State of the World's Children 1998

Carol Bellamy, Executive Director, United Nations Children's Fund

Foreword by Kofi A. Annan, Secretary-General of the United
Nations

Chapter I

Malnutrition: Causes, consequences and solutions

Malnutrition is rarely regarded as an emergency; the children
affected are not facing famine and betray few or no obvious
signs. Yet the largely invisible crisis of malnutrition is
implicated in more than half of all child deaths worldwide
and violates children's rights in profound ways, compromising
their physical and mental development and helping perpetuate
poverty. More widespread than many suspect - with one out of
every three children affected - malnutrition lowers the
productivity and abilities of entire societies. This chapter
examines the scale of this intractable tragedy, the
approaches that are helping resolve it and the new light that
scientific research is shedding on it.

The silent emergency: In this section, the scale of
malnutrition and the complex interplay of factors that cause
it, including poor health services and discrimination against
women, are presented.

Approaches that work: Community involvement, food
fortification, growth monitoring and promotion,
supplementation programmes - these are some of the many and
often overlapping approaches that are changing, and saving,
children's lives.

Bringing science to bear: Vitamin A reduced maternal death
rates by 44 per cent on average, according to a recent study.
This section spotlights some of the breakthroughs that
science is making in the fight for better nutrition.

Chapter II


                         * * * *

Foreword

To look into some aspects of the future, we do not need
projections by supercomputers. Much of the next millennium
can be seen in how we care for our children today. Tomorrow's
world may be influenced by science and technology; but more
than  anything, it is already taking shape in the bodies and
minds of our children.

In The State of the World's Children 1998, UNICEF - the only
United Nations agency  dedicated exclusively to children -
spells out a simple but most pressing truth. Sound nutrition
can change children's lives, improve their physical and
mental development, protect their health and lay a firm
foundation for future productivity.

Over 200 million children in developing countries under the
age of five are malnourished. For them, and for the world at
large, this message is especially urgent. Malnutrition
contributes to more than half of the nearly 12 million
under-five deaths in developing countries each year.
Malnourished children often suffer the loss of precious
mental capacities. They fall ill more often. If they survive,
they may grow up with lasting mental or physical
disabilities.

This human suffering and waste happen because of illness -
much of it preventable; because breastfeeding is stopped too
early; because children's nutritional needs are not
sufficiently understood; because long-entrenched prejudices
imprison women and children in poverty.

The world knows what is needed to end malnutrition. With a
strong foundation of cooperation between local communities,
non-governmental organizations, governments and international 
agencies, the future - and the lives of our children - can
take the shape we want and they  deserve, of healthy growth
and development, greater productivity, social equity and
peace.

Kofi A. Annan
Secretary-General of the United Nations

                      * * * *


Chapter I

Malnutrition: Causes, consequences and solutions
The silent emergency

It is implicated in more than half of all child deaths
worldwide - a proportion unmatched by any infectious disease
since the Black Death. Yet it is not an infectious disease.

Its ravages extend to the millions of survivors who are left
crippled, chronically vulnerable to illness - and
intellectually disabled.

It imperils women, families and, ultimately, the viability of
whole societies. It undermines the struggle of the United
Nations for peace, equity and justice. It is an egregious
violation of child rights that undermines virtually every
aspect of UNICEF's work for the survival, protection and full
development of the world's children.

Yet the worldwide crisis of malnutrition has stirred little 
public alarm, despite substantial and growing scientific
evidence of the danger. More attention is lavished on the
gyrations of world stock markets than on malnutrition's vast
destructive potential - or on the equally powerful benefits
of sound nutrition, including mounting evidence that improved
nutrition, such as an adequate intake of vitamin A and
iodine, can bring profound benefits to entire populations.

Malnutrition is a silent emergency. But the crisis is real,
and its persistence has profound and frightening implications
for children, society and the future of humankind.

Malnutrition is not, as many think, a simple matter of
whether a child can satisfy her appetite. A child who eats
enough to satisfy immediate hunger can still be malnourished.

And malnutrition is not just a silent emergency - it is
largely an invisible one as well. Three quarters of the
children who die worldwide of causes  related to malnutrition
are what nutritionists describe as mildly to moderately
malnourished and betray no out ward signs of problems to a
casual observer.

