NEWS AND VIEWS

Famine in Africa

Despite several reports since August 1990 pressing for an emergency response to prevent massive loss of lives, misery and displacement, world attention remained focused on the Persian Gulf crisis and Soviet events. Now, with a large-scale famine developing in Africa, many who reacted to images of Ethiopian famine victims in 1985 now suffer from "compassion fatigue" - with similar reports being met with apathy, as the problem has apparently not gone away. Since 1985, however, several consecutive years of drought, regional wars, and massive movements of refugees have been added to the enormous economic and social stress and food insecurity that many African countries were facing.

The facts now are all too stark. The food emergency is deepening in the Horn of Africa, where only a massive international relief programme can avert widespread suffering and loss of life in the months ahead. Taking into account the amount of food aid pledged by the European Commission, European Community member states, and promised by international donors, there still remains a large deficit of emergency food aid. Logistic constraints are impeding food distribution in Ethiopia, with severe food shortages and widespread starvation in North Omo, the Ogaden and Hararghe. In recent weeks, shipments through the Southern Line to Tigray and Wollo have increased, although they still remain below requirements. WFP reached an agreement with the EPLF to allow use of the port of Massawa for relief distribution to Eritrea and other northern areas. While this will facilitate operations and reduce costs, additional donor support is urgently needed to expand over-land transport capacity and air-lifting operations.

Serious food shortages persist in Sudan. Prices of cereals are well beyond the purchasing power of large sections of the population. The widespread onset of the rains in July and August, while benefiting early crop development, has rendered many areas inaccessible by road, particularly in areas, where the population are most at risk. The position of Ethiopian refugees and returning Sudanese is critical. Reports of a meningitis epidemic in a remote part of southern Sudan which killed 35,000 people have also recorded the presence of a massive famine affecting nearly everyone in that area.

Malnutrition and deaths from starvation continue to be reported from Somalia, where as much as 50 per cent of the population need emergency food assistance. So far only limited relief supplies are reaching the affected populations through those few NGOs which are still operating. What little food there is available on local markets is being sold at exorbitant prices beyond the reach of the majority of the population.

Serious food shortages also persist in Angola, Liberia and Mozambique, partly aggravated by war and civil strife. Relief operations in Mozambique continue to be impeded by security problems with numerous attacks by armed bandits on food convoys. The dilapidated road and rail network in Angola has cut off large sections of the population, and donor funding is urgently needed for its rehabilitation. In South Africa and Zimbabwe, no export surpluses are available after a poor harvest.

Famine in Africa is now in the news. The seriousness of the situation has attracted the attention of the international community, albeit very slowly. A short-term reactive response to this emergency situation may - after many thousands of people have lost their lives - help to deal superficially with famine conditions. But since the prospects for implementation of any famine preventive policies towards food security for Africa remain gloomy, are we to witness a repeat of history in the years to come?

War, Drought and Crisis in Africa

The six most seriously affected countries are depicted in the map opposite. In some there has been a drought, but for each there has been. or still is. war. War kills both directly and indirectly. It disrupts the planting, harvesting and distribution of crops. Markets and transport systems may be destroyed, so that what there is available may not be accessible. As a result, those people who in normal years would anyway be struggling to maintain food security, are pushed deeper into poverty and desperation. This has been the case in the last few years in Ethiopia, Sudan, Somalia, Liberia, Angola and Mozambique. War, not drought, has been the common denominator in their present situation.

(Sources: FAO Food Crops and Shortages, various, 1991; Development Forum. May-June. 1991)

International Relief - A Mixed Blessing?

Perhaps the only positive thing in a disaster stricken area is the solidarity among local and outside helpers to save lives, to provide medical care, shelter, food, clothes, etc. for the survivors and to decrease, as much as possible, the sufferings of victims of such events. But what if the well-meaning actions of those sending/bringing external help will not benefit those receiving them?

The World Health Magazine in its January-February 1991 edition devoted to disaster preparedness, contains an article by Claude de Ville de Goyet and Patricia Bittner dealing with this question. They note that unsolicited and hastily-assembled donations by the public as well as the arrival to the disaster area, of a large number of foreign staff to help -themselves in need of food, shelter, transport, guidance and translation services - may in fact add to the load of the already overburdened local managers. The danger would then be that external relief actions were competing with, rather than complementing the local efforts. Similarly, Nick Cater (In Disaster relief: if you want to help, stay away. The Observer, 14 April 1991) has addressed this same problem saying that "Not only do well-meaning, but often misguided, rescue teams fail to save many lives but they can hamper local groups which respond most rapidly to natural disasters. Following the 1988 Armenian earthquake, 21 international teams flew into the stricken area with 1427 staff. Despite heat-seeking cameras, sensitive listening equipment and snifter dogs. they managed to dig out only 64 of the 15,000 people pulled out of the rubble. The local community saved 95% of those rescued, and Soviet teams saved most of the rest."

According to WHO'S definition, a disaster is "any occurrence that causes damage, economic disruption, loss of human life and deterioration in health and the health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area". What response and how it should be given - particularly from afar - is an issue which is attracting more and more attention.

It is perhaps true that up to now and in most cases, international response to the occurrence of disasters has been an immediate overreaction followed by a fairly quick turn to other probably more fresh events requiring humanitarian attention. However, based on frequent past experiences, while in many cases even a least prepared country can deal more or less effectively with the immediate needs of the victims, what is mostly required and often lacked is long-term resources to rebuild and reestablish the infrastructure. New guidelines to control international search-and-rescue teams in earthquakes, floods and hurricanes are needed and have been the subject of meetings such as a recent intergovernmental meeting in Austria. Several recommendations have also been included in the World Health article mentioned above. In brief, the main message is that international assistance is in great need of improvement and reorientation if we want to avoid being a mixed blessing to those unfortunate enough to be hit by a natural disaster and prevent getting the wrong results from well-meant actions.

(Sources: Based on the references quoted above)

African Experience with Food Aid - A WB/WFP Study

A joint World Bank (WB) and World Food Programme (WFP) study on food aid, begun in 1988 and largely concluded in 1990, focused on the African experience with food aid. The study aimed to highlight what are considered to be key issues that must be addressed in order to improve the supply and use of food aid to Africa, whether emergency, programme or project aid. To do so, a series of consultations with African countries and institutions, food aid donor countries, NGOs, academic and other experts on food aid in Africa was undertaken. Moreover, a literature review commissioned for this study was published in 1990 as WFP Occasional Paper No. 13. This review identified over 300 items on food aid in sub-Saharan Africa, mostly written during the past ten years. The study came out with the following conclusions of which many, although intended to apply specifically to Africa, are also relevant to other developing regions,

- Africa has the potential to feed itself. Agricultural production in Africa could be greatly expanded, but transforming agriculture and expanding productive capacity to improve living standards will take time to achieve. In the meantime, external assistance, including both emergency and non-emergency food aid, will be required to help expedite this transformation.

- Food aid now contributes more than 30 per cent of the region's cereal imports and about 8.5 per cent of all official development assistance (ODA) to Africa. A higher level of food aid could be accommodated to offset growing food imports and help increasing numbers of malnourished people. Many African countries are finding it increasingly difficult to import food commercially owing to their worsening balance of payments situation, exacerbated by the high level of debt servicing. However, due regard must be taken of absorptive capacity for particular food commodities at both national and sub-national levels.

- Both programme and project food aid have made positive contributions to food security and long-term development in Africa. However, programme food aid has seldom made a large direct contribution to the alleviation of poverty and hunger through the use of saved foreign exchange, sales proceeds or the food itself. In addition to the fact that the main objective of the programme food aid has often not been alleviation of poverty and hunger, problems have included irregular timing, poor programming of counterpart funds and the dissipation of food resources in generalized food subsidies. Project food aid reaches the poor and hungry, but direct distribution of food to the beneficiaries can be very costly and requires greater rigour in selection and design of projects. Project food aid has also been handicapped by the shortage of complementary financial and technical resources and by administrative and logistical difficulties.

- A revision of emergency response mechanisms is required to provide a sound resource base in advance of emergency food aid needs, access to donors' food supplies at short notice, and cash to allow rapid purchase of food close to where emergencies occur. Long-term refugees and displaced people require more developmentally-oriented approaches. Development assistance (including food aid) should be provided in drought-prone areas to address the root causes of recurring emergencies.

Markets, Democracy and Development

Meeting the challenge of development needs an undistorted policy climate, and is principally in the hands of the developing nations themselves, writes the Economics Editor of the Guardian, Will Hutton. The piece he has contributed to the Guardian on this, is quoted below.

"The World Bank has called for a market-oriented approach to economic development, arguing that the prospects for the one billion people who live on less than a dollar a day lies in their own hands. Lawrence Summers, the World Bank's chief economist, commenting on the 1991 World Bank Development Report, said that a new 'market-friendly' consensus on economic development was emerging. But although competitive markets were the best way forward, they sometimes 'prove inadequate' or fail altogether. That was why governments must, for example, 'invest in infrastructure and provide essential services to the poor'.

"The report says that the central theme in development is the relation between governments and markets. The evidence over 40 years was that intervention, price controls and administrative allocation of credit distorted performance. In an analysis of 1200 projects, economic rates of return were between 50 to 100 per cent higher under a relatively undistorted policy climate. Equally, protection in the industrialized countries hurt developing nations, and the authors estimate that unrestricted access to First World markets would add $55 billion to Third World earnings.

"The Bank is optimistic about the prospects for growth in the developing world over the next decade. Per capita incomes could grow by 3 per cent a year, and with the right combination of policies, growth could be up to 2 per cent higher.

"The Bank is now an enthusiast for democracy, stressing the old view that only authoritarian governments can make the 'hard choices' about economic development as 'patently false'. Governments need to retain popular support for their actions, and aid and finance agencies should question backing countries whose first priority is to add to their military strength.

"The World Bank supports the OECD, IMF and Bank for International Settlements orthodoxy that the best economic policy governments can pursue is a stable macro-economic foundation of sound money and public finance. The best help the developed world can give to the development process is to roll back restrictions on trade and to address the debt crisis. This remains an obstacle to growth, and more countries should be eligible for commercial debt and the debt service reduction. Above all, the industrialized countries should keep rates low and achieve steady non-inflationary growth.

"The report concludes that the developing countries' prospects are principally in their own hands, and it repeats the market message that strategies 'in which governments support rather than supplant competitive markets offer the best hope for meeting the challenge of development'."

(Source: The Guardian, 8 July 1991)

Safe Motherhood Initiative

Maternal deaths - defined by WHO as death of a woman who is or has been pregnant during the previous 42 days -account for one quarter of all deaths during the child bearing years. Almost all of these (99%) take place in developing countries. For instance, the lifetime risk of dying from pregnancy-related causes is 1 in 25 for Africa and 1 in 38 for South Asia, compared to 1 in 1750 in developed countries. The number of maternal deaths occurring in India in one week equals the combined totals for all European countries in one year! Almost all of these deaths are preventable. But because of inadequate levels of health, currently over half a million women die needlessly of pregnancy-related causes every year. This amounts to about 1400 women dying daily.

Concern about the neglect of maternal health especially in developing countries led to the launching of the Safe Motherhood Initiative at the International Conference on Safe Motherhood held in Nairobi in February 1987 (see SCN News No. 1, p. 8). The conference was jointly sponsored by the World Bank, the United Nations Fund for Population Activities (UNFPA) and the World Health Organization. The Initiative is, in fact, a culmination of several events including the Strategy for Health for All by the Year 2000, the UN Decade for Women and the Mexico Population Conference of 1984. Decision makers from many developing countries have considered what needs to be done to alleviate the desperate situation of many women throughout poor countries. The Safe Motherhood Newsletter describes the initiative in this way.

"The Safe Motherhood Initiative is a global effort to reduce maternal mortality and morbidity. The target is to reduce maternal deaths by at least half by the year 2000.

