd Edition).
· Coping strategies always include an evaluation/monitoring component. These need to be recognized, understood and strengthened. A community development programme that is capable of monitoring and evaluating itself will reduce the problems more efficiently than one that does not have this capability. With a changing environment, the first solutions are approximations. When the community collects and analyses data, the programme can be modified and improved for the "second round". People with very limited formal education can handle improved community-based information systems. The "monopolization" of data collection and analysis by government officials should be broken. If people agree on the need for data, they will easily learn the necessary techniques.
· Since human, financial and organizational resources are limited at every level, targeting is necessary. Priority should be given to the more deprived, the poorest, instead of the less poor; to women, instead of men; to children over adults; to the illiterate, rather than the educated. Development programmes should be assessed and evaluated according to the degree to which they reach the poorest. The targeting should primarily aim at breaking the poverty making processes and not be limited to the provision of services for the "target group".
· As a result of the disappointment with biases in rural development studies and with delayed, and sometimes inappropriate data from large surveys, a number of new innovative methods for rural assessment and analysis have been developed. Rapid Assessment Procedures (RAP) uses an anthropological approach (Scrimshaw, et al. 198712), while Participatory Rural Appraisal is a process of learning from, with and by rural people about rural conditions (Chambers, 199013). Experience has shown that poor rural people have a much greater capacity to assess and analyse their problems than has been commonly supposed.
12. Scrimshaw, Susan, and Hurtado, Elena. 1987. Rapid Assessment for Nutrition and Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness. UNU, Tokyo; UNICEF and UCLA Latin America Center Publications, University of California, Los Angeles.13. Chambers, Robert. 1990. Rapid and Participatory Appraisal for Health and Nutrition. The Silver Jubilee Celebration of the Nutrition Society of India, Hyderabad, December 1-3, 1990.
· In a normative-driven, goal-oriented process, it cannot be assumed that everybody in a community agrees on the goals and the strategies to attain the goals. Some may even be against obvious changes.
Social mobilization is therefore necessary. The identification and support of "strategic allies" in the community is an important aspect in the initial stages of a social mobilization effort. With more and better community-based data, increasingly more people will participate in the programme, and opportunities for a broad alliance of many people, who normally would not cooperate, may become a reality. That is the beginning of a community-based movement.
· In order to establish and sustain community participation, there is a need for a minimum of community organization and infra-structure. Community-level development committees, with clearly defined tasks and with accountability, have proven to be a very important contribution to empowerment and self-reliance.
· Several of the above mentioned components of community-based development strategies will require human resource development and all would benefit from it. Knowledge and skills for how to assess and analyse the community problems, and to design actions, based on the limited resources, contribute to community empowerment. In order to be more effective, education and training need however to be focused on basic life skills (WCEFA 199014). Teaching and learning must also become more participatory. Instead of "learning" from "teachers", poor people and other resource people should establish a dialogue that aims at "sharpening each other" (Rahman 199015). Potential animators in the community should be identified and supported in their work. Motivation, leadership and commitment should be the basic criteria for the selection of such animators.
14. WCEFA, Inter-Agency Commission, (UNDP, UNESCO, UNICEF, World Bank). 1990. Final Report: World Conference on Education for All. New York: WCEFA. WCEFA, Inter-Agency Commission. 1990. Meeting Basic Learning Needs: A Vision for the 1990s. New York: WCEFAY15. Rahman, Anisur. 1990. Towards an Alternative Development Paradigm. Bangladesh Economic Association, Dhaka. November 23, 1990.
· Community-based development programmes have often been started as "pilot-projects". They have been seen as a kind of "people's projects"; a "bottom-up" effort, sometimes in protest to the state, and often without any linkages with the government. This explains in part why many of these projects have stayed as "pilot projects". The whole idea of a necessary conflict between "top-down" and "bottom-up" needs to be challenged. It should be replaced by a better understanding of the interaction and possible synergism between "top-down" advocacy and social mobilization for human survival and development, and "bottom-up" processes of empowerment and participation to achieve the same goals. Community-based development programmes should therefore not be planned and implemented in isolation from national programmes of the government, but rather be linked to these in such a way that positive lessons and the enthusiasm resulting from a success are immediately shared by government officials at higher levels. The government also needs to feel a certain degree of "ownership" of a community experiment.