Malnutrition's global toll is also not mainly a consequence
of famines, wars and other catastrophes, as is widely
thought; in fact, such events are responsible for only a tiny
part of the worldwide malnutrition crisis. But such
emergencies, like the ongoing crises in the Great Lakes
region of Central Africa and in the Democratic People's
Republic of Korea, often  result in the severest forms of
malnutrition. Meeting food needs in these situations is
essential, but so is protecting people from illness and
ensuring that young children and other vulnerable groups
receive good care.

Child malnutrition is not confined to the developing world.
In some  industrialized countries, widening income
disparities, coupled with reductions in social protection,
are having worrying effects on the nutritional well-being of
children.

Whatever the misconceptions, the dimensions of the
malnutrition crisis are clear. It is a crisis, first and
foremost, about death and disability of children on a vast
scale, about women who become maternal mortality statistics
partly  because of nutritional deficiencies and about social
and economic costs that strangle development and snuff out
hope.

Malnutrition has long been recognized as a consequence of
poverty. It is increasingly clear that it is also a cause.

In some parts of the world,  notably Latin America and East
Asia, there have been dramatic gains in reducing child
malnutrition. But overall, the ab so lute number of
malnourished children worldwide has grown.

Half of South Asia's children are mal nourished. In Africa,
one of every three children is underweight, and in several
countries of the continent, the nutritional status of
children is worsening.

Malnourished children are much more likely to die as a result
of a common childhood disease than those who are adequately
nourished. And research indicates a link between malnutrition
in early life - including the period of foetal growth - and
the development later in life of chronic conditions like
coronary heart disease, diabetes and high blood pressure,
giving the countries in which malnutrition is already a major
problem new cause for concern.

The most critically vulnerable groups are developing
foetuses, children up to the age of three and women before
and during pregnancy and while they are breastfeeding. Among
children, malnutrition is especially prone to strike those
who lack nutritionally adequate diets, are not protected from
frequent illness and do not receive adequate care.


Illness is frequently a consequence of malnutrition - and
malnutrition is also commonly the result of illness. Malaria,
a major cause of child deaths in large parts of the world,
also takes a major toll on child growth and development. In
parts of Africa where malaria is common, about one third of
child malnutrition is caused by malaria. The disease also has
dangerous nutritional consequences for pregnant women. In
addition, pregnant women are more susceptible to malaria, and
children born to mothers with malaria run a greater chance of
being born under weight and anaemic.

There is no one kind of malnutrition. It can take a variety
of forms that often appear in combination and contribute to
each other, such as protein-energy malnutrition, iodine
deficiency disorders and deficiencies of iron and vitamin A,
to name just a few.

Many involve deficiencies of 'micronutrients' - substances
like vitamin A and iodine that the human body cannot make
itself but that are needed, often in only tiny amounts, to
orchestrate a whole range of essential physiological
functions.

Each type of malnutrition is the result of a complex
interplay of factors involving such diverse elements as
household access to food, child and maternal care, safe water
and sanitation and access to basic health services.

And each wreaks its own particular kind of havoc on the human
body.

Iodine deficiency can damage intellectual capacity; anaemia
is a factor in the pregnancy and childbirth complications
that kill 585,000 women annually; folate deficiency in
expectant mothers can cause birth defects in infants, such as
spina bifida; and vitamin D deficiency can lead to poor bone
formation, including rickets.

Vitamin A deficiency, which affects about 100 million young
children worldwide, was long known to cause blindness. But it
has become increasingly clear that even mild vitamin A
deficiency also impairs the immune system, reducing
children's resistance to diarrhoea, which kills 2.2 million
children a year, and measles, which kills nearly 1 million
annually. And new findings strongly suggest that vitamin A
deficiency is a cause of maternal mortality as well,
especially among women in impoverished regions (Panel 1).

At its most basic level, malnutrition is a consequence of
disease and inadequate dietary intake, which usually occur in
a debilitating and often lethal combination. But many more
elements - social, political, economic, cultural - are
involved beyond the physiological.

Discrimination and violence against women are major causes of
malnutrition.

