Malnutrition, national development, and planning

BullPan Am Healrh Organ 13(3), 1979.

MALNUTRITION, NATIONAL DEVELOPMENT, AND PLANNING’

Ivan Beghin,’ Juan de1 Canto,3 and Charles Teller4

Since 1971 the Institute of Nutrition of Central America and Panama (INCA P) has been assisting in formulating of national food and nutrition plans and policies (1, 2). This paper briefly examines, in the light of past experience and research, how the authors have come to regard mutual interactions between mal- nutrition and underdevelopment, relationships between nutri- tion and development, and the place of nutrition in overall

development planning.

Malnutrition and Underdevelopment

It is now generally admitted by nutrition workers that malnutrition is the result of the complex of multiple factors-such as low income and underemployment, igno- rance, poor sanitation, lack of access to medical services, inadequate participation and social organization, family instability, etc.-all of which are characteristic of a special social status described by the English phrase “social deprivation” the Spanish term “marginalizacio’n, ” or the more common word “poverty.” Indeed, malnutrition is considered to be one of the most typical and most intolerable manifes- tations of poverty.

Poverty, in turn, is regarded by some as the outcome of a complex and still not ful- ly understood set of circumstances wherein exploitation, inequity in the distribution of economic and political power, and in-

equalities in sharing the fruits of economic activity all play a central role. Although this view is far from being universally accepted, the authors firmly believe that poverty and lack of social justice are struc- turally founded, i.e., that their fundamen- tal causes rest within the actual structural and institutional pattern of the social sys- tem, which is unable to meet the basic needs of a large share of the population (3, 4). This assumption is based largely on value judgments, as is probably true of most assumptions directed at solving social problems. But the implications of this par- ticular assumption are unusually far- reaching, the major implication being that malnutrition cannot be attacked without at the same time attacking the roots of pov- erty.

People working in the field, when they propose or design programs for combating or preventing malnutrition, have tended to

lFrom a paper presented at the International Con- ference on Practical Approaches to Combat Malnutri- tion, with Special Reference to Mothers and Children, held in Cairo, Egypt, on 25-29 May 1977 under the sponsorship of the Arab Republic of Egypt, the Na- tional Institutes of Health of the United States, and the International Union of Nutrition Societies. Also appearing in Spanish in the Roletin de la Oficina Sanitaria Panamericana, 1979. Preparation of this

work was supported by the W.K. Kellogg Foundation. 2Institute of Tropical Medicine, Antwerp. Bel- gium. Formerly Chief of the Department of Applied Nutrition, Institute of Nutrition of Central America and Panama (INCAP), Guatemala.

SAgricultural Economist, Department of Applied Nutrition, INCAP.

?$ociologist-Demographer, Department of Applied Nutrition, INCAP.

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look at malnutrition in isolation and to ignore the context within which it occurs. They overlook the fact that, regardless of

how profoundly and persistently their “in- terventions” are implemented, malnutri- tion will keep reappearing if this context is not changed. The era of rehabilitation cen- ters, supplementary feeding schemes, wean- ing mixes, etc., was characterized by this “vertical” nutrition programs approach. That era has now ended. There is no tech- nocratic solution to malnutrition. Nutri- tion interventions cannot be effective and at the same time remain in pristine isola- tion, free from political considerations. Nutrition is not aseptic. This point needs to be emphasized; in fact, it is so important that it cannot be overstressed.

Nutrition and Development

Material poverty does exist in wealthy nations, but not so profoundly or extensive- ly as in underdeveloped countries. Thus, since poverty is one of the most terrible manifestations of underdevelopment, and since malnutrition is inseparable from pov- erty, a balanced approach to combating malnutrition will entail two simultaneous courses of action. These are (1) seeking to combat poverty-recognizing the deep structural causes of social deprivation and inequality, and hence the need to modify those causes; and (2) taking stop-gap mea- sures to alleviate malnutrition and its worst immediate consequences. The first course of action clearly relates nutrition to develop- ment and development planning, and there- fore goes beyond the strictly technical realm, while the second is more within the domain of the technician.

As regards the relationship between nu- trition and development, it should be noted that we are using the broad and modern concept of development-a concept that en- compasses well-being, social justice, and equitable distribution of goods and services as well as economic growth (5). Very few

economists today deny the failure of the old concept (equating development with a rising Gross National Product) to offer an improved situation to a majority of the peo- ple of the developing countries. On the con- trary, they are compelled to recognize that in many countries, despite economic growth, the gap between rich and poor has actually widened.