· Specific interventions seem less important in determining a success than how things are done in terms of community participation and empowerment, mobilization of the bureaucracy, etc. (Radel, 199016). There should always be a compromise between objective actions required to attain a human development goal and the community's right to reject proposals and to suggest alternatives, based on their own felt needs. It is important, in the beginning of a programme, to implement a certain number of activities that have an early, visible and felt impact. Some of the conventional health services, such as immunization, ORT, etc. have proved very useful in this sense.
16. Radel, David. 1991. Personal communication.
· Affordability, replicability and sustainability of programs and projects are all dependent on the needs for resources compared with the availability, control and willingness to use resources for that particular purpose. So far focus has been on the external costs of programmes and projects. This should be expanded to include national and local costs, together with estimates of the needs of all types of resources, i.e. human, economic and organizational resources. It is also important to recognize the resource needs over time. A division of "resource costs" into "start-up", "expansion" and "running" costs is useful (Parker, 198817). A project with a relatively high "start-up" cost, but low "running" costs is more sustainable than a project with low "start-up" cost but relatively higher "running" cost. The promotion, protection and support of breastfeeding probably belongs to the first category while a food distribution programme may belong to the second.
17. Parker, David, 1988. "Cost and Affordability" in Government of Tanzania. WHO and UNICEF. 1988, see note 20.
· Successful community-level development programmes are often characterized by good management, including clear accountability for all actors. Community members and community groups, who actively participate in a programme, should have specific and clear roles. Management committees at different levels improve management, including monitoring of the program. During the last decade, district level management has been strongly promoted. A "district" normally covers about 200,000-350,000 people. This is, however, too large a number of people to promote community participation and community ownership of a programme. A much smaller unit is required, probably about 10,000 to 20,000 people.
An Example from Nutrition - The Iringa Nutrition Programme
In early 1984, a nutrition programme was started in Iringa region, in the Southern Highlands of Tanzania, with the assistance of the Italian funded WHO/UNICEF Joint Nutrition Support Programme (JNSP). The programme covered initially 168 villages with about 250,000 people, of which about 50,000 were children under five years of age. In less than three years the rate of severe malnutrition (weight/age below 60% of standard) was reduced from more than 6 per cent to about 2 per cent.
The programme was expanded in 1987 to cover the whole of Iringa region (1 million people). The "Iringa Approach" spread fast to other regions and by the end of 1990, 20 percent of all villages in Tanzania were covered. A number of external agencies are supporting these community-based nutrition programmes. The UNICEF new programme of cooperation (1992-97) will provide additional support and it seems possible that the whole of the United Republic of Tanzania (including Zanzibar) will have adopted the "Iringa Approach" by 1995. Impact up to end of 1989 in five regions is shown in Figure 1. It is important to note that for each expansion the estimated external cost per child has been reduced and is now estimated to be about US$2.50 per child per year (UNICEF, 199118).
18. UNICEF. 1991. Strategy for Improved Nutrition of Children and Women in Developing Countries: A UNICEF Policy Review. New York: UNICEF.
Severe Malnutrition in Children Under-Five in CSD Programmes in Four Regions
The Iringa Nutrition Programme has been well documented elsewhere (UNICEF/WHO 198619; Government of Tanzania, 198820; Yambi, et al. 198921; Kennedy and McGuire, 199022; ACC/SCN 199123) and will therefore not be described here. The success of the approach is the result of both programmatic and environmental (Tanzanian context) factors. A summary of the most important programmatic factors will be presented here. They all reflect the com ponents described earlier for successful community-based development programme, reflecting the different aspects of a new development paradigm.