Women are the principal providers of nourishment during the
most crucial periods of children's development, but the
caring practices vital to children's nutritional well-being
invariably suffer when the division of labour and resources
in families and communities favours men, and when women and
girls face discrimination in education and employment.

A lack of access to good education and correct information is
also a cause of malnutrition. Without information strategies
and better and more accessible education programmes, the
aware ness, skills and behaviours needed to combat
malnutrition cannot be  developed.

There is, in short, nothing simple about malnutrition -
except perhaps the fact of how vast a toll it is taking.

Of the nearly 12 million children under five who die each
year in developing countries mainly from preventable causes,
the deaths of over 6 million, or 55 per cent, are either
directly or indirectly attributable to malnutrition (Fig. 1).

Some 2.2 million children die from diarrhoeal dehydration as
a result of persistent diarrhoea that is often aggravated by
malnutrition.

And anaemia has been identified as a contributing factor, if
not a principal cause, in 20 per cent to 23 per cent of all
post-partum maternal deaths in Africa and Asia, (1) an
estimate many experts regard as conservative.

If there were no other consequences of malnutrition, these
horrific statistics would be more than enough to make its
reduction an urgent global priority - and inaction a
scandalous affront to the human right to survival.

But the issue goes beyond child survival and maternal
mortality and morbidity. Malnourished children, unlike their
well-nourished peers, not only have lifetime disabilities and
weakened immune systems, but they also lack the capacity for
learning that their well-nourished peers have.

In young children, malnutrition dulls motivation and
curiosity and reduces play and exploratory activities. These
effects, in turn, impair mental and cognitive development by
reducing the amount of interaction children have both with
their environment, and with those who provide care.

Malnutrition in an expectant mother, especially iodine
deficiency, can produce varying degrees of mental retardation
in her infant.

In infancy and early childhood, iron deficiency anaemia can
delay psychomotor development and impair cognitive
development, lowering IQ by about 9 points.

Anaemic pre-schoolers have been found to have difficulty in
maintaining attention and discriminating  between visual
stimuli. Poor school achievement among primary school and
adolescent children has also been linked to iron deficiency.
(2)

Low-birthweight babies have IQs that average 5 points below
those of healthy children. And children who were not
breastfed have IQs that are 8 points lower than breastfed
children.

The depletion of human intelligence on such a scale - for
reasons that are almost entirely preventable - is a
profligate, even criminal, waste.

Robbed of their mental as well as physical potential,
malnourished children who live past childhood face 
diminished futures. They will become adults with lower
physical and intellectual abilities, lower levels of
productivity and higher levels of chronic illness and
disability, often in societies with little economic capacity
for even minimal therapeutic and rehabilitative measures.

At the family level, the increased costs and pressures that
malnutrition-linked disability and illness place on those who
care for them can be devastating to poor families -
especially to mothers, who receive little or no help from
strained social services in developing countries.

And when the losses that occur in the microcosm of the family
are repeated millions of times at the societal level, the
drain on global development is staggering.

In 1990 alone, the worldwide loss of social productivity
caused by four over lapping types of malnutrition -
nutritional stunting and wasting,  iodine deficiency
disorders and deficiencies of iron and vitamin A - amounted
to almost 46 million years of productive, disability-free
life, according to one reckoning. (3)

Vitamin and mineral deficiencies are estimated to cost some
countries the equivalent of more than 5 per cent of their
gross national product in lost lives, disability and
productivity. By this calculation, Bangladesh and India
forfeited a total of $18 billion in 1995. (4)

Malnourished children's low resistance to illness diminishes
the effectiveness of the considerable resources that are
spent to ensure that families have access to basic health
services and sanitation. And investments in basic education
by governments and their partners are compromised by
malnutrition's pernicious effects on brain development and
intellectual performance.

Iodine deficiency and iron deficiency anemia, which threaten
millions of children, are especially worrisome factors as
countries strive to improve their educational systems.

