World Bank Document · 2016-07-15 · HE WORLD BANK INTERNATIONAL FINANCE CORPORATION OFFICE MEMORANDUM ... review of nutrition policy and programs of the 1980s, ... A feeding …

HE WORLD BANK INTERNATIONAL FINANCE CORPORATION

OFFICE MEMORANDUM DATE: February 2, 1990

TO: All PHR Divisions

FROM: Alan Berg ~b EXTENSION: 33433

SUBJECT: New and Noteworthy in Nutrition (No. 8)

1. The top news in international nutrition this issue is the dramatic new evidence about the effect of vitamin A on morbidity and mortality (see page 10). Also, Brazil's new president announced a major (2 percent of GDP) targeted nutrition program (see page 9). A~d, UNICEF is about to unveil its new strategy which will highlight nutrition for the 1990s, with the same emphasis given to immunization and oral rehydration in the '80s (see page 13). This issue is organized as follows:

Operations Page 1 Nutrition in the News Page 9 New Twists in Project Design 4 Science and Technology: Insights in Bank Reports 4 What Has Been Learned 10 Nutrition at the PHR Retreat 5 More on the Income-Nutrient Thalwitz's Nutrition Intake Relationship 11

Brainstorming 6 New Publications 11 Nutrition for Non-Nutritionists 7 Seminar and Speech Highlights 12 Nutrition and Education 8 People 12 Nutrition and Agriculture 9 Other Agencies 13

Food Update 13

Operations

2. Asia: Project preparation begins this week in Dhaka for a first Bank-assisted Bangladesh nutrition project. A reconnaissance mission in late November (in collaboration with UNICEF) found project interest that cut across several ministries. Focal point for the preparation will be the Planning Commission. The Government also intends now to include for the first time a nutrition chapter in the upcoming five year plan; Bank consultant Asok Mitra, former secretary of India's Planning Commission, has been helping the Planning Commission in this effort. (Project under Martin Karcher, ASlPH, assisted by Paula Valad; handling the work on the scene is Philip Gowers of the resident mission and consultant Jim Levinson.)

3. In Sri Lanka, a community based pilot operation patterned after the Tamil Nadu Integrated Nutrition Project is now under way. It is financed under an existing Health and Family Planning Project, but will be broadened under a new project, as experience unfolds. This approach was recommended in the 1989 Sri Lanka Nutrition Review. Former President of Sri Lanka Jayewardene personally initiated the request to the Bank for a nutrition project. (Task manager: Jim Greene, ASTPH.)

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4. The appraisal mission currently is in the field for India Nutrition II. Meanwhile, preparation for Nutrition III also is well advanced. The UN ACC Sub-Committee on Nutrition (SCN), in its current review of nutrition policy and programs of the 1980s, states that Nutrition I "is now widely held as a state-of-the-art free-standing program with a markedly positive nutritional impact on the young children targeted." (Task manager: Jim Greene, ASTPH, with Richard Heaver, AS4PW/New Delhi.)

5. Africa: The Tanzania Health and Nutrition Project (described in the November 2 New & Noteworthy), originally scheduled for Board presentation at the end of May, is ahead of schedule and will be brought forward to a March presentation. Negotiations were successfully completed last week. (Task manager: John Innes, AF6PH.)

6. The first nutrition component in a Women I~ Development project has been appraised in The Gambia. A feeding program, implemented by community management committees and providing locally-grown foods donated by the communities themselves, will serve children under three and pregnant and breastfeeding women. It builds on earlier work by two NGOs (Save the Children Foundation and Catholic Relief Services) and extensive nutrition research undertaken in The Gambia by the British Medical Research Council's nutrition unit in Keneba. (Task manager: Florent Agueh, assisted by Bruna Vitagliano, AFSPH.)

7. Part of the policy framework paper being negotiated now between the Government of Mozambique, the Bank, and the IMF calls for the elimination of a consumer subsidy on wheat and introduction of one 'On yellow maize. Because of its lower perceived value than white maize, the subsidized yellow maize would selectively benefit the neediest. An income transfer program for the nutritionally needy also is being negotiated. (These actions reflect the nutrition analysis of the Bank's Food Security Mission, headed last year by Jane Armitage, AF6CO and Neeta Sirur, AF6PH.)