"The Initiative aims to enhance the quality and safety of girls' and women's lives through the adoption of a combination of health and non-health strategies. However, the initiative places special emphasis on the need for better and more widely available maternal health services, the extension of family planning, education and services, and effective measures aimed at improving the status of women.

"Activity within the Initiative may take many forms: increasing awareness of the dimensions of the problem and the need for action; strengthening maternal health services; training of health workers and others; facilitating educational and economic opportunities for women; and research, particularly operational research.

"Partners within the Initiative are governments, agencies, non-governmental organizations and other groups and individuals who stimulate and participate in efforts likely to reduce the number of women suffering and dying as a result of pregnancy and childbearing."

Financial support for achieving the Initiative's goals have been committed by a number of organizations including WHO. WB, UNDP and UNFPA.

For more information on the Safe Motherhood Initiative and for a free subscription to the Safe Motherhood Newsletter please contact: The Manager, Safe Motherhood Initiative. Division of Family Health, World Health Organization. 1211 Geneva 27, Switzerland. Tel: 41 22-791 3386; Fax: 41 22-791 0746.

(Source: Safe Motherhood Newsletter. Issue 5, March-June, 1991)

Vitamin A - A Moral Responsibility

The theme of the XIV IVACG (International Vitamin A Consultative Group) meeting held in Guayaquil, Ecuador in June 1991 was community-based interventions (see SCN News No. 6). Assessment of vitamin A status and its effect on mortality and morbidity were some major topics discussed in the meeting. The IVACG Chairman, Dr A. Horwitz (who is also SCN Chairman), highlighted some related issues discussed in the meeting. The following are some extracts from his closing remarks.

"What makes the XIV Meeting of IVACG clearly different from all others that preceded it, is the emphasis placed on community based interventions. Although vitamin A supplementation is one of the approaches, the major interest has been on long range solutions based on behavioral change and dietary choice. The rationale is clearly stated. As long as people regularly consume vitamin A rich foods -either preformed from animal products or preformed as carotenoids from plant sources - all conditions associated with its deficiency can be prevented. In this process the main actors are the people and specifically their knowledge, attitudes and behavior. What is needed is to induce the choice of appropriate foods and to change traditionally entrenched old practices related to the consumption of products lacking or poor in vitamin A.

"We need to keep in mind that because the pace of formal education and cultural imitation as well as economic development has been too slow to induce better health, the need to enlist people's cooperation calling their attention to the consequences of their behavior has become urgent. Mothers as agents of change are our main target related to vitamin A deficiency of children. However, society at large must be informed about any condition affecting large groups of human beings requiring a healthier life style.

"I submit that perhaps the greatest contribution of the Primary Health Care Movement - the integrated one not the selective one - stemming from the Declaration of Alma Ata, has been the focus on an active participation of the people in the decisions that deal with their health and nutritional status, as well as of their families and the communities where they live. But this fundamental objective cannot and will not be reached through the traditional health and nutrition education approaches. Experience shows that these did not motivate the people, because messages were not understood and the need for changing behaviors deleterious to health was not felt. Hence the need for the modern approach to nutrition education, based on methodologies stemming from the social and the biological sciences. They should be applied to vitamin A deficiency prevention and control.

"Although some of us agree with the objectives of social marketing, we are not convinced of the need of adopting the methodologies of commercial marketing. What we want is to persuade people, not to lure them. Once convinced, we expect them, properly informed, to actively change their behavior so as to avert death, prevent disease and malnutrition, and promote health. To this end, as stated, the biological and social sciences have designed appropriate methodologies and should, through research, create even more efficient and cost-effective ones.

"There is evidence of a new development paradigm reflecting the recognition of the role of the poor in poverty eradication and development. There is also a stronger emphasis on normative and moral arguments. From passive recipients to main actors, the poor should play a major function in the 'bottom up' approach to solve priority problems identified by them. However, the 'top-bottom' approach, also needed, should be normative but ethical.

"For sustainable community level programs, four elements are critically important - awareness, choice, empowerment and public demands. We must recognize that management is the weakest link in the program implementation process. It explains, to a large extent, why we apply in nutrition much less than what we know, and why we witness failures in well formulated health plans. Isolated interventions have a lesser impact than integrated synergistic ones for improving the health and nutritional status of children. If income generating schemes are included, and funds are administered by the mother, results stand a better chance of becoming sustainable. Maternal literacy reduces the risk of vitamin A deficiency and is associated with sustained participation in the interventions. It is long known that the higher the level of education of mothers the lower the infant and elderly childhood mortality rates.

Despite limited information - because we still lack a focal point for monitoring all vitamin A control programs even in the countries with a high prevalence of deficiency -morbidity and mortality rates also indicate that people are not consuming what they should, even where vegetables and fruits containing adequate amounts of beta-carotene are available. We submit that governments and the international community of agencies should develop programs, community-based and culture-specific, on effective production and consumption of vitamin A rich foods, and not rely exclusively on supplementation.

"The need has become evident for exploring the mechanism that induces significant mortality reduction, or lack of it, as a result of vitamin A supplementation. This is becoming a rather urgent area of research to facilitate consistent policy decisions. On the basis of the information available and forthcoming, we will need to establish in detail when and how vitamin A supplementation should be applied, a recommendation to governments to decide on the uses of this intervention.

"Since the World Summit for Children, programmes to control micronutrient deficiencies are gaining momentum. The Heads of State of a large number of countries of the world committed themselves to virtually eliminate these conditions, affecting more than a billion human beings most of them from developing countries, during this decade. Governments count on the technical and financial cooperation of the international community of agencies. However, the task ahead is as large as it is essential, and time is running short to reach the overall humanitarian goal. Although it has a price, the outcome is priceless, as it is precious. Every agency represented in this meeting must review its objectives and available resources in the light of the overall decision taken. We must not have children going blind nor dying prematurely because they lack on time an essential nutrient, vitamin A, that nature generously provides. This is our collective moral responsibility. As long as we keep it constantly in mind - what more poignant than the vision or the image of a child going blind - we will succeed.

"What we learnt, if we are diligent, should serve many in need. What we do not yet know about vitamin A deficiency should stimulate our imagination to find appropriate answers that will enable us to serve an even larger number of human beings who are awaiting our cooperation. The more we advance in the effective application of proven technologies as well as in the investigation of new knowledge, the greater will be the real success of this meeting."

(Source: Dr A. Honvitz, Director Emeritus, Pan American Health Organization; Chairman, ACC/SCN)

One Spot of Blood to Identify Multiple Nutritional Deficiencies

Can various micronutrient deficiencies be identified by a single blood-spot? Some recent advances suggest its feasibility soon. A recent workshop at Emory University brought together scientists from several nutrition organizations to determine the feasibility of applying one single blood-spot test to determine human deficiencies in iodine and iron. During the workshop, held 22 April, 1991, under the auspices of the UNICEF-supported International Program Against Micronutrient Malnutrition (PAMM), Kansas University Medical Center (KUMC) discussed progress in their USAID-supported research to develop a method for assessing iron deficiency. The Centers for Disease Control, also at the meeting, have already developed a blood-spot test for determining iodine deficiency. The workshop concluded with optimism that these two testing methods can be merged into one paper blood-spot technique which assesses both micronutrient levels. Such a technique would be very cost effective and improve the identification of people at risk. The PAMM stands ready to expand their country level assessment programme to include iron when the dual test methodology is ready.

This workshop illustrates the effective coordination of efforts to alleviate malnutrition in accordance with the goals of the World Summit for Children. The expectation is to use one spot of dried blood to assess multiple micronutrient states, including vitamin A in the long run.

(Source: Office of Nutrition, USAID, May 1991)

Solar Drying to Improve Vitamin A Status in Haiti

Solar drying uses the sun's energy for drying food while protecting it from the vitamin-depleting effects of solar rays. It is an inexpensive and promising means of food preservation for developing countries.

VITAL, USAID's Vitamin A Field Support Project, through a collaborative effort with Save the Children, is providing technical assistance to introduce inexpensive solar drying processes to Haitian communities. The community dryer will be used for locally-grown fruits and vegetables, focusing on the mango, a fruit abundant in the region and containing extremely high levels of beta-carotene.

Haiti is the seventh largest producer of mangoes in the world, yet due to transportation difficulties and a short growing season much of the produce goes to waste before it can be consumed. When dried properly using the appropriate technology and techniques, the mango can provide plentiful vitamin A. The acceptability of the dried fruit makes it an attractive food source of vitamin A for children at risk for deficiency.

The project will not only promote increased consumption of the dried vitamin A-rich fruit by the target population, but will focus also on nutrition education activities to link the population and consumption goals of the project. This modification of a traditional technology holds promises for populations facing seasonal constraints to food security.

(Source: Office of Nutrition, USAID, May 1991)

Climate Change Threatens Human Health

The world has come a long way in the past two years in realizing the dangers of global warming, known as the "greenhouse effect" because of the way certain gases in the atmosphere act like greenhouse glass, allowing passage of incoming solar radiation but trapping some of the outbound heat radiation from the earth. This article is based on a contribution from George Sanderson, of the UN Envriron-ment Programme. Carbon dioxide buildup - mainly from combustion of fossil fuels like oil, gas, and coal, and from clearing and burning forests - is believed responsible for about half this world-wide warming, while chlorofluorocar-bons (CFCs), methane, ground-level ozone, and nitrous oxide emissions account for the rest. On present trends, scientists predict that these gases will warm the earth further by about 0.3 degrees Celsius in each decade of the next century. This rise, faster than any experienced over the past 10,000 years, could increase the planet's mean temperature by 3°C before the year 2100, making it warmer on average than it has been for 100,000 years.

This may not sound especially ominous, but left unchecked global warming could alter rainfall patterns, flood vast areas of low-lying land as warmed seas rise (possibly by as much as a metre), and drive countless species to extinction as fragile eco-systems collapse.

It could also affect human health by disrupting food and fresh water supplies, displacing millions of people, and altering disease patterns in dangerous and unpredictable ways. "Human health could be affected by even quite small changes in average mean temperature, and there is the prospect of some major diseases flourishing in warmer conditions and of more resistant strains of infection emerging", warned the Commonwealth Secretariat in 1989. The populations most vulnerable to the negative impacts of the greenhouse effect are in developing countries, in the lower-income groups, residents of coastal lowlands and islands, those living in semi-arid grasslands, and the urban poor in the squatter settlements, slums and shanty-towns of large cities.

Present strategies for immunization, coping with disease vectors or carriers, providing safe drinking water, and improving nutrition are all based on existing climate regimes, ecosystems, sea and solar-radiation levels. These are all expected to change, but exactly how much cannot be predicted with any certainty, making it virtually impossible to adjust health and nutritional strategies now to take account of possible climate changes.

Humans adapt well to moderate changes in temperature and to occasional extremes. But this adaptive capacity -developed over many thousands of years - is relatively low in infants and the elderly; it rises through childhood and adolescence to reach a maximum which can be maintained up to about 30 years of age.

Currently, the temperature in Washington DC exceeds 38°C on an average of one day per year; it rises above 32°C about 35 days every year. "But by the middle of the next century, these figures could rise to 12 and 85 days respectively per year", according to the World Meteorological Organization (WMO). "'The effect of such temperature rises on human health in Washington and similar cities throughout the world is difficult to predict. But there is no question that increased urban heat stress could come to claim many lives". The same conclusion was reached by the Intergovernmental Panel on Climate Change (IPCC), which warned in June 1990 that the increase in deaths caused by a greater number of summer heat waves "would be likely to exceed the number of deaths avoided by reduced severe cold in winter". (The Panel was created in 1988 under the auspices of WMO and the United Nations Environment Programme.) A changing climate is also likely to shift the range of conditions favouring certain pests and diseases, according to the final scientific statement issued by the Second World Climate Conference in November 1990.