19. UNICEF and WHO. 1986. Joint WHO/UNICEF Support for the Improvement of Nutrition in the United Republic of Tanzania. Report of a mid-term review.20. Government of Tanzania, WHO and UNICEF. 1988. JNSP Iringa 1983-1988. Evaluation Report. Dar es Salaam, October 1988.
21. Yambi, Olivia, Jonsson, Urban and Ljungqvist, Bjorn. 1989. The Role of Government in Promoting Community-based Nutrition Programmes: Experience from Tanzania and Lessons for Africa. Cornell PEW Lecture Series.
22. Kennedy, Eileen, and McGuire, Judith. 1990. Successful Nutrition Programmes in Africa - What Makes Them Work? IFPRI.
23. ACC/SCN. 1991. Managing Successful Nutrition Programmes. Nutrition Policy Discussion Paper No. 8 (In press).
The Triple-A Approach Poor people's coping strategies can be described as a cyclical process of assessment of the nutrition problem, analysis of the causes of the problem, design of appropriate actions, re-assessment (monitoring) of the impact of actions taken, improved analysis, better actions etc. (Triple-A). This cyclical process is "fuelled" by information. Growth monitoring and promotion, when properly used, is a good example of a triple-A process at household/individual level. Community action, using community resources and based on a community information system, is another example. The idea is shown in Figure 2.
Fig. 2
No pre-set "technical package" was promoted in Iringa. Instead a very large number of community leaders and other "strategic allies" were involved in a dialogue to understand the problem and to articulate their own coping strategies. The whole programme was reviewed and re-planned every three months involving all key actors in implementation.
The promotion of a "Triple-A" thinking and approach enabled people to better understand the dynamics of their own communities - it empowered them. They became more aware of the need for more and better information about malnutrition and its causes, and they became more clear about which resource would be required for the improvement of nutrition. Communities in Iringa understood that it was their triple-A cycles that should be strengthened, which made it obvious that the resources at household and commun- ity levels were the most important to mobilize, re-orient and use. This explains the early cost-sharing of some services (community health workers and child care attendants) and the rapid expansion of the programme to other regions of the country.
The Conceptual Framework The initially proposed conceptual framework, indicating the immediate, underlying and basic causes of malnutrition, was changed and improved upon several times during implementation of the programme (see SCN News No. 6, p. 12). This framework became the analytical tool used by everybody involved in the programme. It facilitated multi-sectoral cooperation, because it showed that "everybody was important". The classic dispute between staff from health and agriculture, for example, ceased to exist after some time. The framework became an important empowering instrument. It encouraged and guided people not only to look for the obvious immediate cause of malnutrition, but to extend the analysis to the underlying and more basic causes of the problem. The actions that were taken often consisted of a combination of short- and long-term interventions, reflecting an unexpected capability and creativity.
Human Resource Development Training of all cadres at all levels, from household to regional level, was an important thrust of the programme. A combination of "top-down" training of extension workers and a more "Freirerian" approach to empower people through participation was used. Improved understanding of the nutrition problem in the community increased peoples' motivation and commitment. The demand for more information became stronger. Growth monitoring and promotion was never "pushed" into communities; it was never an "entry-point". Instead it was introduced as a response to an articulated demand for information by the communities.
Advocacy and Social Mobilization The Iringa Nutrition Programme was inaugurated in December 1983 with a powerful speech by the Prime Minister. Almost all community leaders in Iringa were present. This started off an impressive advocacy campaign that is still going on. All kinds of mass-media personnel were involved in the programme, not as journalists, but as communication experts in their own rights. This resulted in a constant flow of newspaper articles and radio programmes about nutrition in general and the Iringa Programme in particular. After two years almost everybody in Tanzania knew about the "Iringa Approach".
The advocacy campaign explains to a large extent the successful social mobilization in Iringa. Leaders at all levels advocated the right of all children to survive and to be well-nourished. "Strategic allies" presented themselves in community meetings and became strong animators in the programme. They demanded information and they got information from the community-based growth monitoring system. The progress, or lack of it, of each village was reviewed in meetings at ward, division and district levels. Leaders were made accountable for lack of progress and congratulated if progress had been made. A village that did not cope well was soon visited by a team from the district or divisional level to review the programme and to try to assist.