8. A hybrid lending operation (consisting of a policy component, supporting quick disbursements·linked to macro economic policy reform, and an investment component) can be found in the Zaire Social Sector Adjustment Credit which will be negotiated mid-March. A nutrition and food security policy will be prepared to address the conditions contributing to malnutrition. The Center for Human Nutrition Planning will be coordinator, as well as the Secretariat for a new national nutrition and food security committee organized under the adjustment program. The investment component (totaling about $7 million) includes a national Iodine Deficiency Control Program (Zaire has one of the highest rates of iodine deficiency in Africa -- at least 6 million people are at risk), a community-based nutrition program for villages, and a child feeding program designed to move from the current effort using food aid to one based on locally-produced foods provided through community participation. (Task manager: Jacques Baudouy, AF3PH, and E.J.R. Heyward, consultant.)

9. In an uncommonly bold action, the Bank terminated its support at the end of the year to Madagascar's Popular Canteen Program, one of the

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nutrition actions under way as part of the PASAGE Social Sector Action Project. Although it was being run efficiently, the Canteen activity was not serving the poorest segment of the population. This was one of several useful lessons learned from the modest-scaled PASAGE activities that were designed as pilots for the full-fledged project dealing with nutrition issues, now under preparation. (Task manager: Qaiser Khan, AF3PH.)

10. Two new African projects have taken seriously the recently expressed notion that maternal nutrition can be improved just as much by reducing caloric expenditure, as by increasing caloric intake. In both the upcoming Malawi Health and Nutrition and the Cameroon Food Security Projects, components are being considered to reduce the very considerable energy expenditure by the poorest women. In the Malawi project, for instance, hand-operated maize processing mills (requiring 20 minutes of work per day) will be introduced to calorie-deficient village women who now spend a full day each week hand-pounding the maize. (Besides saving energy, the women will save time as well, which might be put to other uses, including child care, and will be less likely to have low birthweight babies and all the risks this implies.) (Malawi Task manager: Nwanganga Shields, AF6PH, with Jim Levinson, consultant; Cameroon: Minh Chau Nguyen and Yasmin Saadat, AFlAG.)

11. In Nigeria, the Budgetary and Financial Policy Project, being appraised this month, includes specification that the Government undertake a food and nutrition strategy. A Bank mission late in 1989 helped lay the groundwork for a separate project flowing from the strategy. (see para 17).

12. EMENA: A study of the nutrition implications of adjustment has been completed in ~. in conjunction with an upcoming Structural Adjustment Loan. The report found that, while the ration system has been successful in improving and protecting nutrition of the poor, it has entailed large and costly leakages to the non-nutritionally needy. Opportunities for targeting -- protecting the poor, but lowering overall costs -- are evident. (Task manager: Jamil Salimi, EM3PH, with Eileen Kennedy, consultant.)

13. LAC: Whatever happened to the three unexpected, unsolicited requests for Bank-assisted nutrition projects in Latin America? The Colombia Child Development and Nutrition Project will be presented to the Board on March 27; appraisal for the Venezuela Social Development and Nutrition Project also will be in late March; and a mission is scheduled to visit Argentina later this month, in response to the new Government administration's request for a nutrition project there.

14. The Bolivia Social Investment Fund Project, scheduled for the Board in March, includes "nutrition support programs for infants and lactating mothers and for children of nursery and primary school age."

15. LAC's first sub-regional nutrition meeting will be held in Guatemala, April 2-6, hosted by the Institute of Nutrition for Central America and Panama (INCAP). Attending will be officials from the poorer LAC countries, with inadequate resources to run nutrition programs, plus

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other donors. The meeting will concentrate on ways countries can improve targeting methods to make programs more cost-effective and can secure needed external funds. The second regional meeting, for middle­income LAC countries, will be held in Brasilia in June. (Contact: Bill McGreevey, LA2HR.)

New Twists in Project Design

16. Being considered for an upcoming Bank-assisted nutrition operation in Madagascar is the novel concept of a food bank. During bad months, the needy would obtain food on credit and pay back at harvest, either in cash or in kind, with a small surcharge for the service. Warehouses are already available, and consideration is being given to mobilizing their staffs for this purpose. For this and other imaginative approaches, Food Security and Nutrition in Madagascar (by Qaiser Khan and Edmond de Gai~fier, under Alain Colliou, AF3PH) is recommended reading.