As temperatures rise, the boundaries of the tropics may extend into the present subtropics and parts of temperate areas may become subtropical, favouring a poleward movement in both hemispheres of the vectors or agents that carry or cause many tropical diseases (e.g. mosquitoes, snails etc.). Some communicable illnesses, including those transmitted through air, water, and food, could therefore become common in regions that once rarely knew them, with a possible rise in death rates. Diseases like malaria, hepatitis, epidemic cerebral meningitis, poliomyelitis, tetanus, cholera, and bacillary dysentery, which flourish in hot, humid weather, could increase while those associated with cold weather would be expected to diminish. In a warmer climate, malarial mosquitoes and other disease vectors also may migrate vertically, up into formerly inhospitable highlands. This may be particularly hazardous in tropical highland areas where there is no natural resistance to malaria.

Changes in temperature, rainfall, humidity and storm patterns may affect vector-borne diseases in two ways. First, they may directly affect the vector's range, longevity, reproduction rate, biting rate, and the duration and frequency of human exposure. Second, they may modify agricultural systems or plant species, thus changing the relationship between vector and host.

Development rates of mosquitoes, for example, would increase with warmer temperatures, provided these pests have wet areas in which to breed, and the snail-borne disease schistosomiasis is likely to spread if global warming forces increased irrigation or causes people to migrate towards irrigation projects. Changes in human migration patterns, along with increased temperature and rainfall, may extend the geographic range of hookworms too.

Moreover, "warmer, humid conditions may enhance the growth of bacteria and moulds and their toxic products, such as aflatoxins", cautioned a World Health Organization (WHO) task group on the potential health effects of climate change. "This would probably result in increased amounts of contaminated and spoilt food."

In the oceans, toxic "red tides" - which kill off marine life due to the proliferation of minute organisms called dino-flagellates - may become more frequent as temperatures rise and nutrients from agricultural fertilizers leach into rivers and coastal waters. This proliferation would disrupt marine food stocks and raise incidences of ciguatera poisoning, caused by eating tropical fish or shellfish which have consumed organisms that have ingested dinoflagel-lates.

Sea-level rise could spread infectious disease by flooding sewerage and sanitation systems in coastal cities, and increase the incidence of diarrhoea in children. The flooding of hazardous waste-dumps and sanitation systems could result in long-term contamination of crop lands. As well, rising, warmer seas may disrupt marine habitats and aquatic food chains. Since fish constitute 40% of all animal protein consumed by the people of Asia, such a disruption of the marine ecosystem would affect the food supplies and incomes of many millions of people, and increase malnutrition and deficiency disease.

Food shortages, reaching "famine proportions in some regions", could also follow the inundation of fertile coastal land by rising seas, the WHO task group noted. And the potential scarcity in some developing countries of food, cooking fuel, and safe drinking water because of drought may further increase the extent of malnutrition, with "enormous consequences for human health and survival" to quote the IPCC.

Some of the factors contributing significantly to global warming, such as the burning of fossil fuels and the use of chlorofluorocarbons (CFCs) and halons, threaten human health in other ways too. A typical petrol-driven motor car, for example, emits carbon monoxide, sulphur and nitrogen oxides, hydrocarbons, low-level ozone, and lead, all of which are hazardous to health. The WHO task group and the IPCC predicted that climate change would worsen air pollution - especially in heavily populated urban areas - by altering the composition, concentration and duration of chemical pollutants in the atmosphere.

For their part, the stratospheric-ozone-depleting CFCs and halons also subject humans to increased risk of skin cancer, eye cataracts, snow blindness, and lower immunity to a host of other illnesses as a result of increased exposure to ultra violet B radiation from the sun. "Skin cancer risks are expected to rise most among fair-skinned Caucasians in high-latitude zones", according to the IPCC. The WHO task group reached a similar conclusion, noting that "the incidence of non-melanoma skin cancer could increase between 6% and 35% after the year 2050. These increases may be much larger in the southern hemisphere, where total ozone depletions have been larger."

Finally, changes in the availability of food and water as well as radical shifts in disease patterns could initiate large migrations of people, increasing the number of "environmental refugees" and leading to overcrowding, social stress and instability, all of which may impair human health and increase health inequality between peoples of developed and developing countries.

The upshot of all this, according to leading scientists, is that much more emphasis must be placed on research into how people contribute to and cope with climate change, and on public awareness and education programmes. "Not only do we need more information about environmental conditions... we also need information about health conditions if we are to target our efforts and use our ever-limited resources to best serve health needs", notes Dr Wilfried Kreisel, Director of the World Health Organization's Division of Environmental Health. "Sad to say, environmental health globally suffers from informational malnutrition, ranging from mild to severe."

(Source: Based on an article provided by George Sanderson, Deputy Chief, Information and Public Affairs, UNEP, May 1991)

Earth Summit

The decision by the General Assembly of the United Nations in late 1989 to convene the Earth Summit in Brazil in June 1992 (see SCN News No. 6, p. 34), is one distinct response to the need to heighten awareness and to undertake appropriate action. The Summit's aim will be to ensure global environmental and economic security. The preparation for the United Nations Conference on Environment and Development (UNCED) is well under way. To complement the release of the papers and reports prepared for the conference, the United Nations NGO Liaison Service (NGLS) is planning to do analytical summaries of some of the main documents. Another excellent source of information is Network '92, a monthly newsletter from UNCED, published by the Centre for Our Common Future, Palais Wilson, 52 Rue des Paquis, CH-1201 Geneva, Switzerland. Tel: 41 22 732 7117. For more information on NGLS' activities, contact NGLS at Palais des Nations, 1211 Geneva 10, Switzerland. Tel: 4122 734 6011 ext. 2005; Fax: 733 6542.

(Source: Development Forum, March-April 1991)

The Black Triangle

In relation to environmental destruction and risk to human health the following report released by UNICEF is of special interest.

At a seminar organized in Florence at the headquarters of the International Child Development Centre, it was revealed that the degree of environmental destruction in the countries of Eastern Europe, and in particular the "black triangle", is alarmingly high. The black triangle is an industrial region stretching across several central European countries including Silesia in Poland, Bohemia in northern Czechoslovakia, the Sudeten region in former East Germany, and post-Chernobyl Ukraine. Life expectancy is reported to be 5 to 8 years lower than in non-industrial areas of these countries, and almost one half of pregnancies could be at risk. An extraordinarily high concentration in the air of lead, cadmium and the highly carcinogenic substance benzo-alphapyrene has been reported in Upper Silesia, where children and young people make up one third of the 3.9 million population. The effects of such pollution on children are incalculable: 40% of those living in the Bukowno region suffer from saturnism, an incurable illness caused by lead poisoning which affects the whole nervous system. 17% of all land in the Soviet Union is in ecologically critical condition and 36% of the population is in danger because of the state of the environment.

The Florence seminar, which was attended by important political figures, environmental and public health specialists, and journalists from both East and West was an opportunity not only to listen to alarming testimonies but also to share the thoughts and suggestions of scientists and journalists.

(Source: International Review, 3 April 1991)

Malaria-preventing Bednets

Deaths due to malaria may considerably be reduced simply by using bednets impregnated with a biodegradable insecticide. Recent studies by Drs Greenwood and Alonso (of the UK Medical Research Council Laboratories) in 17 Gambian villages attributed a 70% reduction in malarial mortality of children between 1 and 4 years to this method of malaria control. Moreover, the study found no adverse effects on people using the bednets, and no difference in death rate between using the impregnated bednets alone or together with taking antimalarial drugs.

The nets are simply impregnated twice a year by dipping them into the insecticide solution and wringing them out. The insecticide deters mosquitos from entering homes, or kills a large share of those mosquitos that come into contact with it. The nets thus prevent the mosquitos from infecting the child. The up-front cost is estimated by WHO at US$3.60 per net, plus a small amount for insecticide.

Malaria is a child killer disease in Africa, resulting in the death of some 500,000 children annually. "Despite the considerable research and control efforts devoted to malaria since the turn of century, it is still the most prevalent and, from a public health standpoint, most devastating parasitic disease in the tropics" says Dr Godal, Director of the WHO Special Programme for Research and Training in Tropical Diseases. The situation is worsening in many areas, because of increasing resistance of the parasite to most anti-malarial drugs, as well as people's migration to malarial areas.

WHO is planning a US$5 million programme to conduct several massive trials each involving 150,000 people, to investigate the effectiveness and cost of using nets in different ecological and socioeconomic areas. Plans for a national programme to introduce within 2 to 3 years impregnated bednets into almost all villages are already formulated by the Gambian government.

(Source: WHO Press Release 35, 20 June 1991)

New Strength and New Momentum for Health

At the 44th World Health Assembly in Geneva in May 1991, James P. Grant, the Executive Director of UNICEF, highlighted a number of significant steps taken internationally since the World Summit for Children in September 1990 and emphasized the future actions to be taken. Among the points covered in his statement were the following:

"... We have for the first time international agreement on the goals that you - the leading health officials of the world -have long espoused and long sought concerted action and resources to implement. Now we have the attention and engagement - and financial commitment - of your national leaders to an unprecedented degree, with the goals personally endorsed and committed to by more than 100 heads of state or government and over 50 other senior representa tives of countries who have signed the World Summit Declaration and Plan of Action...

"The ultimate test of the World Summit commitments is the progress achieved in countries. And already indications bode very well for meaningful follow-up.....In Mexico, for example. President Salinas has appointed the Secretary of Health as overall coordinator of the National Commission for the Implementation of the World Summit Commitments, which has four specialized commissions at the national level and a similar structure in every state. President Salinas will personally devote a day every six months, beginning last November, to reviewing his country's follow-up to the Summit.

"In November 1990, in response to the Summit, the seven Central American health ministers, together with their counterparts in the field of education, met in Punta Arenas, Costa Rica, and hammered out agreement on a series of areas in which they could work together for the welfare of children.

"In Canada, Prime Minister Mulroney has designated the Minister of Health to coordinate the implementation of his government's World Summit commitments. Committees to oversee follow-up to the World Summit and draw up plans of action have also been named in the Central African Republic, Costa Rica, Guinea-Bissau, the Maldives, Spain and Uganda, among other countries.

"As part of its post-Summit effort, Brazil's Minister of Health presented a Plan to reduce infant mortality to 40 per 1,000 live births by 1995, down from the 1989 rate of 61. In the United States, a World Summit for Children Implementation Act of 1991 has been introduced in Congress, which would provide some US$2.7 billion in 1992 and US$3.1 billion for 1993 for specific domestic and international follow-ups to the World Summit....

"... While the World Summit for Children gave us great new leverage to support our common WHO and UNICEF health goals for the 1990s, it also challenged us to do much more spade work in several critical child health fields. I am pleased that our two organizations, along with other key actors, are already collaborating to move us forward on several of these concerns, including:

· reduction of micro-nutrient deficiency - to be discussed in Montreal later this year

· control and treatment of acute respiratory infections - to be discussed at the International Conference on ARI in Washington in December

· the need for better and more comprehensive vaccines -the objective of the Children's Vaccine Initiative - for which UNICEF financial and other participation was just endorsed by our Executive Board

· prevention of HIV infection and the special needs of AIDS-affected children

· and accelerated promotion and protection of breast-feeding.

"...UNICEF estimates that reaching these objectives will require additional resources in developing countries rising to the magnitude of US$20 billion per year by mid-decade, of which some US$3 billion will be needed towards meeting the basic health goals, US$9 billion for water and sanitation, and some US$5 billion for meeting the education goals... These sums are large, but not impossible. The world, after all, still spends more than US$1,000 billion annually on arms, and tobacco companies spend more than US$3,000 million annually on advertising in North America! It certainly should be possible to mobilize the resources necessary to fulfill these historic promises to children...."