Community Ownership The Iringa Nutrition Programme (INP) is a remarkable example of an externally assisted programme, where the ownership of the programme was rapidly moved to where it should be - Tanzania and Iringa. The first phase of preparation was made without any "outside" involvement. There was no outside "mission" that flew in to help. UNICEF established an autonomous sub-office in Iringa in order to reduce the dependency on the office in Dar es Salaam. Only one expatriate worked for a substantial time in the programme, and he lived in Iringa, not in the capital. He knew Tanzania very well, including the language, the culture and the politics. All this contributed a lot to a true "ownership" of the INP by the people in Iringa. A sign of this ownership was the fact that the name of the programme was changed at an early stage from the JNSP to the Iringa Nutrition Programme (INP).
Community Participation Shrimpton24 (1989) studied the role and degree of community participation in four community-based nutrition programmes. (Tamil Nadu, India; Thailand; UPGK, Indonesia; and Iringa, Tanzania). He assessed on a scale 1 to 5 the degree of participation in needs assessment, organization, leadership, training, resource mobilization, management, orientation of activities and monitoring/evaluation. The Iringa Nutrition Programme scored highest with a total of 36 points out of a maximum of 40 points.
24. Shrimpton, Roger. 1989. Community Participation in Food and Nutrition Programs: An Analysis of Recent Governmental Experiences. Cornell Food and Nutrition Policy Program. May 1989.
The triple-A approach is basically a participatory approach. In Iringa it meant something more than just the involvement of communities in programme implementation. It meant the creation of an environment in which "outsiders" were accepted and allowed to participate in community development.
Targeting and Early Provision of Key Services It is not only external agencies that want immediate results - communities do as well. In Iringa, a system of nutrition rehabilitation at community level was established at an early stage of the programme. Target families for immediate support were identified by communities using data from the growth monitoring system. Other important immediate services with high impact and visibility were: universal immunization, ORT and the provision of essential drugs.
Information and Monitoring The early mobilization of village communities created a demand for information. This made it possible to establish a system of growth monitoring and promotion in all 168 villages within a very short period of time. The information was collected, compiled and discussed at community level. Decisions were made about how to support households with malnourished children. The compiled information was then sent to the next administrative level for discussion and decision about how that level could support villages that did not progress as well as expected. Finally the regional committee received summarized information for decisions about how certain districts could be supported.
As Pelletier25 (1990) points out, the particular aspect of the Iringa monitoring system is the fact that the information is used for decisions to continuously re-orient the programme at all levels, and not, as is usually the case, for difficult-to-read reports that nobody uses.
25. Pelletier, David. 1989. An Analysis of the Uses and Limitation of Information in the Iringa Nutrition Program, Tanzania. Cornell Food and Nutrition Policy Programme.
Management The existence of development committees at almost all levels in Tanzania is one of the most important environmental factors that have contributed to the success of the Iringa Nutrition Programme. These structures were strengthened by the creation of management and implementation committees at village, ward, division, district and regional levels. A high-level National Steering Committee, chaired by the Deputy Principal Secretary of the Ministry of Local Governments contributed to the replication of the "Iringa Approach" in several other regions. In that sense the programme all the time was a government programme. Each quarter of a year, regular meetings of these committees were held; a detailed review of the programme was made and plans for the next quarter were discussed and agreed upon. Responsibility and accountability for each activity were clearly defined during these meetings.
From a Programme Towards a Movement
The Iringa Nutrition Programme moved from an "experimental" programme in one part of the country to a "movement" covering the whole country within seven years. What made this change and expansion possible? And what lessons can be drawn from this experience for how to transform the present global commitment to child survival and development into a global movement for the eradication of poverty in the next few decades? History helps to understand future opportunities. National and global movements have changed and are changing people's lives. There are global movements for disarmament and peace and for environment and anti-apartheid. Below is an effort to summarize some of the aspects that seem to characterize many of these movements.