17. Among the innovative ideas of the recent Food and Nutrition Strategy Mission to Nigeria (see para 11) is a Food and Nutrition Fund, as a means of decentralizing nutrition interest to the state level. The federal government would initially make an outright grant to the proposed fund, to which the state would be required gradually to contribute if it wants to participate in targeted food and nutrition programs. Each participating state would decide which of a set of pre­established programs it likes and is able to implement. (Task managers: Rashid Faruquee, AF4AG, and V. Srinivasan, AF4PH.)

18. A new type of targeted audience: To reach the need at the critical time, India Nutrition II will provide iodine injections in the poorest, endemic areas to all women of child-bearing age who have not yet completed their families. (Jim Greene, ASTPH.)

Insights in Bank Reports

19. The value of the Survey of Living Conditions in the on-going Social Sectors Development Project in Jamaica was again seen in the recent preliminary report, distributed only two months after the survey was completed. Among other findings: only a fraction of the malnourished children under the public health clinic system receive food stamps. The SLC discovered that the program failure probably stems from program regulations. Registration for the program is only possible at a primary care health facility through a food stamp officer, and a birth certificate must be shown. In fact, the primary level of the health care system is frequenty by-passed, food stamp officers ar.e present at the clinics only on a limited number of days, and birth certificates often do not exist or are not available.

20. The most recent preparation mission for the Malawi Health and Nutrition Project reported that during a recent national debate over the minimum wage, the Government's Food Security and Nutrition Unit was able to present graphically the number of days that a "minimum wage family" would have to work just to purchase a 90 kg. bag of maize. This proved central in the Government's decision to raise the wage, with almost certain nutrition benefit.

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21. The term "food security" apparently is rubbing some countries in an unintended way. Kenyan officials, for instance, take objection to their country being considered "food insecure." Apparently "security" there also has overtones to some of "national security." So the excellent study, going into green cover next week, now bears the title, Food and Nutrition Policy Sector Study. Similarly, some of the Nigerian officials with whom the Bank's recent mission met are reluctant to admit their country is food insecure, but are willing to talk about nutrition.

22. SDA's "Prevalence and Determinants of Malnutrition in Cote d' Ivoire", by consultant David Sahn, supports the general contention that malnutrition is a problem of poverty but, "this being said, waiting for economic growth to reduce malnutrition likely represents an unacceptably long time horizon." Even though malnutrition is low in Cote d' Ivoire compared with ~ub-Saharan African nations, 16 percent stunting and 7 percent wasting call for "immediate targeted action," he says, and "this, of course, requires expanding institutional capacity to plan projects and deliver services, a costly challenge in its own right."

Nutrition at the PHR Retreat

23. Ann Hamilton, in her introductory remarks to the January 8-9 Retreat at Yestfields, noted that "we've probably made more progress in the last two years in nutrition than we had in the previous ten. Lots of lending and lots of innovation. The Bank has emerged as the leading donor in the field." Later, in the Nutrition and Food Security workshop, she noted that the growth of nutrition in the Bank came about without a 'special emphasis' designation or "treating the sector like a basket case, which denigrates the subject."

24. In his plenary discussion of "PHN strategy for the '90s," Tony Measham announced a new initiative by his PHRHN division in micronutrients. The technologies are there, he said, "all that is lacking is international commitment and resources to deliver the available technologies." (See paragraphs 42-43.)

25. Chair of the two Nutrition and Food Security sessions, David de Ferranti, AF6PH, spoke of the demand for nutrition operations. "Nutrition is breaking out all over," he said. "But it's not because I am telling people in our division that they should stress nutrition. They are just listening in the countries."

26. Raised at both sessions was the question: Isn't nutrition just an income issue? The panel's response was that, clearly, better off people are more likely to be better nourished. But--- (see paragraph 28). Another question: Don't nutrition operations depend on a strong health system being in place? Certain nutrition interventions do not rely on health services -- for instance, micronutrient fortification, targeted food subsidies, and behavioral change efforts through mass media. The main thrusts of most success stories in nutrition-- Iringa (Tanzania), Dominican Republic, Tamil Nadu, for example -- all have bypassed the health system. Bank projects in nutrition have been linked to Ministries of Commerce, Agriculture, Social Welfare, Local Government

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and Planning, as well as Health. Moreover, in some instances nutrition operations have been the opening wedge for building a primary health care program (Indonesia) or were used to strengthen a fragile primary health care system (Colombia).