Nutrition in UNICEF/WHO Joint Health Policy

"Improving nutrition remains among the most challenging tasks for the last decade of the twentieth century", according to the UNICEF/WHO Joint Committee on Health Policy (JCHP). Recognizing that nutrition is a multi-disciplinary area that would benefit from continuing inter-agency collaboration, the Committee expressed concern that "achievements will remain limited so long as nutrition is considered simply a health problem". The Committee, thus, stressed that "by linking nutrition with all related economic and social sectors, every United Nations organ or agency would be concerned in addressing the problem", with the ACC Sub-Committee on Nutrition coordinating the nutrition-related efforts of the various United Nations agencies. It was further stated that the new International Development Strategy has included six nutritional goals for human development.

Since nutrition is a vital factor to child survival, in the Committee's view, priority should be accorded to the prevention of malnutrition. Target groups include households, health services, and maternal care facilities. Development planners should be encouraged to use nutritional status as an indispensable and direct indicator of national development, it was recommended. The JCHP endorsed the nutritional precepts reproduced below:

- Measures to attack poverty and reduce inequity go to the root of the problem of hunger but much can be done to improve the nutrition of children under two years of age by strengthening the "caring capacity" of mothers - their knowledge and understanding and ability to apply these -for example, through contriving to reduce the burden on their time and energy.

- The growth of children is the outcome of a series of processes that ultimately influence household food security and health security, and the caring capacity of mothers and other members of the family. All three are necessary for good growth but none is sufficient by itself.

- The most critical period is the first two years of life, when the growth pattern for the future is set.

- Improved nutrition of women is important for their own health and for that of their children.

- Exclusive breastfeeding is especially important not only for optimum nutrition of the child but also for protection from the frequency and severity of infection and for delaying conception.

- While breastfeeding should continue as long as possible, additional food must be introduced from the age of 4 to 6 months, with special attention paid to the frequency of feeding.

- Families must have access to sufficient and appropriate food to satisfy the needs of all their members throughout the different seasons of the year (i.e. be food secure). For many, this will mean adequate purchasing power, especially important for women; for some, it will mean direct involvement in food production for themselves.

- Community level action (supported as appropriate from outside), stemming from community involvement in assessment and analysis of the situation, is often the most effective way of mobilizing human and other resources for sustained economic and social development leading to improved nutrition.

- Access to credit and technical resources is frequently denied the poor, especially women, inhibiting initiative and self-help.

- Deficiency of vitamin A can lead not only to blindness but also to markedly increased mortality from infectious disease. Emphasis should be on improving dietary intake, but periodic supplementation with high doses of vitamin A to children below six years of age can be useful. Because of greater vulnerability to infection in the early years, it is sensible to ensure good liver stores during infancy. The great success of immunization programmes in reaching out to children in the first year of life provides a new opportunity to reach children also with vitamin A.

- Iodine deficiency is the single most important cause of mental deficiency as well as a cause of infant death, stunted growth, and poor physical performance. The addition of iodine to salt is the traditional way of attacking the problem, of proven effectiveness. Newer methods that have been shown to be effective are the addition of iodine to water supplies and the provision of iodized oil by mouth once in two years - especially important for pregnant women and young children to prevent cretinism.

- Iron deficiency is widespread throughout the world and is especially serious for pregnant women. A course of iron tablets daily throughout the second half of pregnancy can cost only 25 US cents.

Roger Moore, Special UNICEF Representative

"The actor Roger Moore, who played James Bond in some of the popular films, will become a special representative for the film arts for UNICEF. He will join such personalities as Sir Edmund Hillary, the conqueror of Mount Everest, and the Pakistani cricketer Imran Khan in helping to win support for the UN children's agency."

(Source: The International Herald Tribune, 9 August 1991)

A Breastfeeding Culture

A "massive shift to a breastfeeding culture" is called for by James Grant, UNICEF Executive Director. A global initiative called the World Alliance for Breastfeeding Action (WABA), aims to strengthen the efforts for breastfeeding promotion in line with the Innocenti Declaration on protection, promotion and support of breastfeeding (see SCN News No. 6 p. 33). Only 7 out of 90 countries have fully adopted the International Code of Marketing of Breast Milk Substitute, initiated by WHO and UNICEF in 1981, explains Grant. Meanwhile activities for marketing breast milk substitutes have been intensified. Organizations active in breastfeeding promotion such as La Leche League International, World Council of Churches, International Baby Food Action Network (IBFAN), International Lactation Consultant Association (ILCA), the International Organization of Consumers Union (IOCU) and the Inter-faith Centre for Corporate Responsibility (ICCR), are in the steering committee of WABA. Pat Young of ICCR remarks: "in the 1970s the cause was established, in the 1980s the Code was established, and in the 1990s compliance will be established".

(Source: Anwar Fazal. Development Forum, 19 (2), March-April 1991. For more information about WABA contact: WABA, c/o IOCU. PO Box 1045. 10830 Penang. Malaysia. Fax: +60-4-366506)

Baby Friendly Hospitals

Institutions that adopt and apply "Ten Steps to Successful Breastfeeding" (quoted in the SCN News, No. 4, p. 40), will be designated as "baby friendly" and will receive a plaque or other award of public recognition. This new initiative to promote breastfeeding through the creation of baby friendly hospitals has been launched by WHO and UNICEF at a meeting of the International Pediatric Association in Ankara, Turkey, on 28 June 1991, which endorsed the Innocenti Declaration (see SCN News No. 6, p. 33), with "Ankara Affirmation". The aim is to change hospital practices towards promoting, protecting and supporting breastfeeding.

The "baby friendly" concept has, according to UNICEF, already received support from numerous organizations, health professions, government ministers, as well as personal support of the Presidents of Finland, Mexico and Nigeria, and of the Surgeon-General of the USA.

Both the WHO World Health Assembly and the UNICEF Executive Board at their sessions in 1991 recommended that the Innocenti Declaration be used as the basis for their policies, specifically emphasizing the "ten steps". The resolution by the UNICEF Executive Board has also called upon "manufacturers and distributors of breast-milk substitutes to end free and low-cost supplies of infant formula to maternity wards and hospitals by December 1992, thereby reducing their detrimental effect on the initiation of breastfeeding". It also "encourages States to ensure the application at the national level of the International Code by integrating it, in particular, into their legislation". Mr Borasio. the President of the International Association of Infant Food Manufacturers has pledged full cooperation and confirmed in a letter to WHO and UNICEF that its members agree with the goals of ending donations or low- priced supplies of infant formula to maternity wards and hospitals.

(Sources: WHO Press Release/38, 4 July 1991: UNICEF Program Committee, 1991 session)

Iron Fortification

In June 1990. the ACC/SCN convened a workshop to consider how to make iron supplementation work on a large scale (see feature article in SCN News No. 6, p. 1). The recent ACC/SCN document on "Controlling Iron Deficiency" (ACC/SCN State of the Art Series, Nutrition Policy Discussion Paper No. 9) based on that workshop, sets out a framework for problem analysis and provides detailed guidance on effective iron supplementation. The need for complementary long-term approaches to iron deficiency control, namely food fortification, dietary modification and parasitic disease control was emphasized.

Effective food fortification, a long-term method of choice in many situations, requires long-term commitment, a bio-available but non-reactive iron source, and suitable vehicles or foods to be fortified. While "fortification does not necessarily substitute for supplementation, if it is effective in the long term, supplementation may be of less urgency and may become only very specifically targeted (i.e. only for 2-3 months during pregnancy). If fortification and supplementation are undertaken concurrently in an area, then iron deficiency anaemia prevalence may be reduced faster than is possible using supplementation alone, allowing the latter to be withdrawn once the problem has been sufficiently alleviated. Adequate monitoring of the impact of fortification is needed, which necessitates a consideration of the technical means for assessment and evaluation."

A next step was therefore to look again at iron fortification, which was done at a meeting convened by INACG at the end of 1990. This article is based on the draft report of that meeting.

The International Nutritional Anaemia Consultative Group (INACG) was established in 1976 by USAID to bring together scientists and practitioners from the United States, other countries, private industry, and the donor community in order to exchange information, develop plans and strategies and mobilize resources to address issues in iron deficiency. In December 1990, INACG held a workshop entitled "Combatting Iron Deficiency Anaemia through Food Fortification Technology", the objective being to produce an action plan for developing national iron fortification programmes through partnerships among industry, government, and donor groups. Current and experimental iron fortification systems were described and followed by discussion of issues such as safety, cost, marketing, and policy. The workshop involved multidiscip-linary working groups, charged with developing action plans for economically sustainable and effective iron fortification. In the process they were asked to define the appropriate role to be taken by industry (both national and multinational), donor agencies (multilateral, bilateral, and NGOs), and country leadership (at the level of ministries, state and provincial government, and community). The recommended action included the following.

· Countries having a high prevalence of iron deficiency should require the mandatory iron fortification of country-specific foods in order to achieve long-term and sustainable prevention of iron deficiency. This should be within the context of a broader anaemia control strategy requiring the commitment of political leaders. A national coordinating committee should be established to link the various sectors responsible for various aspects of food fortification.

· Leadership at the ministerial level (most likely the health sector) should be involved and recognize that consumer groups and public health activists serve an important role in obtaining political commitment and influencing donors and industry.

· Country capacity should be made adequate in areas of food fortification technology, regulatory and monitoring mechanisms, consumer research, and information dis-semination.

· Initial financial support may be sought from donor agencies, although the development of a fortification programme should eventually become financially self-sustaining.

Roles of different groups

To begin a national iron fortification programme, formation of a national coordinating committee was considered essential. This committee could consist of members from concerned ministries (most likely Health, Education, Industry), involved industry (national or multinational), relevant academic and technology groups (research, public health, food technology), public health consumer groups, and others with interest and expertise in public health issues, consumer education and marketing. This group would define the problem of implementing iron fortification in country-specific terms and propose a strategy to overcome impediments.

At national level, the political leadership needs to be convinced of the significance of iron deficiency anemia in their country; commitments at the ministerial level are needed to create the necessary policies to implement a programme; a national planning and coordinating committee should be set up to develop a country specific programme, and legislation initiated where necessary to establish it. At state, provincial and community level, the need for the programme should be recognized, its value promoted to the population affected, and implementation of the programme at the local level facilitated. Academic institutions can assist with the epidemiological and food consumption data needed to identify the appropriate fortification vehicle; technological development to provide an effective fortification vehicle; and the assessment and monitoring of effectiveness of the programme.

Donor and international agencies should promote awareness of the serious problem of iron deficiency anaemia to the governments of seriously affected countries, perhaps providing seed money to aid in initiating action where needed, expertise in developing and implementing programmes, and helping with information needed to obtain political commitment assisted.

Within industry, at national or multinational level, technical expertise should be provided in the development of appropriate products, including quality assurance. Local industry should be involved in preparing the specified product, maximizing use of local materials where feasible to minimize costs, maintaining an effective quality control programme, and assisting in promoting educational efforts aimed at the targeted population.

Awareness by the consumer of the serious adverse effects of iron deficiency anaemia can be a strong factor in obtaining political support for inducing and sustaining action at the government level.

Non-governmental organizations (NGOs) or PVOs can aid in developing local solutions, organizing local industry to provide a demonstration of the effect of an appropriate iron fortification programme at the village level. This, in turn, can result in a growing demand for solutions at a national level.

(Sources: Draft summary of the XII INACG Meeting, 5-7 December 1990; "Controlling Iron Deficiency", ACC/SCN Nutrition Policy Discussion Paper No. 8. The report of the meeting and additional information available from: INACG, The Nutrition Foundation Inc., 1126 16th St NW, Washington DC, 20036, USA. Fax: 202-659-3617 Phone: 202-659-9024)

Dietary Control of Chronic Musculoskeletal Diseases

The importance of healthy nutrition and diet in the prevention and control of chronic diseases was highlighted by Dr Hiroshi Nakajima, Director-General of WHO, in his opening address to the 4th Interscience World Conference on Inflammation, Antirheumatics, Analgesics and Immuno-modulators, co-sponsored by the World Health Organization, which took place from 15 to 18 April 1991 in Geneva.

