Letter to the Editor (on the same topic), The Lancet, Vol.351, June 13, 1998, p.1812.
To the Editor,
The authors of this letter represent three different continents (Latin America, Asia and North America) and both the medical and social science disciplines, but have come to similar conclusions about the state of international nutrition and specifically the relative balance of attention given to solving the problems of micronutrient deficiencies and those of protein-energy malnutrition.
Before 1980, most nutrition attention in developing countries focused on PEM. The culmination of this attention was the era of multisectoral nutrition planning in the 1970s when we not only took PEM seriously, but understood the importance of working with a range of development sectors to address the problem. In retrospect, those of us pursuing multisectoral planning met with disappointment, partly because of the mainly “nutriocentric” lens through which we viewed development, and partly because at least some of us failed to pay adequate attention to the underlying socioeconomic and political determinants of malnutrition.
The reaction of a large portion of the nutrition community was to pull strongly in the opposite direction, one which has been labelled “nutrition isolationism”. (If we will not be taken seriously by other development sectors, we will ignore them, and pursue nutrition interventions we can carry out and control largely on our own). And indeed there were attractive candidates. New understandings of the consequences of micronutrient deficiencies, particularly vitamin A and iodine, and improved technologies and logistics for delivering micronutrients (massive dose supplements and fortification) made possible significant and attractive achievements within relatively short periods of time.
Accordingly, many of us have pursued these micronutrient interventions, in some cases with remarkable success, and can take some pride in these accomplishments. Nothing in this letter should suggest any reduction in efforts directed toward micronutrient malnutrition. We remain their staunch advocates. At the same time, it is clear that we have, all too often, neglected the overriding problems of inadequate caloric intake and its determinants which are continuing to take such an enormous toll on vulnerable population groups.
We know considerably more today about addressing PEM through the combined efforts of food security, nutritional care of women and children and public health interventions than we did 20 years ago. But the attention of the nutrition community and the resources of donors nowadays often are more attracted by the glamour of micronutrients, a largely technical and often top-down solution (as close to a “quick fix” magic bullet as we are likely to get in this field), than by the messier and often politically sensitive business of poverty alleviation, people’s empowerment, and equity necessary to assure that mothers and children have access to needed services – and adequate food to eat.
In India, micronutrient deficiencies are significant and deserving of serious attention. At the same time, however, the poorest three deciles of the population consume only 1681 adult equivalent calories per day, while 78% of Indian children suffer from undernutrition.
Both sets of problems are wholly unacceptable, but they need to be kept in proper perspective.
At a recent meeting of African nutrition experts, representatives of one country with disturbingly high rates of moderate and severe malnutrition listed 16 nutrition research “priorities,” 13 of which were micronutrient related. This may not be surprising given the orientation of donor assistance and the appeal of journal articles. But the list hardly reflects the most urgent nutrition needs of African countries.
All too often, indeed, governments and donors have concluded that they can “check off” their concern and attention to nutrition by launching a micronutrient or an isolated breastfeeding project, and ignore entirely the challenges of PEM so seriously affecting the ultimate welfare of women and children, as well as longer term development processes.
The challenge that we face, as we move forward into the next century is not only to maintain our momentum in pursuing micronutrient interventions, which clearly are reducing suffering and saving lives, but also to redress the imbalance, and the relative neglect of the problems of PEM and food insecurity which often require a very different set of interventions. Our hope in the years to come is that the technical skills and partnerships which have driven salt iodization and vitamin A and iron supplementation programs can be coupled with the political acumen which has sparked successful social mobilization movements to bring about the significant reductions in global undernutrition we all desire.
Claudio Schuftan,
M.D. V. Ramalingaswami,
M.D. F. James Levinson, Ph.D.
Saigon, Vietnam
New Delhi India
Cambridge USA
reprints from: schuftan@gmail.com