Thalwitz's Nutrition Brainstorming

27. The week after the PHR retreat, new PRE Senior Vice President Yilfried Thalwitz invited a group for a fruitful brainstorming session on nutrition -- the main purpose, he said, to better acquaint himself with the issues, goals, and priorities. In addition to PRE staff, the perspective from Operations was presented by David de Ferranti (Africa), Bill McGreevey (LAC), and Richard Skolnik (Asia). Much of the nearly two-hour discussion centered on replicable ways to address malnutrition without adding measurably to the burden of public spending. Nutrition pro1ects are appropriate, Mr. Thalwitz agreed, when they help to reallocate resources away from generalized subsidies and other costly, ineffective programs to targeted cost-efficient programs with a greater impact on nutrition. It was pointed out that interventions like Tamil Nadu become less costly over time because beneficiaries learn how to improve nutrition themselves and no longer require public feeding. Moreover, such programs have a high payoff in increased productivity and in greater returns to health, education, and population investments.

28. The group went on to consider the malnutrition-income issue, in response to Mr. Thalwitz's description of growth as a healer. It was pointed out that increased income may not be reflected in improved nutrition at the household level because, for example, the added income may be used for other kinds of consumption (or investment), poor health condition may negate the benefits of added food, women's time might be too constrained, or household food practices might be too ingrained. The nature, source, frequency, and family earner of the income all influence the extent to which the increased income translates to better nutrition. Also noted was, _first, the unacceptably long time it would take in many countries for income growth to meet nutrition needs and, second, the powerful evidence from Bank projects that, even when there is no increase in income, nutrition can be improved through better use of existing resources.

29. The group also discussed free-standing nutrition projects versus integrating nutrition in other sectoral projects. The view from Operations was that nutrition components in health, education, and agriculture projects were effective when they arose naturally, not as a result of forced association. In the case of the latter, added nutrition components have often commanded too little attention from governments or from Bank staff (in supervision) to make much of a difference. Nor are projects in other sectors (health being the main exception) necessarily located in the geographic areas or directed at the particular groups in which nutrition problems are greatest. Meanwhile, Operations staff noted there is increasing demand for nutrition projects as such. Experience has shown that free-standing nutrition projects focus attention on the problem and can harness political commitment to develop national policies, plans, and programs. In fact, from the Bank's perspective, a free-standing project can be an

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important means of raising issues; a health or population project is a poor vehicle for examining food distribution policy or raising nutrition-related agricultural issues. We all agreed that local circumstances dictate the optimum operational approach to nutrition.

Nutrition for Non-Nutritionists

30. Two additional sessions of the successful "Nutrition for Non­Nutritionists" course are being planned for FY91. The first rendition of this training, organized at the request of Operations Senior Vice President Moeen Qureshi, was held at the Wye Plantation for three days shortly before Christmas. Nearly twice as many staff applied as could be accommodated. Commissioned for the course were case studies of successful nutrition programs in Tamil Nadu, Tanzania, Bolivia, Dominican Republic, Zimbabwe, Philippines, Pakistan, Bolivia and Jamaica. (These are available, upon request, from organizer Judy McGuire, ext. 33452.) She also brought together as lecturers several of the top figures in international nutrition. A number of interesting insights came up in the informal discussions:

o Primary health care centers are as good at g~v~ng out foods as grocery stores are at giving immunizations. (Food stamps through health centers, though, are okay.)

o There is danger of targeting a nutrition program so tightly that you can eliminate political support. In Colombia, the "success" in targeting a food stamp program (in which the Bank's Nutrition-! was involved) meant losing political constituency for the program. By contrast, one of the reasons for Tamil Nadu's success was that, in one form or another, most families had a stake in it.

o In countries where it is politically difficult to talk about income re-distribution, it sometimes is easier to talk in terms of addressing malnutrition.

o Severely anemic women have four-to-five times the risk of maternal mortality as non-anemic women, primarily because of hemorrhaging. Also on anemia: For every 10 percent decline in hemoglobin, a 20 percent decline can be anticipated in work output.

o Are genetic differences responsible for what we call malnutrition? Genetically similar children from high income families in poor countries grow at the same curve as children from rich countries.

o In pushing new employment opportunities under WID, the potential negative nutrition effects on childcare must be taken into account.