Musculoskeletal diseases, consisting mainly of chronic rheumatic and arthritic disorders - of which inflammation of the joints is the prominent feature - include more than 100 specific disease entities. Chronic rheumatic diseases place a considerable social and economic burden on societies. These conditions are not only a health problem for developed countries, but as life expectancy increases in developing countries they are recognized as equally important health problems in these societies.

The WHO Director General stressed that "in dealing with chronic inflammatory and auto-immune disorders, attention should not be focused solely on drug treatment. Diet is one of the major factors linked to a wide range of diseases. Intense research activity is starting, for example, on some polyunsaturated fatty acids for the treatment of different inflammatory and auto-immune diseases, such as rheuma-toid arthritis, diabetes and psoriasis. The prospects are promising for the use of omega-3-polyunsaturated fatty acids - contained mainly in seafoods - in the prevention of coronary heart disease."

According to the WHO Director General this dietary approach broadens the perspective for the integrated prevention and control of a group of chronic diseases through modified nutrition. More research is nevertheless needed to explore the preventive and therapeutic potential of life-style modifications in relation to chronic inflammatory and auto-immune diseases.

Advances in immunology and molecular biology have enhanced our understanding of the basic pathological mechanisms, and progress in pharmacology and therapeutics helped us to reduce the pain and deprivation of those who suffer from these musculoskeletal diseases. Dr Naka-jima further emphasized that "equally important is that we investigate how to prevent these diseases, through care of our bodies and healthy nutrition and life-styles".

(Source: WHO Press Release, 19 April 1991

Diet and Colon Cancer

About 1.25 billion people in the world are estimated to obtain around 40% of their daily calorie consumption from fat. This level is three times as much fat per person as is consumed by the remaining 4 billion population of the globe (as cited by Alan Durning in the November-December 1990 edition of the World Watch). Most of this fat comes from eating large quantities of red meat in the daily diet, with, for example, per capita meat consumption in the former East Germany being over 70 times that of India. This high level of red meat consumption is suspected to be at least partially responsible for the high prevalence of several diseases known as the "diseases of affluence".

An extensive body of prospective data provides further evidence for a now rather old hypothesis that the incidence of colon cancer is associated with red meat consumption. What is more, these data, collected during a six-year follow-up study of a large sample of women, indicate that the carcinogenic effect of meat consumption is independent of the total amount of energy consumed.

Numerous epidemiological studies have shown an association between dietary factors - notably high intake of animal fat and low dietary fibre intake - with an increased incidence of colon cancer. For example, migration from an area where the incidence of colon cancer is low to a higher incidence area and adoption of new eating habits of that area have been considered to increase the individual risk of developing colon cancer. The significance of a new study (see Sources) lies in the fact that it is large, involving about 89,000 women, whose eating habits were studied before any diagnosis of colon cancer was made. Furthermore, the study design controls for the effect of total energy intake on the observed associations, an issue which made most previous studies rather inconclusive.

The strongest association was found with high consumption of beef, pork or lamb. The subjects consuming these as a main dish (over 100 g/day) showed 2.5 times higher risk for colon cancer development. Neither other sources of dietary fat (like butter, cheese, ice cream or vegetable oils) nor protein content of meat were significantly related to the risk of colon cancer. This implies that the responsible factors are fat in the meat or some other red meat component as yet unidentified. Furthermore and as might be expected, those women consuming the highest quantities of red meat together with the lowest energy-adjusted crude fibre intake showed the highest susceptibility to developing colon cancer.

The underlying mechanisms for the observed association are still unknown. Carcinogens resulting from the cooking of meat, increased bile acid secretion into the colon, or increased faecal concentration of endogenous nitrosamines from a high meat diet are postulated as possible related factors. Further research is undoubtedly needed to identify the involved mechanism(s) inducing colon cancer following meat consumption. Moreover, it is yet to be seen whether the same association also exists for male subjects.

(Source: Willet, W. et al., Relation of meat fat and fiber intake to the risk of colon cancer in a prospective study among women. New England Journal of Medicine, 323 (24): 1664-1672, 1990)

Risks of Deliberate Weight Loss?

Obesity as well as large involuntary weight loss both have adverse health outcomes. On the other hand, with high prevalence of dieting to lose weight, there are many who go through repeated episodes of weight loss and regain. It was, however, only in 1986 that experiments on rats called attention to the possible association between weight variability and later health outcomes. Since then other prospective studies have been conducted on the relation of weight fluctuation and health outcomes. Recently Brownell and his colleagues from Yale University have published the results of their analysis of weight fluctuations based on the data from 32 years of follow-up of 3130 subjects participating in the Framingham Heart Study in Massachusetts.

The pattern of weight cycling was established on the basis of variability in each subject's measured body-mass index (the weight in kg divided by the square of the height in meters) at the first eight biennial examinations during the study and on their recalled weight at 25 years of age. Data on total mortality, mortality from coronary heart disease, and morbidity due to coronary heart disease and cancer of this large sample were analysed in relation to the variations in body weight of each individual. To control for any effect of possible preexisting diseases causing weight changes, only those end-points occurring during a follow up period of at least 4 years after the last body weight measurements were used for analysis. The relative risk of each end point among the subjects whose weight were most variable was compared with those whose weights varied least.

The results indicate that mortality and morbidity risks from coronary heart disease are significantly higher in the subjects with greater fluctuation in body weight. Furthermore, weight fluctuation was found to be most strongly associated with adverse health outcomes in the youngest cohort aged 30 to 44 years. The study also found that the relative risk estimates for both total mortality and coronary heart disease endpoints tended to be higher for men than women

The risk was found to be comparable in magnitude to other known risk factors attributed to obesity itself, for total mortality, cardiovascular disease, and coronary heart disease. At least two major conclusions may be reached. First, the public health implications of current weight loss practices need to be further investigated. Second, the results reflect an adverse effect of voluntary weight loss when this is not maintained. Thus, it appears that it may not be a good idea for an overweight person to try to lose weight if the new lower weight is not kept and repeated cycles in body weight are experienced.

(Source: The New England Journal of Medicine, 324 (26), 1839-1844, 27 July 1991)

Cholera Outbreak Reappears

A major cholera epidemic starting in Peru earlier this year - with more than 177,000 people being affected throughout the country by mid-May - came as a surprise to many who considered cholera a disease of the past. The outbreak claiming 1300 lives in the Peru alone was but another example of the way in which health and wellbeing is affected by poor environmental conditions. In fact, serious outbreaks of fatal diseases were not unexpected by the health officials who witness appalling living conditions and deterioration of environmental health standards in poor neighbourhoods. The disease spread to 13 out of 25 Peruvian provinces and shortly reached nearby Ecuador, Colombia, Chile, and Brazil. By July 1991, over 250,000 cholera cases and 2500 deaths were reported by 8 countries in America.

By this time, reports from 10 African countries showed an alarming rise in cholera cases, sweeping through Africa at a catastrophic pace in some countries. Although the number of cases reported - over 45,000 - were lower than American region, the number of deaths were substantially higher (about 3500).

Cholera is a diarrhoeal disease caused by acute intestinal bacterial infection. It is transmitted mainly through contaminated food and water, usually in poor crowded communities where proper sanitation measures such as safe drinking water are inadequate. Without proper treatment it brings quick death to affected adults and children alike, although exclusively breastfed infants are rarely affected. About 80-90% of patients can usually be treated by oral rehydration therapy, while intravenous fluids might be necessary for those few who are severely dehydrated. During a cholera outbreak specific measures to avoid contamination through food consumption are to practise good food hygiene, cook food thoroughly and consume it immediately after cooking, avoid transfer of contamination from raw to cooked food, and consume only those vegetables which are peeled before eating.

"Even though this pandemic is entering its fourth decade, this new peak in cases and deaths reminds us again that once cholera attacks it is there to stay" says Dr Nakajima, Director General of WHO. "Death from cholera is all the more tragic because the disease is treatable and the conditions that spread cholera can be corrected" he adds. The rapid spread of cholera throughout Africa, and its persistence for more than 20 years, have challenged some concepts about disease transmission and shown the ineffectiveness of inappropriate measures used to prevent it. Dr Tulloch, Director of the WHO Division charged with control of diarrhoeal and acute respiratory diseases and coordinator of the WHO Task Force on Cholera Control is of the view that "the high rate of deaths from cholera in Africa is a reflection of the levels of poverty, mass migration and inadequate access to health care in some areas...in spite of progress in delivering ORT (oral rehydration therapy) over the past several years, the death rate in Africa is worsened by factors including lack of access to life saving ORS (oral rehydration salts), and delayed or incorrect management of cholera cases."

A Global Task Force on Cholera Control was created by WHO in April 1991 to accelerate activities to fight the disease. WHO is organizing a series of regional meetings to plan new actions against the disease. Emergency planning meetings will be held in Africa, the Eastern Mediterranean Region and the Americas in the second half of this year. The aim is to reinforce policies and guidelines, improve intercountry collaboration and surveillance, and expand direct support to individual countries, including provision of emergency supplies of ORS, education and information programmes, and training activities for health workers. It is now fully realized that without appropriate long-term preventive measures the underlying poverty and social stresses in poor countries will allow this and other similarly fatal diseases to reappear and to persist.

(Sources: WHO Press Release/39, 22 July 1991; Disaster Preparedness in the Americas, Issue No. 46, 1991; In Point of Fact, No. 73, WHO, April 1991)

Food Standards Conference

A Joint FAO/WHO Conference on "Food Standards, Chemicals in Food and Food Trade" was held - with GATT collaboration - in Rome, Italy, from 18 to 27 March 1991. The objectives of the conference, (see SCN News, No. 6), were to make Codex work on food standards more responsive to the current needs of governments; to review the achievements and efficacy of the Joint FAO/WHO expert committees on food additives and pesticide residues; to identify major problems in import/export control obstructing international trade in food and to suggest solutions. 360 participants at the level of senior administrators and technical experts, from 78 countries and 20 international organizations, attended. Some highlights of the major recommendations were as follows.

The Codex Alimentarius Commission (CAC) should review the Codex standards, from the standpoint of their current relevance and sound scientific basis, in view of the new international status which they would have under GATT proposals in the area of sanitary and phytosanitary regulations and measures, under the Uruguay round of Multilateral Trade Negotiations: in addition

· efforts should be made to simplify Codex standards as much as possible:

· procedures for acceptance of Codex standards should be reviewed, to increase acceptance rates;

· a review of Codex mechanisms should be undertaken to facilitate greater developing country participation in Codex;

· more should be done to increase consumer participation in decision-making, nationally and internationally;

· the activities of the Joint FAO/WHO Expert Committee on Food Additives should be enlarged to encompass novel foods and food ingredients and foods derived from biotechnology;

· FAO and WHO should increase technical assistance in food control to developing countries; training of inspectional, laboratory and managerial staff is a high priority;

· a series of recommendations were adopted aimed at helping developing countries to obtain information on import requirements, and in the area of information exchange.

World Food Prize Won by Nutritionist - Dr Nevin S. Scrimshaw

The World Food Prize is the foremost international award recognizing outstanding individual achievements in improving the quality, quantity or availability of food in the world. It is the largest prize given for accomplishments in food and agriculture. During its five-year history, however, those honoured excelled in the increasing production of food through improving agriculture. Awarding the 1991 World Food Prize - for the first time - to a physician and international nutrition expert, Dr N.S. Scrimshaw, was in fact an official acknowledgment of the contributions of nutrition and nutritionists in alleviating hunger and malnutrition in the world. Laureates of the World Food Prize receive a cash award of $200,000 and a sculpture by world-renowned designer Saul Bass.