· Most movements are driven by normative, human rights oriented goals. It was never primarily scientific arguments that were used in the struggle against slavery, the equal rights to vote, gender issues, etc. Most of the time the arguments for a change were derived from moral values, often based on a call for human rights. This normative orientation makes the work in a movement very similar and often identical with political work.
· Often movements are results of protests. Something is basically wrong, unfair or unacceptable. In many cases "a common enemy" is identified which contributes to the mobilization of both people and governments.
· Most movements are pluralistic. The over-riding concern to attain a priority goal over-shadows most other aspects which previously might have divided people and groups of people with a different political or ideological background.
· Normally movements do not "allow" anybody to be "neutral". All people have to take a position for or against.
· A movement is most often a struggling process, involving a lot of voluntary work, driven by enthusiasm. using targeted slogans and challenging existing dogma and myths.
· Young people have been in the "frontline" of most successful movements. A movement deals with the future; it promises a better future for young people.
A lot is being said about the UN at present. Some criticize the UN for avoiding the real problems in the world and for becoming an international bureaucracy. The 1990s is a big challenge for the UN, our only existing global organization. The UN must provide global leadership for the creation of a true global movement for the fulfilment of the two promises, upon which it was created - peace and human rights. The eradication of poverty including all types of malnutrition must be a first step in this endeavour.
Research shows varying responses of consuption of different micronutrients to changes in incomes or prices.
Recent research has revealed how the intake of different dietary nutrients responds to changes in income or food prices, with important implications for nutrition policies and programmes. The findings, based on data collected in the Philippines, are described below in a condensed version of a paper prepared by Howarth Bouis of the International Food Policy Research Institute, in sum, intakes of vitamins A and C do not respond to changes in either household income or food prices in the same way as calories and iron do. While consumers appear to be conscious of fluctuations in the calorie content of their diet and make adjustments to maintain (as far as possible) adequate levels of calorie consumption as income and prices fluctuate, such an awareness is not the case with vitamins A and C.
Consumption of vitamins A and C varied directly with the price of green leafy vegetables - by far their main source. Most of the vegetables consumed were home-grown (in the study). As the prices of vegetables increase, a larger proportion of what is produced may be sold, with consumption of these vitamins consequently reduced both ways. As Bouis points out, demand behaviour for vitamins A and C is fundamentally different to that of iron, because the source of these vitamins is concentrated mainly in vegetables, which being cheap do not respond to income changes; moreover consumers are unaware of their intakes. These intakes therefore fluctuate widely with prices and availability.
Iron intake behaves differently. Its intake increases faster with income than either calories or vitamins A and C; as income increases, consumers will purchase more meat and fish which are both relatively expensive and rich in bioavailable iron. Overall intake of iron fluctuates less with food price changes than intake of vitamins A and C, owing to the normal dietary sources of iron being diverse; thus a price change in one source will not dramatically affect overall iron consumption. This also means that iron consumption is more likely to be inadequate for poorer households, but less seasonally variable. Further, within households, iron intakes of pregnant and lactating women may be highly inadequate.
Relevant actions with potential for increasing vitamin A and C consumption may thus include both extension programmes for improving home vegetable production, and educational programmes for increasing consumption. In contrast, these may be less relevant to iron deficiency, for which programmes that aim to generate increased incomes are likely to be more beneficial. Fortification may also have its place, and where intakes for certain individuals are particularly low, supplementation should be considered.
Dietary Patterns, Income and Food Prices: An Analysis of Micronutrient Intakes for Philippine Farm Households by Howarth E. Bouis, International Food Policy Research Institute, 1776 Massachusetts Ave., Washington, DC 20036
Most economic studies of demand for nutrients have focused on demand for calories. This preoccupation among economists in estimating the determinants of energy deficiencies among poor populations of developing countries is the direct result of the widely held view among nutritionists that (in general) inadequate calorie consumption is the most serious nutrition problem in these countries. However, this signal from nutritionists may be changing. For example, there is increased concern with inadequate intakes of iron. vitamin A, and iodine.