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Nutrition and Education

31. Recognizing the consequences to school performance, the Education Sector Adjustment Project in Ghana has added a program to deworm 1.5 million school children. Intestinal parasites are present in the large majority of students, which worsens their already malnourished condition. The twice-a-year distribution of piperazine will be combined with a hygiene/nutrition education program aimed at changing practices conducive to the parasites. (Developed by Nicholas Bennett AF4PH, Ghana resident mission.) A similar effort is being planned by him for Nigeria.)

32. BRAC, the well-regarded NGO in Bangladesh that will have a main role in the upcoming primary education project there, has an unusual nutrition project under way in the J,SOO schools in its primary school program. Students -- even young students, eight years old -- learn to do nutrition surveys. They are taught to.take arm circumference measures of preschool children in their village; this intended to expose them to a bit of social science, and, more important, make them conscious of malnutrition.

33. A nutrition and educability team, headed by UNESCO, visited Zimbabwe late last year to start developing a program to improve primary school performance through nutrition intervention. . The main lesson was the need to get the Ministries of Health and Education to work together if the program is to succeed. Several options have been laid out and a follow-up mission is scheduled for next month. (A report available from me for those interested.)

34. "Nutrition and School Performance" is the theme next week in Paris of the annual nutrition symposium of the UN ACC Sub-Committee on Nutrition. One of the papers, on economic and planning issues related to the topic, will be presented by Dean Jamison, former PHRHN Division Chief. Others will summarize the research evidence and program experience. (Highlights will be noted in next quarter's New and Noteworthy memo.)

35. If you have not yet seen it, you may want to get hold of Ann Hamilton's November 14 memo on "Teachability of Children." This makes the case for including nutrition in primary education projects as a means of improving school performance.

36. The benefit of mothers' schooling to their children's nutrition status generally is recognized (albeit the Bank's Indonesia Nutrition I project demonstrated conclusively that lack of education does not prevent women from improving child feeding behavior and improving their children's nutrition -- if the women receive highly specific messages, appropriately tailored and delivered). Now, in a recent issue of the Journal of Human Resources, Jere Behrman and Barbara Wolfe ask whether more schooling makes women themselves better nourished and healthier. The conclusion: a resounding yes. In the recent Bank study on the Cote d'Ivoire (see para 22), a difference also was noted between the

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relationship of women's and men's schooling to a child's nutrition status, with women's being more positive.

Nutrition and Agriculture

37. Ministries of agriculture usually get brought into nutrition kicking and screaming, if at all. By contrast, in Bangladesh the Ministry of Agriculture and the member for the Planning Commission responsible for agriculture are taking leadership roles in nutrition. With improved nutrition as the goal, one of the three agricultural objectives of the upcoming fourth five-year plan will be to obtain a significant, positive rate of growth for minor crops. The reason: with the emphasis on foodgrains in Bangladesh, there has been a marked decline in the availability of vegetables and other foods. Pulses, for example, have declined over two percent a year in the 1980s. A recent agricultural policy study found that, as Bangladesh gets very close to any of several definitions of foodgrain self-sufficiency, it must begin talking more seriously of diversification. Bangladesh research shows that minor crops are not only as profitable as high-yielding varieties of foodgrains but, with regular agricultural inputs, can be more profitable -- three or four times, in some cases.

Nutrition in the News

38. Brazil: New President Fernando Collor de Mello, in one of his first post-election pronouncements, announced that two percent of the GDP (about US$7 billion) will go for targeted nutrition programs. (According to a December seminar in Brazil, aftended by Bill McGreevey, LA2HR, only one in five malnourished Brazilian children now receives food support.) What could be helpful groundwork for this has been laid from nutrition targeting techniques developed as part of the Bank­assisted Brazil Nutrition Project, which ended in 1983.