Dr Scrimshaw's scientific integrity and moral qualities have placed him as a distinguished international nutritionist and one of the principal food and nutrition advisors to national and international organizations. In the nutrition world he has been well-known for his pioneering work leading to the landmark publication on interactions of nutrition and infection (Scrimshaw el al.. 1968). while at the same time he has contributed greatly and in numerous different ways in combating malnutrition and hunger. In 1949, Scrimshaw established the Institute of Nutrition of Central America and Panama (INCAP) and was its first director. His research there produced advances in the treatment of kwashiorkor and endemic goitre. A vegetable-based protein formula called Incaparina was devised using cotton-seed flour and maize, upon which several developing countries still rely heavily. In India, a similar baby food was developed using peanut flour and wheat and named Balahar. He encouraged other countries to develop their own protein-rich weaning foods using suitable and locally available ingredients. In the early 1950s, Scrimshaw and co-workers found an iodization method suitable for the crude bulk salt in Central America, where goitre was a serious public health problem. Today this method is used all over the world. In 1961. he moved to the Massachusetts Institute of Technology (MIT) in Cambridge to establish its Department of Nutrition and Food Science. His laboratory became a world centre for evaluating the nutritional value and safety of novel proteins for human consumption. Recognizing the vital role of the nutritionist in alleviating hunger and malnutrition, he has established numerous organizations and institutions to train young researchers from the third world countries.

Dr Scrimshaw currently works with United Nations University (UNU), where he organized the World Hunger Program, which established institutes of nutrition in Asia, the Near East and Latin America. He directed the UNU's Food, Nutrition and Development Program while serving as an adviser to numerous governments, universities, international agencies, and scientific organizations. He has recently been involved in studying the effects of chronic energy and iron deficiency, as well as promoting the application of anthropological methods to Rapid Assessment Procedures (RAP), for the improvement of nutrition and health related programmes.

He gave the following official statement on receiving the prize:

"I particularly appreciate the honor of receiving the World Food Prize, because this year it recognizes the contributions of nutritionists to the solution of the grave nutrition and food problems that continue to plague human kind - even where food production is adequate. It will encourage the efforts of nutritionists in all countries to overcome the terrible consequences of hunger for individuals and societies.

"Famines associated with war, civil disturbances and natural disasters are tragic and shameful. However, even more widespread, is the hidden hunger due to chronic energy and micronutrient deficiencies that afflict a majority of the population in most developing countries.

"Both famine and hidden hunger have disastrous consequences for human health, survival and welfare, and retard social and economic development. Improved food production and food aid are not enough. Modern hunger, whether hidden or overt, can only be overcome when, through multidisciplinary efforts, we change the political and social factors that are responsible".

(Source: The World Food Prize News, Des Moines, Iowa, 22 July 1991)

World Hunger Award Winners 1990

The Alan Shawn Feinstein World Hunger Program - named after its founder - was established at Brown University in 1984 to address the long-term persistence of hunger in the world through research, the development of unique resources, and through public recognition. The fifth annual Alan Shawn Feinstein World Hunger Award of US$25,000 was won by the People of Iringa region in Tanzania in recognition of their admirable efforts to improve the nutrition conditions of their children through community-based nutrition programme. Recipients of the other two US$10,000 awards were Patricia Young - national coordinator of the National Committee for World Food Day - receiving the Feinstein Public Service Award, and Professor Nevin S. Scrimshaw of the United Nations University who won the Feinstein Research and Education Award.

Iringa Nutrition Programme's success was mainly due to its grassroots organization, in which nutritional improvement was achieved through increasing the society's capacity to assess and analyse local problems for establishing appropriate actions. This community-centred programme, in which the people of Iringa participated actively, resulted in reduction of severe malnutrition by 60% and lowered the young child death rate by 30%. The programme was expanded from 168 villages originally selected to all 620 villages in the Iringa region. Similar models are planned to be implemented nationwide. (See feature article on Community-based Development earlier in this issue.)

Patricia Young of Scranton, Pa., and Washington, DC, a graduate of Indiana State University, has been a full time volunteer behind the educational and action-oriented efforts for the World Food Day in the United States each year. She created the US National Committee for World Food Day, a coalition now totaling more than 400 organizations and institutions. Working together, they energize nearly 14,000 volunteer organizers around the country to mobilize people to seek ways of ending hunger through cooperation and action. Beyond the community level, Young offered the leadership and guidance to educational institutions by setting up annual national teleconferences on hunger, seen on hundreds of university campuses and in elementary schools in more than 30 states. She drafted language which appeared in House and Senate versions of last year's farm bill, directing the President to submit to Congress each year on World Food Day an assessment of progress towards food security in each country receiving US food assistance. Because of her success on a national level, her advice has helped create a global movement of cooperating national World Food Day committees.

Through his 40 years of research, writing and teaching, Nevin S. Scrimshaw has directly contributed toward the reduction of hunger in developing countries. Dr Scrimshaw has received various other awards and honours in recognition of his scientific contributions, see previous article.

(Source: The Brown University News Bureau, 28 January 1991)

International Conference on Nutrition

The International Conference on Nutrition (ICN), co-sponsored by FAO and WHO, is set for December 1992, in Rome. This inter-governmental conference, involving all the UN member nations, will "provide the world community with an opportunity to look critically at the continuing problems of hunger, malnutrition and diet-related disease and how they can most effectively be addressed".

A progress report on preparations for the ICN is in "Programme News", under FAO/WHO.

Sixth Asian Congress of Nutrition

As announced previously (SCN News No. 5, p. 42), the Sixth Asian Congress of Nutrition was held in Kuala Lumpur, Malaysia, from 16 to 19 September 1991. The scientific programme of this Congress consisted of plenary lectures, symposia, free communications and poster sessions. Moreover, several pre and post-Congress workshops and conferences were coordinated to coincide with the Congress. The proceedings covering topics given below will be published by the organizers.

The following topics were covered in the plenary lectures: challenges and frontiers in nutrition in Asia (C. Gopalan, India); nutrition in transition: lessons from developed countries (M.L. Wahlqvist. Australia); human energy requirements (W.P.T. James, UK); nutrition and immunity: new insights and practical applications (R.K. Chandra, Canada); trace metals in health and disease (Yang Guan-Qi, China); nutrition intervention programmes: success and failure (K. Tontisirin, Thailand); modern techniques of amino acid production towards future nutritional needs (R. Tsugawa, Japan)

The symposia included the following topics: recent advances in nutrition research methodologies; maternal and child nutrition; nutrition and ageing; nutritional toxicology; nutrition and cancer; nutrition and cardiovascular disease; energy adaptation and obesity; iron deficiency and iron deficiency anaemia; nutrition in transition (changing dietary patterns); nutrition and diabetes; food and nutrition policies in national development; vitamin and minerals in health and disease; food industries and nutrition; sports nutrition; nutritional aspects of edible oils and fats; nutrient composition of foods in Asia; control and elimination of IDD; rapid assessment procedures for the evaluation and improvement of nutrition programmes; dietetics in Asia - the next decade; and effective nutrition communication for behavioural changes.

Information from: Dr A.Valyasevi, the United Nations University, Institute of Nutrition, Mahidol University. Nakornchaisri, Nakorn-pathom, 73170 Thailand. Telex: 84770 UNIMAHI TH.

Symposium on Clinical Nutrition

The Fourth International Symposium on Clinical Nutrition was held in Heidelberg, Germany - from 2 to 4 October 1991 - by the International Union of Nutritional Sciences (IUNS) and the Deutsche Gesellschaft fur Ernährung (DGE). The symposium aimed to highlight the increasingly recognized role that nutrition plays in both prevention and treatment of many diseases, and to review recent advances in the field. The main topics covered include: geriatric nutrition; non-nutrient components of food of clinical significance; food allergy and intolerances, nutrition and cancer; medical practice of nutrition in hospital; recent advances in parenteral nutrition; total parenteral nutrition in special diseases; and omega-3-fatty-acids.

Information from: Prof. Dr G. Schlierf. Klinisches Institut fur Herzinfarktforschung an der Medizinischen Universitatsklinik, Bergheimer Strasse 58. D-6900 Heidelberg. Tel: 06221/568640.

Workshop on Protein-Energy Interactions

The International Dietary Energy Consultative Group (IDECG - affiliated with ACC/SCN) held a meeting on 21 to 25 October, 1991 in Waterville Valley, New Hampshire, USA. The following issues were discussed and reviewed: the cellular basis of protein-energy interrelationships; effects of specific amino acids and amino acid composition of the protein source on protein-energy interactions in vivo; significance of the source and level of energy substrate intake on protein-energy interactions and thermogenesis; effects of different levels of energy intake on protein metabolism and of different levels of available protein intake on energy metabolism; growth and its effects on protein-energy interactions; effects of pregnancy and lactation on protein-energy interactions; effects of increased physical activity and energy expenditure on protein-energy interactions: impact of aging on protein-energy interactions; metabolic and nutritional interrelationships between energy and protein in sepsis, trauma, and major disease; effects of chronic degenerative diseases on protein and amino acid requirements relative to energy intake; effects of fasting and very low energy diets on metabolic relationships between energy and protein; effects of protein-energy interactions on immune function and response to disease; effects of intestinal functions on protein-energy interactions and nutritional needs; and protein-energy relationships: experience with parenteral nutrition. The proceedings will be published.

A workshop on "Effects of Maternal Nutrition Status and Energy Intake during Pregnancy on Birthweight", is tentatively planned for 1992, the date and location of which will be announced later by IDECG.

Information from: Dr B. Schurch, Executive Secretary of IDECG, c/o Nestle Foundation, PO Box 581, 1001 Lausanne, Switzerland.

(Source: IDECG Annual Report 1990)

IDD Elimination - Symposium in USSR

The elimination of IDD, especially in the USSR, is the topic of a forthcoming international symposium. The meeting is planned to be held in Tashkent from 18 to 22 November this year, hosted by the USSR and sponsored by the ICCIDD, WHO and UNICEF. The conference covers IDD effects, epidemiology and assessment as well as national control programme and interventions for their prevention and treatment. A roundtable is planned on problems in implementation of IDD control programmes in the Republics of the USSR.

Information from: Dr Basil Hetzel. Executive Director ICCIDD, PO Box 10041 Gouger Street, Adelaide. 5000 Australia. Fax: 61-08-232 4969.

Nutrition and Health in the Elderly

The First European Congress on Nutrition and Health in the Elderly is to be held in Noordwijkerhout, The Netherlands, from 5-7 December 1991. A study in Europe on Nutrition and Health in the Elderly forms the main topic of the scientific programme of the conference. This study -known as the SENECA project - A Euronut Concerted Action Programme - has been carried out, by a strictly standardized methodology, on some 2600 subjects born between 1913 and 1918 in 19 cities and towns across Europe. The congress will present the observed European patterns of dietary intake, nutritional status and life style including physical activity and social network. Other related topics of concern to elderly health and nutrition will also be discussed.

The congress will be organized by the Department of Human Nutrition of the Wageningen Agricultural University in the Netherlands on behalf of the participants of the EC Concerted Action on Nutrition and Health in the Elderly (SENECA Project) and the project Management Group of the Euronut Concerted Action on Nutrition and Health.

Information from: Ms R. Hoogkamer. Department of Human Nutrition, Wageningen Agricultural University, Bomenweg 2, 6703 HD Wageningen, the Netherlands. Tel: 31 0 8370-84214, Fax: 31 0 8370-83342.

2nd European Conference on Food and Nutrition Policy

To continue efforts to promote food and nutrition policy through multisectoral coordination and action, and following the 1st European Conference in Budapest, the 2nd European Conference on Food and Nutrition Policy is scheduled for 21-24 April 1992 to take place in the Netherlands Congress Centre, the Hague, the Netherlands.