In response to the growing attention that nutritionists are giving to the serious problem of low micro-nutrient intakes, researchers at IFPRI have initiated several research activities to reanalyze household survey information, focusing on demand for micronu- trients. Some preliminary results are now available from a study in the Philippines that analyzes household-level intakes of iron and vitamins A and C and compares them with calorie intakes.
Nutrient Adequacy Ratios The data were collected in connection with a study of the nutrition effects of agricultural commercialization in Bukidnon Province on the southern island of Mindanao in the Philippines. Four survey rounds were undertaken at four-month intervals during 1984 and 1985. 448 households that were present during all four rounds constitute the sample used in this analysis.
520 separate food items were identified during the 24hour food recall surveys. Nutrient conversion rates for these foods are found in food composition tables published by the Food and Nutrition Research Institute in the Philippines. Food quantities consumed (recorded during the 24-hour recall) were then multiplied by these conversion rates to give an estimate of total household consumption of each nutrient.
Table 1 presents the simple sample average of household adequacy ratios for five nutrients by expenditure quintile. The Bukidnon sample population eats a corn-based staple diet, while the most widely consumed staple food in the Philippines is rice. Iron intake is quite strongly and positively correlated with income, whilst income elasticities would appear to be somewhat lower for calories and proteins, and lowest for vitamins A and C, the only two nutrients for which a pattern of monotonically increasing adequacy ratios across expenditure quintiles is not in evidence.
On average, the lowest expenditure quintile is consuming the recommended allowances of protein and vitamin A; otherwise diets are generally deficient in other nutrients. By contrast, the diets of the highest expenditure group appear not to be deficient in any of these nutrients. These average figures however do mask a good deal of variation around these means.
This variation is particularly apparent for vitamin A and vitamin C. For example, despite the fact that the average adequacy ratio for calories for the highest expenditure quintile is 0.99 as compared with that of vitamin A of 1.38, other analyses found that only 15% of households in this quintile were below 80% of calorie requirements on average, as contrasted with 34% of households which were below 80% of requirements for vitamin A.
Micronutrient Food Sources Sources of iron are well-distributed among the seven food groups, more so than for any other nutrient analyzed. Meats and fish account for two-thirds of the marginal increase in iron intakes as income increases (these are sources of more bioavailable iron, too). By contrast, sources of vitamin A are relatively concentrated. Vegetables provide 70% of vitamin A and meats and fish provide most of the remaining 30%, although meat and fish provide more than 50% of the marginal increase in vitamin A as incomes increase. Horse radish tree leaves (known locally as malunggay leaves) provide just under 40% of total vitamin A intakes.
Variation in Nutrient Consumption across Survey Rounds Information on seasonal variation in nutrient intakes (the first and fourth round surveys record information for the same season in two different crop years) is presented in Table 2. The percentage of households below 80% of requirements is lowest during the first and fourth rounds, coinciding with the corn harvest and lowest corn prices. More importantly, Table 2 shows that vitamin A and vitamin C intakes in the fourth round - shown as adequacy ratios - are only about one-third the intakes of these micro-nutrients in the first round! Food expenditure data which were also collected provide a plausible explanation for the observed decline in green, leafy vegetable consumption. Prices of green, leafy vegetables, which are more expensive than other types of vegetables, increased substantially from the first to the second crop year. Up to three-fourths of consumption of green leafy vegetables comes from own-production. Further analysis of these data is required to determine the extent to which the decline in consumption is due to declining production (for example, due to poor weather leading to higher prices), or due to the sale of a higher percentage of home production of green, leafy vegetables, given more favorable market prices.