39. Eastern Europe -- Romanian Nutrition Debacle: Of all the strange events that were uncovered to the world after the fall of Romanian dictator Nicolae Ceausescu, one of the most shocking was his "scientific nutrition program." To pay off Romania's $20 billion foreign debt, Ceausescu exported vast quantities of food, and to achieve this he limited Romanians to ration levels well below accepted international requirements -- along with exhortations that such a diet was better for them. The result: three million malnourished. Reuters reported "fresh fruit and good vegetables became a distant memory. A whole generation of children never saw certain fruits and vegetables." Mic+onutrient diseases, such as rickets which is rarely seen elsewhere anymore, were common. Ceausescu kept the nutrition scheme going, even after the debt was cleared. The country's chief nutritionist said "future generations would be affected by the nutrition policies of the late dictator."

40. Hungary -- Ulterior Motives in Nutrition: As would be expected, most (but not all) problems of malnutrition in Hungary are those of overnutrition rather than undernutrition. What was not expected by a staff member who was there in November is that the Government's consumer food subsidy system contributes to bad diets. Meats are subsidized and cheap and are consumed in enormous quantities. Most fruits, vegetables,

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and fish are not subsidized; they are expensive and consumed rarely. In the market, produce is two-thirds the cost per kilo of the best ste&ks, and in restaurants the cost of a small mixed salad is two-thirds the cost of the most expensive entrees on the menu. Heart disease and other diet-related ailments are rampant and increasing. The Government has tried nutrition education but, reportedly, to little effect. One reason given by a senior Hungarian official: Government promotional efforts in Eastern Europe lacked credibility. Worse than that: they were viewed by many for ulterior motives. (Why does the Government want me to eat broccoli?)

41. Bellagio Declaration: A Rockefeller Foundation-financed group, convened under the impetus of the World Hunger Program at Brown University, met in Italy in November to pronounce a "Bellagio Declaration on Overcoming Hunger in the 1990s." There are four goals: eliminate famine deaths, end hunger in half of the poorest households, reduce malnutrition among women and children by half, and eliminate iodine and vitamin A deficiencies. The Declaration, unfortunately, does not do justice to an excellent background paper -- one of the best such overviews we have come upon -- that had been prepared for the meeting. To use words like "eliminating" or "eradicating" stretches credibility. Similarly, the notion of cutting malnutrition among women and children in half does not suggest there was much serious arithmetic behind it. Calls for action of this type are laudable, so long as there is follow­through, but we so often have heard similar unsubstantiated ambitions that perhaps such proclamations begin to fall on deaf ears.

Science and Technology: What Has Been Learned

42. Big news in vitamin A: At the annual meeting of IVACG (the International Vitamin A Consultative Group), held in Kathmandu in November, Chairman Abraham Horwitz announced that new research on the benefits of vitamin A in a wide variety of circumstances "may become a fundamental breakthrough in the history of public health." The scope of the findings are impressive: A Ford Foundation-sponsored study in Madurai, South India, by the Aravind Eye Hospital demonstrated that small weekly doses of vitamin A (compared to placebos) over a year-and­a-half, reduced mortality by 64 percent in children aged one-to-five .... A smaller study in South Africa, undertaken for the London School of Hygiene and Tropical Medicine, found that in hospital patients admitted for measles those given vitamin A had 70 percent less mortality than in those not given vitamin A. (An earlier study in Tanzania came up with a SO percent difference) .... In Micronesia, an observational study showed that children with subclinical vitamin A deficiency were more anemic and had more ear infections .... In Thailand, serum vitamin A levels were correlated with risk of respiratory disease and diarrhea and, with provision of vitamin A, there was a large reduction in the respiratory disease and some smaller reduction in diarrhea .... Most of these findings corroborate earlier work in Indonesia, reported at a Bank nutrition seminar by Dr. Al Sommer of Johns Hopkins. But that work had left certain questions unanswered. (Replication studies of the Indonesia work under different health circumstances are now under way in Brazil, Ethiopia, and Nepal.)

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43. What is the mechanism for the vitamin A impact? Apparently vitamin A helps the lining of the lungs and intestines better resist microbial invasion of infection. (Judy McGuire, PHRHN, currently is at work on a substantial micronutrient initiative, including vitamin A.)