The various areas of food and nutrition policy will be illustrated, together with discussions on the different types of measures of policy implementation. Identification of the nutritional issues in Europe, setting the objectives for change and selecting priorities, are among the issues to be covered in the plenary sessions. Speakers from various sectors will be invited to demonstrate how they can contribute to better health through sound food and nutrition policies.

The conference - with English as the official language - is open to a limited number of persons active in the field of food and nutrition policies, e.g. decision-makers, industry (marketing and development), consumers (representatives of national consumer bodies), government (ministries of Health and Agriculture), trade (leaders of retail companies, catering sector) and health educators. Registration fee is Dutch Guilders (Hfl)500 before 1 October 1991, and Hfl600 after that. Closing date for abstracts is 1 January 1992.

Information, and to register: Secretariat Food and Nutrition Policy, Flora de Vrijer, c/o TNO Nutrition and Food Research, PO Box 360, 3700 AJ Zeit, the Netherlands. Tel: +31 3404 44218; Fax: +31 3404 57224.

International Famine Workshop

A Meeting on "Dynamics of Social Groups Most Vulnerable to Famine" will be held as the Third International Famine Workshop of the International Geographical Union Study Group on Famine Research and Food Production Systems, at Tufts University, School of Nutrition, Medford, Massachusetts, from August 4-7, 1992. The symposium will consist of three days of professional presentations, plenary sessions, and panel discussions focusing on issues relating to groups potentially the most vulnerable to famine - the very old, very young, women, the poor, the landless. There will be a whole section on '"Human Needs, Wants and Rights", and a short course on "Overcoming Hunger in the 1990s: A new Geography of Hunger and its Alleviation", organized by the World Hunger Programme. A registration fee of US$350 will include symposium packet, accommodation, meals, coffee breaks and an opening reception.

Information from: Dr de Souza, Secretary General, 27th International Geographical Congress, 1145, 17th Street NW, Washington. DC 20036, USA.

Dietary Assessment Methods

The 1st International Conference on Dietary Assessment Methods is planned for September 20-23, 1992, in the Saint Paul Hotel, St Paul, Minnesota. The topics to be covered include recent advances in collecting dietary data; assessing diets of diverse populations; assessing diets of children and the elderly; assessing intake of specific food components; methodologic issues in the use of International Data Sets; and evaluating and interpreting dietary data. Abstract for research presentations will be accepted through 15 January, 1992.

Information: Department of Professional Development and Conference Services, 210 Nolte Center, 315 Pillsbury Drive SE, University of Minnesota, MN 55455-0139; 612/625-3451. Fax: 612/626-1632.

Degree in Applied Human Nutrition

As announced before (see SCN News No. 3, early 1989, p. 24, Programme News under Kenya), the Department of Food Technology and Nutrition of the University of Nairobi organizes a two-year full-time postgraduate programme leading to a Master of Science degree in Applied Human Nutrition. This is the only programme of its kind in the African continent serving mainly the Eastern Central and Southern Africa region. The forthcoming programme commencing in October 1993 consists of a year of course work followed by a year of individual research leading to a thesis. Candidates must already have an undergraduate degree with either an upper second class honours or its equivalent in natural science (e.g. biochemistry, agriculture, etc.), social science (e.g. anthropology, economics, etc.) or medical sciences from any recognized university. They should also have work experience of at least one year following their primary degree.

Information and application forms (which must be submitted by March 1993) from: Dr G.K. Maritim, Head, Applied Human Nutrition Programme, University of Nairobi, PO Box 41607, Nairobi, Kenya.

Off-campus Programs in Human Nutrition

The Deakin University in Australia offers Off Campus Programs in Human Nutrition (leading to Graduate Diploma of Human Nutrition: Graduate Diploma of Nutrition Education) which are available to students throughout the world by correspondence.

Study in the off-campus mode normally does not require attendance at the University. Study materials are posted to students and arrangements can be made to sit examinations at various centres throughout Australia and elsewhere. Graduate diplomas can be completed in a minimum of 2 years' and a maximum of five years' part-time study. For entry to these programmes, a university or college of advanced education degree or its equivalent is required. Enough chemistry and biology should have been undertaken at tertiary level to understand and work with nutritional concepts. Preference will be given to those applicants who are in a professional field where nutritional knowledge or skills are needed.

Information from: Mrs. [.H.E. Cole-Rutishauser, The Off-campus Coordinator. Department of Human Nutrition. Deakin University, Geelone. Victoria. Australia 3217. Tel: (052) 47 1547. Fax: (052) 41 1299.

"Nutrition in a Sustainable Environment" - IUNS 1993

The International Union of Nutritional Sciences (IUNS) will hold the XV International Congress of Nutrition in Adelaide. Australia from 26 September to 1 October, 1993, focusing on the nutrition and environmental issues. The congress themes will include: nutrition and environment; nutrition policies and programmes; prevention of chronic disease: nutrition through the life cycle; nutrition and nutritional anthropology of aboriginal peoples; molecular biology of essential nutrients; and nutrition and performance. The plenary lectures will be on the topics of food, nutrition and the environment - future directions in nutrition research: the impact of biotechnology of agriculture; matching nutrition knowledge to nutrition needs; preventing diseases of affluence in developing countries; and nutrition support, present and future. Each of the themes listed will be made up of several symposia, workshops and sessions spread over several days. There will be around 50 symposia and 50 workshops or sessions devoted to the forefronts of nutrition research. Free communications will be scheduled as posters, but all symposia and sessions and some workshops will include brief oral presentations selected from the delegates' abstracts.

Deadlines for Registration and Abstracts are March 1992 and September 1992 respectively. Early acceptance of Abstracts for those who need time to raise funds is December 1992. Other Abstracts by March 1993. The registration fee will be $500 Australian. It will include the cost of the proceedings of the Congress. Some support will be offered to speakers, chairpersons and hopefully also to a limited number of delegates who may need assistance.

Information from The Secretariat, XV International Congress of Nutrition. CSIRO Division of Human Nutrition. PO Box 10041. Gouger Street. Adelaide SA 5000. Australia.Tel: 61-8-224-1800: Fax: 61-8-224-1841.

World Conference for Women

The United Nations Commission on the Status of Women has recommended a World Conference in 1995 to review the progress made to improve the situation of women since the United Nations Decade for Women ended in 1985. The year 1995 will, thus. be an important year for women worldwide.

The Commission's goals aim at galvanizing national action to implement fully the Nairobi Forward-Looking Strategies, adopted in 1985. for the Advancement of Women. By 1995, pay equity policies should be implemented, and gender-biased textbooks should have been revised. Women, by 1995, should hold 30% of all significant decision-making posts in government, the private sector, professional associations and NGOs. These and other related goals represent a challenge from the United Nations Commission on the Status of Women to all governments and activists committed to gender equality. The efforts stem from the recognition that without such empowerment, women will consistently face discrimination in education, health care, nutrition, employment and political participation.

(Source: The United Nations Social Agenda, 4, 1990)

LETTERS

From Mrs J. Katona-Apte

I cannot resist commenting on the cover picture of the last issue of SCN News (No. 6, late 1990). While the photograph does. according to the text accompanying it, depict the "often fatal consequences of bottle feeding" and "the age-old bias in favour of the male", it also indicates that most societies, especially in the third world, do not necessarily consider bottle feeding more modern and thus better than breastfeeding. In Pakistan male children are much preferred over female ones. Therefore, when the mother-in-law recommended that her daughter-in-law breastfeed the male of the twin and bottle feed the female, the mother-in-law wanted to maximize the survival potential of the male offspring. This clearly suggests that the old woman knew that breastfed babies are at an advantage over those bottlefed!

Such knowledge has important implications for health education programmes and breastfeeding promotion. It is preferable to reinforce what is already known and accepted than to start from an incorrect premise that people in third world societies are ignorant of the health benefits of breastfeeding.

J. Katona-Apte.
Senior Programme Adviser,
Human Resources, WFP

********

From Dr Ramesh M. Shrestha

The feature article "Preventing Anaemia" published in SCN News No. 6 presents a brief summary of the current knowledge in prevention of anaemia. Many text books and journal articles deal normally with adult female population only. as it is done in the above mentioned SCN paper. I would like to request you to publish feature articles on anaemia in children in future issues of the SCN News. It is even difficult to find standards for comparison of haemoglobin in children. Few textbooks mention that children's haemoglobin (without specifying age group), living at sea level, ranges between 6 to 10 g% and increases as the child gets older! Aren't there studies specific for children? The problem of anaemia in children may not be as severe as in adult populations but information available in this field on children is very inadequate. I am interested in information on haemoglobin standards for children from birth to nine years of age.

Ramesh M. Shrestha
Programme Officer,
UNICEF- HANOI
PO Box 2-154
Bangkok, Thailand

Reply

Anaemia is, no doubt, an important problem for many children particularly in developing countries. The global anaemia prevalence has been estimated as 43% and 35% for young and school-age children respectively by DeMaeyer and Adiels-Tiegman in 1985. The same authors, however, reported estimates of anaemia prevalence as 51% and 38% for 0-5 and 6-14 year-old children in less-developed countries respectively. The corresponding prevalences for the same age group children in developed countries was reported as 10% and 12% respectively. These estimates were based on the proposed lower limits of normality of haemoglobin for different age groups by WHO in 1959. Suggested cut-off values for children 6 months to 6 years were 11 g%, and for 6-14 years 12 g%. Severe anaemia has been defined as Hb <9.5 g%. These cut-offs have been widely used by different investigators in defining the extent of anaemia present in their sample of children studied. DeMaeyer and Adiels-Tagman collected information on the prevalence of anaemia by age and sex categories, and by country. They included 146 studies published from 1960 to 1980 or later (up to 1984) in which data on haemoglobin in children were given. According to them "There appears to be a renewed interest for studies in young children.... children and women appear to have been studied more frequently than any other age or sex category. This is probably justified by the greater prevalence of anaemia in these two groups". Anaemia in school children is receiving more attention because of the potential of iron deficiency adversely affecting educability and learning abilities (see e.g. SCN News No. 5 feature article on "Food for Thought -Nutrition and School Performance", and "Malnutrition and Infection in the Classroom" by E. Pollit, 1990). A recent ACC/SCN document on "Controlling Iron Deficiency" published in February this year describes priority target groups for intervention as pregnant and lactating women; premature and low-birth-weight infants; pre-school children; school children; and adolescent girls. The document emphasizes that "infants are known to be specially susceptible to the development of iron deficiency, with the period of greatest vulnerability between 6 and 18 months of age".

There are despite the focus on adults, in the literature, quite a number of studies specific to children in which haemoglobin concentrations have been measured. For instance, in China over 170 million children aged 6 months to 7 years have been studied for estimating of anaemia prevalence (data summarized by the Institute of Nutrition and Food Hygiene, Chinese Academy of Sciences). Some of these references are available from the SCN in tabulated form. Also the Second Report on the World Nutrition Situation under preparation by the SCN will provide further information on this topic.

Mahshid Lotfi, ACC/SCN

NOTES

Demaeyer, E. and Adiels-Tegman, M. The prevalence of Anaemia in the world. World Health Statistics Quarterly, 38, 302-316 (1985). E. Pollit (1990) Malnutrition and Infection in the Classroom. UNESCO, Paris.

ACC/SCN (1987) First Report on the World Nutrition Situation. Geneva.

ACC/SCN (1991) Controlling Iron Deficiency, State-of-the-Art Series, Nutrition Policy Discussion paper No. 9.