Iron-deficient children under the age of two years show
problems with coordination and balance and appear more
withdrawn and hesitant. Such factors can hinder a child's
ability to interact with and learn from the environment and
may lead to lower intellectual abilities.(5)

Severe iodine deficiency in utero can cause the profound
mental retardation of cretinism. But milder deficiencies also
take an intellectual toll. In the republic of Georgia, for
instance, a widespread iodine deficiency, recently detected,
is estimated to have robbed the country of 500,000 IQ points
in the 50,000 babies born in 1996 alone.(6)

Many children suffer from multiple types of malnutrition, so
numbers tend to overlap. But it is reliably estimated that
globally 226 million children are stunted - shorter than they
should be for their age, and shorter than could be accounted
for by any genetic variation (Panel 2). Stunting is
particularly dangerous for women, as stunted women are more
likely to experience obstructed labour and are thus at
greater risk of dying while giving birth. Stunting is
associated with a long-term  reduction in dietary intake,
most often closely related to repeated episodes of illness
and poor-quality diets.

A study in Guatemala found that severely stunted men had an
average of 1.8 fewer years of schooling than those who were
non-stunted, while severely stunted women had, on average,
one year less. The differences are important since every
additional year of schooling translated into 6 per cent more
in wages (7) (Panel 3).

Some 67 million children are estimated to be wasted, which
means they are below the weight they should be for their
height - the result of reduced dietary intake, illness, or
both.

About 183 million children weigh less than they should for
their age. In one study, children who were severely
underweight (8) were found to be two to eight times more
likely to die within the following year as children of normal
weight for their age. (9)

More than 2 billion people - principally women and children -
are iron deficient, (10) and the World Health Organization
(WHO) has estimated that 51 per cent of children under the
age of four in developing countries are anaemic. (11)

In most regions of the developing world, malnutrition rates
have been falling over the last two decades, but at markedly
different paces (Fig. 2). The exception is sub-Saharan
Africa, where malnutrition rates began increasing in most
countries during the early 1990s, following the regional
economic decline that began in the late 1980s. As government
budgets shrank, basic  social services and health services
were hit particularly hard. Per capita incomes also declined,
affecting people's ability to purchase food.

In the United States, researchers estimate that over 13
million children - more than one in every four under the age
of 12 - have a difficult time getting all the food they need,
a problem that is often at its worst during the last week of
the month when families'  social benefits or wages run out.
(12) Over 20 per cent of children in the United States live
in poverty, more than double the rate of most other
industrialized countries. (13)

In the United Kingdom, children and adults in poor families
face health risks linked to diet, according to a recent study
that cited high rates of anaemia in children and adults, and
of premature and low-weight births, dental diseases,
diabetes, obesity and hypertension. (14)

In Central and Eastern Europe, economic dislocations
accompanying the transition to market economies and major
cutbacks in state-run social programmes are having a more
profound effect on the most vulnerable.

In the Russian Federation, the prevalence of stunting among
children under two years of age increased from 9 per cent in
1992 to 15 per cent in 1994.(15) And in the Central Asian
republics and Kazakstan, 60 per cent of pregnant women and
young children are now anaemic.

The effects of malnutrition also cross generations. The
infants of women who are themselves malnourished and
underweight are likely to be small at birth.

Overall, 60 per cent of women of childbearing age in South
Asia - where half of all children are underweight - are
themselves underweight. In South-East Asia, the proportion of
underweight women is 45 per cent; it is 20 per cent in
sub-Saharan Africa.


The power of good nutrition

The devastation of malnutrition is hard to overstate, but so
is the countervailing power of nutrition. Not only is good
nutrition the key to the healthy development of individuals,
families and societies, but there is also growing reason to
believe that improving the nutrition of women and children
will contribute to overcoming some of the greatest health
challenges facing the world, including the burden of chronic
and degenerative disease, maternal mortality, malaria and
AIDS.

The most obvious proof of the power of good nutrition can be
seen in the taller, stronger, healthier children of many
countries, separated by only a generation from their shorter,
less robust parents, and by the better diets and more
healthful, nurturing environments they enjoy.

Stronger children grow into stronger, more productive adults.
Well-nourished girls grow into women who face fewer risks
during pregnancy and childbearing, and whose children set out
on firmer developmental paths, physically and mentally. And
history shows that societies that meet women's and children's
nutritional needs also lift their capacities for greater
social and economic progress.