44. Cereal-based oral rehydration therapy: A new and more effective form of oral rehydration therapy for diarrhea was discussed by professionals from 31 countries in November at the Aga Khan University in Karachi. Based on cereal and salt, this form of oral rehydration can be prepared and given at home by mothers and does not require a packaged product. Cereal-based ORT was declared a major advance beyond the original glucose-based oral rehydration salts in that it stops diarrhea more quickly, reduces fluid loss, and prevents dehydration and malnutrition caused by diarrhea. It can be prepared by using rice, maize, millet, wheat or starchy vegetables such as potatoes, with a swall amount of salt and enough water to make a thick drink. Apparently we are relearning what many grandmothers in these societies have long known.

More on the Income-Nutrient Intake Relationship

45. Two recent papers deserve mention: John Strauss and Duncan Thomas of Yale use the Brazilian expenditure survey data set to show that poor households tend to increase their nutrient intake as their income increases. Calorie consumption increases until some threshold level, at which point households switch to food with more prestige (but not necessarily more nutritional) value .... Martin Ravallion, AGRAP, using Indonesian data draws similar conclusions. He argues that income elasticities of calorie demand at mean points (as was estimated by, e.g., Behrman-Deolalikar) understate considerably the nutrient responsiveness of the poor households consuming less than 1900 calories to income increases. This paper makes a significant methodological advance by stressing the need to look at the distribution of nutrient intakes around the mean in assessing the income effects on nutrition. (PPR Working Paper S-YPS 303) .... The debate is not closed, since any model explaining calorie intakes should also include controls for activity levels of individuals. The data sets used by the authors simply do not contain any information on activity levels, which are hard to measure and even harder to incorporate in the analysis. Moreover, the conclusions still must be seen in the context of a time frame and other considerations noted in para 28.

New Publications

46. Malnutrition: Les Remedes Existent: L'experience de la Bangue Mondiale, the French version of the monograph of Bank nutrition experience, has been published and is available in the Bank book store. A Spanish version (Malnutricion: Que Hacer? also has been published.

47. Newly Out: From a YHO/FAO Expert Committee, new Requirements of Vitamin A. Iron. Folate and Vitamin B .... From the ACC Sub-Committee on Nutrition, Women's Role in Food Chain Activities and the Implications for Nutrition. This is another in the useful series of SCN state-of­the-art papers. Earlier subjects were on nutrition education, vitamin

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A, and iron. All are available with us for tho'se interested. Coming soon: one on malnutrition and infection.

Seminar and Speech Highlights

48. The emphasis on immunization and oral rehydration clearly has reduced child mortality in Zimbabwe but, according to Dr. David Sanders in a PHRHN Seminar at the Bank last year, it seems also to have increased need for nutrition services. Children who would have died before, he said, may live now -- but in a malnourished condition, adding to the numbers of nutritionally needy.

49. The successful Chile nutrition experience can be largely attributed to the continuity of programs, despite changes of Government. This, according to Dr. Fernando Monckeberg, Director of the Institute of Nutrition and Food Technology of the University of Chile, at a recent retreat of LAC managers. The remarkable improvements in nutrition "clearly are not the result of economic progress," he said, "since they outpaced economic reality and have managed to retain momentum despite frequent major economic crisis of the past 20 years." .... Dr. Monckeberg also reminds us that Chile provides an example of how nutrition education can change behavior and turn around breastfeeding declines. In 1940, 85 percent of infants were breastfed through infancy. By 1967 this percentage had decreased to 25 percent and by 1974 to 19 percent. As a result of a concerted effort, this has been turned around so that now 52 percent of mothers breastfeed their children for at least three months. (Another excellent paper on the Chile experience has been prepared by Tarsicio Castaneda, LA2HR.)

50. Vice President for Africa Kim Jaycox, earlier this week in a symposium on Household Food Security and the Role of Women organized by the Bank in Harare, noted the special importance of women to food security objectives because women are the main producers of food in Africa, becaus~ they are the main providers for children, because they are more likely to suffer undernutrition (especially during pregnancy), and because the extent to which women are undernourished adversely affects their ability to nourish the family,

51. Florent Agueh, AFSPH, in a recent address at a symposium on Culturally Appropriate Nutrition Programming sponsored by the American Anthropological Association, noted the need for more anthropologists in Bank operations where behavioral change is a key objective and where intrahousehold factors influence project outcome. However, he challenged anthropologists to streamline their methods to make more efficient operational use of their work.