Table I: Nutrient adequacy ratios by expenditure quintile
|
Nutrient |
Q1 lowest |
Q2 |
Q3 |
Q4 |
Q5 highest |
All |
National Average |
|
Calories |
0.81 |
0.88 |
0.92 |
0.93 |
0.99 |
0.91 |
0.89 |
|
Protein |
0.99 |
1.11 |
1.13 |
1.21 |
1.33 |
1.15 |
1.00 |
|
Iron |
0.66 |
0.75 |
0.81 |
0.87 |
1.03 |
0.82 |
0.92 |
|
Vitamin A |
1.06 |
1.08 |
1.35 |
1.30 |
1.38 |
1.23 |
- |
|
Vitamin C |
0.88 |
0.85 |
1.04 |
1.04 |
1.04 |
0.97 |
0.91 |
Table 2: Household calorie, iron, vitamin A, and vitamin C adequacy levels, and percent of households below 80 percent of requirements, by survey round.
|
Survey round
|
Adequacy ratios |
% households <80% reqs. |
||||||
|
Calories |
Iron |
Vit. A |
Vit. C |
Calories |
Iron |
Vit. A |
Vit. C |
|
|
1 |
0.99 |
1.00 |
1.95 |
1.46 |
25 |
42 |
39 |
44 |
|
2 |
0.89 |
0.79 |
1.24 |
0.94 |
40 |
61 |
59 |
60 |
|
3 |
0,85 |
0.78 |
1.03 |
0.96 |
47 |
65 |
72 |
72 |
|
4 |
0.88 |
0.73 |
0.71 |
0.53 |
36 |
69 |
72 |
80 |
|
All |
0.91 |
0.82 |
1.23 |
0.97 |
37 |
59 |
60 |
64 |
Conclusions The essential difference between demand for calories and demand for micro-nutrients is that consumers seem to be aware of fluctuations in calorie consumption, but not of fluctuations in micro-nutrient consumption. Thus, despite the fact that calorie consumption is concentrated in two foods (corn and rice), consumers react to increases in prices of these staples either by switching to other calorie-dense staples or reducing expenditures for non-staples and non-foods to protect (to a large extent if not completely) acceptable levels of calorie consumption.
Iron consumption is also relatively immune to food price fluctuations because iron sources are so diverse, and because staples, especially corn, provide significant amounts of iron (but not vitamin A and vitamin C). Non-staple foods are important sources of iron with high income elasticities, consequently iron income elasticities are also high. Calorie-income elasticities are also positive because of the high propensities for non-staple foods. However, calorie-income elasticities are much lower than iron-income elasticities due to the fact that non-staples are low-density calorie sources, but high-density iron sources.
Demand behavior for vitamin A and vitamin C is fundamentally different from iron because (1) intakes for these two nutrients are concentrated in a relatively few foods, primarily vegetables, (2) vegetables have low income elasticities being relatively inexpensive sources of variety in the diet, and (3) staple grains have virtually none of these vitamins. Because of this concentration and because consumers are unaware of their intakes, intakes may also fluctuate widely with prices, even though it is possible to satisfy daily requirements relatively inexpensively.
Programs to educate consumers about the importance of meeting recommended daily allowances of vitamin A and vitamin C and about commonly eaten sources of these nutrients, then, would seem to have the potential for improving intakes. In Bukidnon province, because so much vitamin A and vitamin C comes from own-production, extension programs to promote growing green, leafy vegetables not only would provide households with a ready supply of these nutrients (unless they sell additional production), but increased production could bring the local price down.
By contrast, it is much more difficult to see how these types of education and extension programs could be effective in increasing iron intakes, if only because sources of iron are so diverse in the diet and, on average, these sources of iron are expensive. While the estimated iron-income elasticity is relatively high (suggesting that policies/programs that increase income may solve the problem without resort to health/nutrition interventions), iron adequacy ratios for low income groups are quite low. Fortification or supplementation may be the best policies for solving the low iron intake problem (depending on the costs of available technologies). Nevertheless, it appears that a real-location of iron intakes within households (from men to women) could have a large impact toward reducing the numbers of severely iron-deficient individuals.
This entire analysis is motivated, of course, by an assumption that increasing micro-nutrient intakes will improve health. Previous economic analyses have concentrated largely on the problem of low calorie intakes. Certainly the data presented here show that the percentages of households far below recommended intakes of micro-nutrients are much larger than for calories.