*****

Editorial note The article on weaning foods by Mahshid Lotfi in SCN News No. 6 has provoked some interesting correspondence. We should recall that two different processes were discussed. First, fermentation of foods can be used primarily to reduce contamination with harmful bacteria; this has a supplementary advantage in somewhat reducing the viscosity hence bulk of the diet, thus increasing the energy density. Second, small amounts of preparations rich in amylases (enzymes that break down starch) can be added to porridges or gruels just before consumption -known as amylase rich flour (ARF) or power flour; this substantially reduces viscosity and bulk and increases energy density. There are two common ways in which amylases (as ARF) are obtained: at home from germinating whole grains then drying and grinding; or by obtaining bulk-prepared ARF, commercially or otherwise.

The correspondence here mostly refers to ARF - rapid reduction in viscosity of food just before consumption - and not much to reducing bacterial contamination.

From Dr Pieter Dijkhuizen

With much interest I have read the article in SCN News No. 6: "Weaning foods - New uses of traditional methods".

I fully agree with the analysis that low energy density and high contamination levels of many traditional weaning foods are major contributors to malnutrition among young children. Addressing these problems using the "traditional methods" of fermentation and mailing undoubtedly has potential from hygienic and nutritional points of view and certainly merits attention.

However, assuring that these promising traditional methods will not continue to slide into oblivion along with so many other potential solutions is the challenge we face. The crucial thing is to convince mothers to incorporate such proven methods into their daily weaning food preparation practices. This aspect I dearly missed in the article. Isn't the proof of the pudding in the eating?

The (Dutch) Royal Tropical Institute (RTI) has been involved with low-cost weaning foods since the 80s. Initially RTI's efforts stressed nutrition and food technology. More recently, the focus shifted to marketing: reaching mothers and caretakers of young children. This shift was based on the common knowledge that the nutrition education has limited success with introducing better weaning foods, while soft drink and cigarette "marketing" is able to change consumer habits dramatically. Why is this the case?

Our experiences in weaning food activities suggest that the reasons can be found in the following model. Changing weaning food practices requires the following five prerequisites:

1. Mothers (or caretakers) must be convinced of the importance of good weaning food practices.

2. The new weaning food must be affordable (two or three times the staple food price seems acceptable).

3. The improved weaning food must be easy to prepare (preferably easier than the traditional practice).

4. The improved weaning food must be continually available.

5. And last, but surely not least, the new weaning food requires a built-in incentive; it must have "status".

The impact of "modern" associations must not be underestimated. The 20th century doctrine of "progress" has left few communities in this world untouched. People everywhere are more than eager to accept innovations, whenever these are within their reach. The term "traditional methods" may well have a nostalgic appeal for scientists; mothers of young children may find it synonymous with drudgery. "Tradition" is certainly no guarantee for success. The failure of nutrition education campaigns to introduce multi-mixes as improved weaning foods at household level is easy to explain when applying the model. It is an excellent nutrition concept, but it increases workload (long cooking time) and does not compensate with increased appeal or status.

A similar situation appears to exist with respect to germination and mailing. Only the "power flour" trials by UNICEF in Tanzania met the nutritional and emotional expectations. Power flour came in pouches with maltase which required the flick of a finger to perform the magic change of the porridge. Unfortunately this approach was not economically feasible.

My conclusion is that the prospects are bleak for germination and mailing to enjoy widespread application at household level. More success can only be expected when the approaches accommodate the stated prerequisites, particularly the "status" aspect.

Though meritorious as discussed above, germination and mailing have other limitations. These methods are not entirely without bacteriological risk; cases of food poisoning have been reported. And although maltase certainly can increase energy density of porridges, protein quality or quantity are not correspondingly improved. Many traditional weaning porridges, particularly when based on tapioca, sago or maize, are protein deficient and require supplementation. Also the oil content of traditional porridges is much lower than recommended; germination and mailing do not improve this.

In response RTI has developed an approach to low-cost weaning food production which is based on a porridge flour composed of indigenous raw materials (cereals, legumes and oilseeds). The processing involves roasting and milling all ingredients. The result is a ready-made weaning food. It is safe, meets Codex standards (energy density around 1 kcal/ml) and needs only 5 minutes' cooking. It is a modern product in image, affordable and convenient, although based on traditional processing methods.

The RTI approach is suitable for community based activities in rural areas and for small-scale industries in (semi) urban areas. It is however, not suited for household level since equipment like roaster and mill are required.

At present projects using this approach are implemented in more than 10 countries. They operate either as community-based activities (e.g. Weanimix-project, UNICEF, Ghana) or as small-scale industries, ranging in output from 25 tons/year (PROSUR, Dominican Republic) to 750 tons/year (MUSALAC, Burundi). The latter project received last year WHO'S World Prize as an outstanding nutrition activity.

In the community-based activities mothers use their own raw materials to make their weaning food. Small-scale industries sell their product at about two times the cost of the local staple food. They operate as economically sustainable without requiring subsidy. At a next opportunity I will be glad to provide more details of these activities.

I would be grateful to hear how the methods of germination and mailing can be retained and made attractive for mothers in the rapidly changing societies of developing countries.

Dr Pieter Dijkhuizen
Weaning Food Section
Royal Tropical Institute
63 Mauritskade,
1092 AD Amsterdam The Netherlands

*****

We invited comments from Prof Gopaldas, in India, from her experience -

From Prof. (Dr) Tara Gopaldas

As we can see, the major concerns of Dr Dijkhuizen regarding the use of traditional methods such as fermentation/germination/malting in weaning foods of poor communities are these:

- Will mothers utilize the traditional food processing method on a regular basis in their weaning food preparation?

- Will such food processing methods satisfy the five criteria listed in his letter by Dr Dijkhuizen for changing weaning food practice?

- Do ARF/Power Flour have a plus over the successful roasted multimixes as propagated by RTI?

Many Asian and African cultures use fermentation and/or germination in their daily food preparation. A few examples are the curds and germinated pulses and grains of India; fermented tempeh and bean sprouts of SE Asia; the Sudanese Nasha; the Njera of Ethiopia; the Obusera of Uganda; etc. Almost all the above stated preparations are fed to the baby as well. They will not go into oblivion. However, Dr Dijkhuizen does have a point in voicing his concern as to whether low income mothers will prepare germinated cereal flours whether it be ARF or Power-flour, on a regular basis? In a study conducted by us in 1988 on the transfer of the "ARF Technology from Lab to Slum" in Baroda, we found that slum mothers had no difficulty in preparing ARF. However, only about a third continued to make ARF on a regular basis even though they were convinced of its benefit to their young child. The reasons stated were "long time required" (it takes about three days in all to prepare); difficulty in getting small quantities of germinated grains milled; and inability to keep the germinated grains out-of-reach of children. However, they said if some Women's Organization or manufacturer could sell the ARF packets at even 10 packets/Re., they would certainly buy. Affordable cost and easy availability were their main considerations - not status. In any case, why do we always insist on the mother having to make ARF or Power-Flour or weaning multi-mixes? Cannot the community, the entrepreneur, or the small-scale industry meet the demand? The proof of the pudding according to us is not whether mothers will make ARF/Power Flour regularly, but that infants/young toddlers (6-24 months) consistently consume much, much more of the energy-dense but low-bulk gruels whether it be in India, Tanzania or Ethiopia. The least appreciated yet most important operative word in the weaning food business for all of us should be high nutrient density with low-dietary bulk. To a harried low income mother, gratification comes with her being able to feed her baby happily and quickly and seeing him grow better as a result. Nutrition and nutritive values are in our minds, not hers. Maybe this is why the traditional nutrition education that all of us have been dishing out for decades has failed.

Do fermentation/germination satisfy the five prerequisites for changing weaning practices?

(i) Most mothers want their babies to consume as much breast milk for as long as possible. The same goes for the other foods she feeds her infant. Hence no mother would begrudge diverting a little more staple flour (whether it be tapioca or any other), pulse flour, oil/oilseed or sugar, if she could offer it to her baby in a form that he could readily accept, namely, one of low-dietary bulk. However nutrient-dense a weaning preparation may be, it would not serve much purpose unless the intended beneficiary ate it in the quantity required.

(ii) The preparation of ARF costs no more than the cost of the cereal grain it is made from. With imputed cost of labour and some fuel it may cost about twice the cost of the staple. In any case both ARF/Power Flour are required only as additives and hence their cost is negligible (a few US cents per child/month).

(iii) Germination/malting whether of small or large amounts is time consuming. This is its negative.

(iv) Our experience is that low income mothers are not good at or comfortable in cooperative efforts. Hence the best prospect for continual availability would be through the route of a cottage or commercial venture.

(v) We do not subscribe to the view that mothers want a weaning food of "status" or that they wish to be "modern". What low income mothers want is a weaning food or a weaning additive that will work and which will be readily available like sugar, salt, flour or chillies, and which can be bought at the corner shop.

We are amazed that so much confusion still exists over the specific roles of ARF/Power Flour vis a vis multi-mixes. Both are required. Neither would displace or supplant the other. In fact we urge manufacturers of weaning foods to incorporate the ARF/Power Flour technology in their multi-mix formulations. This would go a long way in improving the weaning food scenario. Or else the same manufacturers of multi-mixes could also produce ARF/Power Flour in packet or sachet form which could be offered to the mother to be added to the child's gruel/porridge at the time of preparation. Since germinated cereal flour (ARF or Power Flour) is a food, it would not attract the strict quality control stipulations of chemical additives.

A sub-study of Project Poshak in the Seventies demonstrated that infants (6-12 months) rarely consumed more than 7-11 g of Instant Corn Soya Milk (ICSM)/day. The same fate was repeated with our roasted indigenous multi-mixes made from cereal, pulse, oilseed and jaggery. The sad moral of the story is that no matter how nutritious a weaning multi-mix may be, unless it is in an appropriate low-bulk-form, it will not be consumed in the amount required. In short, all that nutrition goes waste.

We would request Dr Dijkhuizen to please let us have 5 kg lots of the weaning mixes used in the 10 countries he speaks of. We will be very happy to conduct viscosity trials for him with and without ARF.

How can we act together to improve the low-bulk characteristics of gruels at the household, community and large-scale feeding program levels?

The ARF/Power Flour technology is such an inexpensive and simple one that it can be applied with ease to any level stated above. For countries where germination is an established practice, trainers and implementors of supplementary feeding programs should be trained in the ARF/Power Flour technology. For example, if the Integrated Child Development Services (ICDS) Program of India adopts the ARF-Technology, over 10 million infants/toddlers (6-24 months) would benefit. In countries where "kimea flour" (germinated sorghum flour) or Power Flour is popular, a safe version of it should be widely popularized.

In countries where germination is not widely practised, Commercial Barley Malt (CBM) is an equally effective ARF. We have had very good results with donated foods such as Soya-Fortified-Bulgar Wheat (SFBW), CSM, the weaning food used in the Tamil Nadu Nutrition Development Program, etc. Experiments on viscosity reduction of child Weaning Foods such as Sarvottam Pittu of Nepal, Triposha of Sri Lanka, and the rice-based multi-mix of Thailand have been planned.

Extruded foods are being widely used in feeding programs. We would urge that manufacturers incorporate the ARF/Power Flour Technology. The viscosity reduction of extruded food coated with amylase was demonstrated a long time ago by Jansen el al. (1981). It has again been validated by Alvina et al. (1990).

We have a ready-to-go-technology for the improvement of Weaning Foods in ARF/Power Flour; it is for agencies like WFP, CARE, USDA etc. to use it in their supplementary feeding programs. We would make a final plea that all of us who are committed to the improvement of weaning foods and to the eradication of PEM, come together in this effort.

Prof. (Dr) Tara Gopaldas
The Faculty of Home Science
MS University of Baroda
Baroda 390 002
India

References

Jansen, G.R., O'Deen, L., Tribelhorn, R.E. and Harper, J.M. The calorie densities of gruels made from extruded corn soya blends. UNU Food and Nutrition Bulletin 13(1): 39. 1981

Alvina, M. et al. Ecology of Food and Nutrition. 24, 189-193. 1990

"The poor are getting poorer, but with the rich getting richer it all averages out in the long run."