Another supposition made here is that most countries are undergoing a process of development, and that although the rate of progress observed depends on the type of criteria used, in most cases the curve is rising. This rise is generally slow, and a few countries are even experiencing a decline. These circumstances, however, do not weaken the working hypothesis presented below; indeed, in a situation where the curve is declining the strength of that hypothesis is reinforced.

It is also being assumed that in a majority of countries the population’s nutritional state is improving, albeit slowly, but that this improvement is tending to lag behind the progress achieved in other areas of de- velopment, particularly economic develop- ment. A slowly ascending curve represent- ing nutrition could thus be drawn, a curve that might or might not parallel the devel- opment curve, depending upon the indica- tors used.

Bexhin et al.

is asymptotic. That is, there is no upper limit-so far as is known-to education, or health, or use of leisure time, to take but a few examples. The point to be made here is that, since there is a practical upper limit to the nutrition problem, all efforts should be made to reach that limit, that level, in the shortest possible time. For one thing, reach- ing that level would tend to free resources that could be used to attack other problems. For another, it can be argued that the eli- mination of malnutrition as a serious public health problem could well cause overall development to accelerate-to proceed faster than it otherwise would.

In I974 the Institute of Nutrition of Cen- tral America and Panama (INCAP) made this set of assumptions explicit in a document presented to its member governments (6). That document contained the illustrative chart shown in Figure 1. The curve “d” shown in this chart represents the slow course of development, while the curve “n” shows the slow trend in nutritional improve- ment associated with this rate of develop- ment. Estimates made jointly by FAO and INCAP (7) suggested that at least three Cen- tral American countries would not reach the optimal nutrition horizon “h” (point A) in the course of the present century. It was felt imperative, therefore, that measures should be adopted as soon as possible (the vertical arrow) to improve nutrition faster

Figure 1. Improvement of nutrition in relation to development.

I

1970 1980 1990 2000 YEARS

and reach the horizon at an earlier date (point B). In other words, it was felt that nutrition could be improved up to a satis- factory level without waiting for a certain degree of development to be reached, if proper action were taken. The assumption made by INCAP was that this would be fea- sible, zythe government of the country were

committed

Nutrition as a Component of Development Planning

Two clearly distinct approaches have been adopted by workers seeking to combat malnutrition: the first is what could be called the “interventionist” approach; the other is the “global” approach sometimes fashionably referred to as the “holistic” approach (8, 9).

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programs are directed by exceptionally skilled, competent, and dedicated profes- sionals. Both rely on a good financial base, and both receive strong government sup- port. There is little doubt that they will have an impact upon the nutritional state of their countries’ most malnourished popula- tion groups. Likewise, there seems to be no doubt that all of us have much to learn from this kind of approach. In this vein, the fact that we are far from exploiting the poten- tialities of the interventionist approach is appropriately pointed out by Alan Berg in his book

The Nutrition Factor (10).

However, there are severe reservations to this approach, which ought to be taken seri- ously. The fact is that the technical lessons that we can draw from these experiences, substantial though they be, do not alleviate the concern that this approach does not seek to change the basic causes of malnutrition - such as unemployment, inflation, or lack of access to land-and that through this ap- proach no significant changes in these basic causes will occur.

The other approach, which we call the global approach, postulates that develop- ment planningcan and should be reoriented so as to give priority to satisfying nutri- tional objectives (8). (In the past, conven- tional development planning tended either to consider nutritional objectives as an out- come of socioeconomic development or to ignore them altogether.) Such objectives can be stated in terms of direct or indirect indicators that refer to the country as a whole or to specific regions, groups, etc., but they should be broad and not be limited to a given sector or branch of gov- ernment.

The idea that global nutrition objectives must be incorporated into the process of development planning is central to this approach. The role of the planner is then to select strategies and recommend policies. Strategies can be defined for one sector (agriculture, health) or can be multisecto- ral. Policies can be broad (dealing with

employment, prices, rural development) or more limited (relating to such things as legislation or institutional development). Such strategies and policies must satisfy three criteria: they must meet conventional goals; they must have an impact on nutri- tion; and they must be consistent with one another.

The strategies selected are then translated into plans and programs. Some of the pro- grams will be very similar to the kind of “intervention” that the first approach would have suggested- but for two funda- mental differences: first, the global inter- vention is selected as part of a broader attack, not just in response to a given prob- lem taken out of the general context; and second, the global intervention will general- ly achieve multiple objectives.