People

52. Anne Tinker, who recently joined PHRHN to organize and manage the Division's Safe Motherhood activities, gives high priority to the heretofore largely neglected nutrition aspect of that program. She has particular interest in such nutrition problems as anemia, food taboos and "eating down" during pregnancy, cephalopelvic disproportion, and the impact of poor nutrition status on low birth weight .... Tania Marek of

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France this week joins the Africa TD to work on nutrition. She comes directly from more than 10 years in the field, in Central and West Africa. Her MPH in nutrition is from Tulane, where she also got her Ph.D. Her specialties: nutrition in primary health care and information systems .... Steen Jorgensen is moving from LA3Cl to AF6PH, which perhaps has the most active nutrition program of any division in the Bank .... Ana-Maria Arriagada has moved from PHRED to LA2HR, where she will be involved in nutrition (and, particularly, pre-school nutrition) in the context of educability .... Joy de Beyer, AF6PH, is now responsible for nutrition in the upcoming Zimbabwe project .... V. Srinivasan, who successfully introduced nutrition in the Bank's Nigeria program (including responsibility for the nutrition portion of the current food security work there), will soon be leaving the Bank to head an NGO in Bombay .... Ed Brown, AF5PH, recently represented the Bank in Brazzaville at the second meeting of the interagency African Regional Task Force on Food and Nutrition Development.

Other Agencies

53. UNICEF's Deputy Executive Director Richard Jolly stopped by the office last week to discuss UNICEF's new strategy, being presented to its Board in March. This will highlight nutrition for the next decade with much the same type emphasis given immunization and oral rehydration in recent years. The strategy features a method of assessment, analysis and action (UNICEF's "triple A approach," developed in its successful IRINGA nutrition program,.on which the new Bank-assisted Tanzania Health ~nd Nutrition Project will be building). Special attention is given to the community level, where members can participate in identifying the malnutrition problem and choosing appropriate remedial actions.

54. Nutrition is one of three top issues on WHO's current agenda, according to Director-General Nakajima in his opening statement, week­before-last, of the YHO Executive Board meeting. It will be a special topic of the World Health Assembly in May .... Also, look for a major WHO announcement next month about its new Report on Dietary Goals (for LDCs). This, a first for that agency, reflects long deliberations of a WHO Expert Committee.

Food Update

55. Latest estimates confirm substantial recovery of the world cereal output in 1989. But for the third successive year global production has fallen short of consumption, leading to a further drawdown of stocks, with those of wheat falling to critically low levels .... Growing conditions for early sown 1990 cereals are mostly good so far .... Famine conditions prevail in parts of northern Ethiopia; FAO says only a major international relief effort can avert widespread loss of life .... Famine also again threatens the Sudan this year, a result of civil war and a steady erosion of the international relief effort, reportedly brought on in part by Government obstructions of relief efforts.

56. The US National Academy of Sciences projects a global shortfall of 74 million tons of cereal (and cereal equivalent) by the year 2000, and this only is a shortfall in meeting effective demand not nutrition need.

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The problem, says the NAS, will be serious in all regions, but particularly in Africa and Latin America.

59. There may well be less food aid available for poor countries in the near future, according to Robert Hindle, AFTFS, at the recent PHR Retreat. The reasons, in addition to lower global stocks, are that (a) the Soviets may be buying more from the market, lowering stocks further still, and (b) of the remaining food available for food aid, Eastern European countries may claim substantially more than they have in the past.

Finally ....

60. Mapplethorpe Revisited:

The Bank had its own Mapplethorpian censorship recently, when the art originally planned for the cover of Technical Paper No. 102 ("A Case For Promoting Breastfeeding In Projects to Limit Fertility") didn't pass the muster of the Publications Department. The reason: the photograph of a breastfeeding mother in a Diego Rivera- type mural in a Mexican nutrition center revealed a bit too much. Concerns were expressed that Middle Eastern readers may take offense. (Unfortunately, the decision not to use the art came well along in the process; the copyright page had already been desk-topped by someone else. This, mistakenly, wasn't changed after the photo was eliminated. The result: a description of the cover mural but, on the cover itself, only a large block of blue ink where the picture was to have been.)

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A Case for Promoung Breastfeeding in ProjeCts 10 Limit Fenllity

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