For example, the Government of Hondu- ras is currently attempting to employ a glo- bal approach (15). The major intervention within the Honduras nutrition plan is a rural water supply program, something that would never have been identified as a “nu- trition intervention” had not a multisec- toral group of technicians undertaken a broad, nationwide assessment of the overall nutrition problem. In general this global approach, while still experimental to a large extent, is considerably more satisfying to workers concerned with social betterment, although short-term results may not be as marked.

Benhin et al. l MALNUTRITION, NATIONAL DEVELOPMENT, AND PLANNING 289

other hand, much progress is being made worldwide in improving planning method- ologies and in clarifying the relationship between society, government policy, and the planning process. This progress permits moderate optimism about the potential overall contribution of planning to devel- opment.

Another difficulty stems from the nature of the global approach itself. Selecting strat- egies and recommending policies are not purely technical activities, nor are the prin- cipal decisions involved in the global ap- proach purely technical. Rather, they are choices of a political nature. Nevertheless, the mere fact that the nutritionist acknowl- edges dependence upon political decisions in itself represents substantial progress. It is only very recently that there has been ex- plicit international recognition of the importance of the socioeconomic and politi- cal context within which nutrition plan- ning is undertaken, and, in particular, of the fact that structures for exercising power and distributing the fruits of development will need to change if lasting improvements in nutrition are to be achieved. Participants at an international symposium on nutrition planning, held at Berkeley, California, in early 1977, gave wide if not unanimous acceptance to the fact that the whole issue of basic decision-making is political (16). The lesson, for the teams in charge of nutrition planning, is that they must learn to recog- nize the authority of political decisions and must make the basic assumptions under- lying those decisions explicit.

Current Nutrition Planning Issues

Some of the key issues now faced by nu- trition planning were discussed extensively at two 1977 meetings, these being the Berke- ley symposium already mentioned and the sessions of the Thirtieth World Health As- sembly held in Geneva, Switzerland, on

2-19 March. At both of these gatherings a broad set of questions relating to the role of the health sector in multisectoral nutrition planning were discussed. A preliminary paper (17) prepared by the WHO Secretariat for the World Health Assembly reflected the common concerns expressed by some 40 countries in response to a questionnaire (18). INCAP found some of the points in this paper-involving such things as prob- lem definition, nutritional surveillance, and public participation in nutrition planning-to be highly relevant to its own work with the governments of the Central American region.

Regarding problem definition (29, ZO), there seems little doubt that much effort is still needed to define malnutrition, not so much in terms of its manifestations as in terms of its overall context. It is likewise clear that we need better functional identi- fication of the population categories af- fected or at risk (19, ZI), and that the time dimension in nutrition planning(as brought out by historical series and projections) has not been sufficiently considered. All of these difficulties are conceptual as well as technical, because problem definition de- pends heavily on value judgments.

Technically, much needs to be done to improve our data base. For example, the in- formation system we depend on must be made more flexible and must correspond more closely to our needs. Hence the impor- tance of developing better concepts and methods of nutritional surveillance.

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Leonard Joy, a participant at the Berke- ley symposium, asked the question “Whose job is it?” with regard to nutrition plan- ning. To a degree the answer is clear: Nutri- tion planning is certainly not the job of the so-called “nutrition planner.” No single in- dividual should be expected to thoroughly master the two disciplines of nutrition and planning, nor would it be desirable to leave nutrition planning in the hands of such a person, were he to exist. Nutrition planning is the job of a team composed of people with different backgrounds and training, a team that should include people representing different sectors and levels as well as a strong contingent of good professional nu- tritionists.

All in all, because nutrition is too serious a matter to be left to nutritionists alone, or to planners alone, the concept of “nutrition planner” is potentially dangerous and cer- tainly misleading. The necessary thing is to teach seasoned planners some nutrition; to train experienced nutritionists in planning; to teach both some sociology, economics, and political science; and then to have them work together.

Another group of commonly considered nutrition planning issues relates to the methodology of nutrition planning and to program design and evaluation. In theory, however, problems in these areas do not pose insurmountable difficulties for an experi- enced and imaginative general planner. Moreover, it has been our experience that if such planners are available, if they have access to competent nutritionists, and if they know how to take advantage of the advice and participation of such nutritionists, good programs and projects can be designed. The bottlenecks that arise will be found to exist elsewhere.

Nutrition at the Community Level

Previous works (22, 23) have expressed our views on the subject of specific actions

at the community level. Those presenta- tions made two principal points. One was that nutrition action at the local level should be organized so as to give due con- sideration to the combined subjects of nu- trition, health, family planning, the pa- tient referral system, surveillance, and community organization. The other was that the people-not merely the local elite-should consciously and actively par- ticipate throughout the community action process, starting with the first stages of community decision-making and diagnosis.

We would like here to make an addition- al point, one that relates to the phrase “mothers and children” that is commonly used and that appeared in the title of the conference where this text was first pre- sented. 5 It seems to us that the time has come to choose another term. Certainly the infant and the young child are, and will remain for quite a number of years, our prime target in both health and nutrition. But we now know enough about the cir- cumstances under which malnutrition orig- inates, circumstances not related in any exclusive way to the mother. We suggest that the term “family health,” which is now increasingly utilized by WHO, pro- vides a much broader and more accurate perspective than the traditional “mother and child health.”

There is, moreover, another reason why we should not employ the term “mother and child health.” That is because it tends to consider the mother in only her reproduc- tive capacity. She receives attention so long as she is pregnant, or delivering, or lac- tating, or at risk of entering any of these states, but not in her own right as a woman. She is the passive recipient of serv- ices “delivered” to her, more as a proxy to her child than out of concern for her own health and well-being. Rather than this,

Beghin et al. . MALNUTRITION, NATIONAL DEVELOPMENT, AND PLANNING 291

let us consider the woman of the family in attitude toward the family that is more in

her various roles, as much a participant accord with two advances of our times: the

and decision-maker as the husband, the new role of the woman in society and our father, the temporary companion, or the recent progress in understanding the true older children, all of whom may be mem- determinants of malnutrition.

bers of the family unit. Let us adopt an

SUMMARY

Since 1971 the Institute of Nutrition of Cen- tral America and Panama (INCAP) has been helping its member countries with formulation of national food and nutrition policies. In the light of experience gained through that work, this article presents the authors’ views on mu- tual interactions between malnutrition and underdevelopment, relations between nutrition and development, and the place of nutrition in overall development planning.

It has been observed that there appears to be a causal relationship between the factors associ- ated with poverty and malnutrition. Indeed, it is generally recognized that one of the most typi- cal and intolerable manifestations of poverty is malnutrition. Poverty, in turn, may be viewed as arising from structural and institutional defects in the social system-defects that must be dealt with if malnutrition is to be overcome. This means that nutrition interventions cannot be effective and at the same time remain in pris- tine isolation, free from political considerations.

In general, two clearly distinct approaches have been adopted by workers seeking to combat malnutrition. One approach, the so-called interventionist approach, assumes that a limited number of well-chosen and well-performed “in-

terventions” can have a lasting impact on a population’s nutritional status. The other, known as the global or “holistic” approach, pos- tulates chat development planning can and should be reoriented so as to give priority to satisfying nutritional objectives.

Naturally, neither approach is problem-free. Though the interventionist approach is impor- tant and still has much to teach, it makes no attempt to change what appear to be the under- lying causes of malnutrition. On the other hand, while the global approach provides a way of getting at these basic causes, it confronts at least two other major difficulties-namely, its implicit assumption that planning is an effec- tive tool of development is not necessarily valid in all cases, and it tends to bring nutrition into the arena of politics to a significant degree.

Looked at another way, however, the very fact that nutritionists are coming to acknowl- edge their dependence on political decisions can be taken as an important sign of progress. Over- all, the lesson that this trend holds for the teams in charge of nutrition planning is that they must learn to recognize the authority of politi- cal decisions and must learn to make explicit the basic underlying assumptions involved.

REFERENCES

(1) Institute of Nutrition of Central America and Panama, Division of Applied Nutrition. Report of Activities of the Four-Year Period, 1971-1975, (mimeographed document). Guate- mala City, 1976. 95 pages.

(2) Del Canto, J ., A. Pradilla, V. Bent, J. Aranda-Pastor, and I. Beghin. National Food and Nutrition Policies in Central America: A

Pragmatic Approach. Paper presented at the X International Congress of Nutrition held in Kyoto, Japan, on 3-9 August 1975. Page 323 (Abstract 7201).

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(4) Galtung, J . Implementing self-reliance. Transnational Pers$ectives 3(3-4):18-24, 1976.

(5) Beghin, I., R. E. Stickney, J. Aranda- Pastor, J. de1 Canto, and A. Pradilla. Malnutri- tion in Central America: The Need for a New Model of Economic Development. Paper pre- sented at the X international Congress of Nutri- tion held in Kyoto, Japan, on 3-9 August 1975. Page 326 (Abstract 7211).

(6) Institute of Nutrition of Central America and Panama, Division of Applied Nutrition. Guia para la definition y formu1aciBn de poli- ticas nacionales de alimentacidn y nutrition (fifth draft, mimeographed document). Guate- mala City, 1974. 88 pages.

(7) Secretaria de1 Tratado de IntegraciBn EconBmica de Centro America and the Food and Agriculture Organization. Pers#ectivas para el desarrollo y la integracidn de la agri- cultura en Centro Amirica (Volume 1 and 2). SIECA, Guatemala City, 1974.

(8) Institute of Nutrition of Central America and Panama (INCAP). La nutricidn en la #la- nificaci6n de1 desarrollo. Mimeographed docu- ment presented at the seminar in Nutrition de- velopment Planning organized by INCAP and the United Nations Economic Commission for Latin America (ECLA) and held in Guatemala City on 14-15 October 1976. 31 pages.

(9) Ghassemi, H. Nutrition policy and pro- gramme planning. In: D. S. McLaren (Ed.), Nutrition in .th.e Community (Chapter 13). John Wiley and Sons, London, 1975.

(10) Berg, A. The Nutritioa Factor: Its Role in National Development. The Brookings Insti- tution, Washington, D.C., 1973.

(II) Pascual, C. R. Nutrition in the Philip- pines. In: D. S. McLaren (Ed.), Nutrition in the Community (Chapter 29). John Wiley and Sons, London, 1975.

(12) National Nutrition Council, the Philip- pines. The Philippines Nutrition Program: Five-Year Plan, 1978-82 (Mimeographed docu- ment.) M.anila, the Philippines, 1977. 44 pages.

(13) Monckeberg, F. Checkmate to Malnutri- tion. Santiago, Chile, 1976.

(14) Consejo National para la AlimentaciBn y la Nutrition y Tecnologia de 10s Alimentos, University of Chile. Antecedentes y acciones para una politica national de aZimentaci6n y nutrici6n de Chile. Edited by F. Monckeberg and S. Valiente. Editora National Gabriela

Mistral, Santiago, 1976.

(15) SAPLAN. Technical Secretariat of the Council for Economic Planning (CONSUL- PLANE). Evaluaci6n de Las dress prioritarias de1 problema nutritional de Honduras y sus PO- sibles soluciones. (Mimeographed document.) Tegucigalpa, 1976. 45 pages.

(16) International Study Symposium on Poli- cy Making and Planning to Reduce Malnutri- tion, Working Group. The Politics of Food and Nutrition Planning: A Preliminary Working Paper on its Socioeconomic Context. (Mimeo- graphed document.) International Study Sympo- sium on Policy Making and Planning to Reduce Malnutrition held at the University of Califor- nia, Berkeley, California, on 29 March-l April 1977. 3 pages.

(17) World Health Organization. The Impor- tance of National and International Food and Nutrition Policies for Health Development. Background document for reference and use at the Technical Discussions of the Thirtieth World Health Assembly. Geneva, 1977. 36 pages.

(18) World Health Organization. Suggested Outline for Use by Countries in Discussing the Importance of National and International Food and Nutrition Policies for Health Development. WHO Document NUT/76.2. Geneva, 1976. 29 pages.

(19) Joy, Leonard. Food and nutrition plan- ning. J Agric Econ 22:165-192, 1973.

(20) Joy, L., and P. Payne. Food and Nutri- tion PZanning. FAO Nutrition Consultants Reports Series No. 35. Food and Agriculture Organization, Rome, 1975. 105 pages.

(21) Valverde, V., F. Trowbridge, B. Pillet, I. Nieves, T. Farrell, N. Sloan, R. E. Klein, and I. Beghin. Claszyicacidn funcional de problemas nutricionales: Conceptos y metodologia desarro- llada en El Salvador. Paper presented at the I Jornada National de Nutrition y Dietetica spon- sored by the Association of Nutritionists of El Salvador (ASONDES) and held in San Salvador, El Salvador, in December 1976.

(22) Beghin, I. Centres for combating child- hood malnutrition. In: D. S. McLaren (Ed.), Nutrition in the Community (Chapter 15). John Wiley and Sons, London, 1975.