Approximately half of the economic growth achieved by the
United Kingdom and a number of Western European countries
between 1790 and 1980, for example, has been attributed to
better nutrition and improved health and sanitation
conditions, social investments made as much as a century
earlier. (16)

Even in countries or regions where poverty is entrenched, the
health and development of children and women can be greatly
protected or improved. In parts of Brazil, for example, the
percentage of underweight children plummeted from 17 per cent
in 1973 to just under 6 per cent in 1996, at a time when
poverty rates almost doubled.

Much has already been achieved. For example, 12 million
children every year are being spared irreversible mental
impairment from iodine deficiency because of iodized salt.
And more than 60 per cent of young children around the world
are receiving vitamin A supplements.

Some effects of even severe malnutrition on a child's mental
development can be at least partially reversed. The
intelligence of severely malnourished children was found to
improve markedly, for example, when health care, adequate
food and stimulation were provided continually. (17)

And there is increasing evidence that good nutrition helps
the body resist infection; that when infection occurs,
nutrition relieves its severity and seriousness; and that it
speeds recovery.

Thirty years ago, most people could readily accept the notion
that a 'good diet' was beneficial to overall health. But the
idea that specific nutrients could help fend off - or, even
more outlandishly, help treat - specific diseases smacked of
'fringe science'.

Today, through clinical trials and studies, the fringe is
edging closer to the mainstream, as nutrition scientists as
well as immunologists, paediatricians and gerontologists test
the implications for public policy of large-scale
interventions to improve nutrition and its effects on an
array of critical physiological processes.

Malnutrition, reflected in the poor growth of children and
adolescents and the high prevalence of low-birthweight
babies, already has well-known effects on a child's capacity
to resist illness. It is thus reasonable to argue that in the
global fight to reduce childhood death and illness,
initiatives to improve nutrition may be as powerful and
important as, for example, immunization programmes.

There are now numerous scientific studies that suggest, but
do not yet prove, that vitamin A deficiency in a mother
infected with the human immunodeficiency virus (HIV) may
increase her risk of transmitting the virus to her infant.

Early in the next millennium, it is thought that between 4
million and 5 million children will be infected with HIV. The
majority, mostly in sub-Saharan Africa, will acquire the
infection directly from their mothers. Although it will take
another year or two to be absolutely sure, improving the
vitamin A status of populations where both HIV infection and
vitamin A deficiency are common may make some contribution to
reducing the transmission of the virus.

The right to good nutrition

However far-reaching the benefits of nutrition may be,
ensuring good nutrition is a matter of international law,
articulated in variously specific language in international
declarations and human rights instruments dating back to the
adoption of the Declaration of the Rights of the Child in
1924 (Panel 4).

Under the 1979 Convention on the Elimination of All Forms of
Discrimination against Women, for example, States parties
must ensure that women receive full and equal access to
health care, including adequate nutrition during pregnancy
and lactation. And the 1990 World Summit for Children, with a
Plan of Action that recognized the devastating effects of
malnutrition on women and their children, set specific
nutritional goals for children and women, including access to
adequate food during pregnancy and lactation; the promotion,
protection and support of breastfeeding and complementary
feeding practices; growth monitoring with appropriate
follow-up actions; and nutritional surveillance.

But the right to nutrition receives its fullest and most
ringing expression in the 1989 Convention on the Rights of
the Child, whose 191 ratifications as of late 1997 make it
the most  universally embraced human rights instrument in
history.

Under the Convention, which commits States parties to realize
the full spectrum of children's political, civil, social,
economic and cultural rights, virtually every government in
the world recognizes the right of all children to the highest
attainable standard of health, to facilities for the
treatment of illness and for the rehabilitation of health -
specifically including the right to good nutrition and its
three vital components: food, health and care.

Under the Convention's pre-eminent guiding principle, good
child nutrition is a right because it is in the "best
interests of the child."

Article 24 of the Convention specifies that States parties
must take "appropriate measures" to reduce infant and child
mortality, and to combat disease and malnutrition through the
use of readily available technology and through the provision
of adequate, nutritious foods and safe drinking water.

The world is obligated to ease child malnutrition on the
basis of international law, scientific knowledge, practical
experience and basic morality.

The ravages caused by malnutrition on individuals, families
and societies are preventable. The measures needed to reduce
and end it are becoming increasingly well understood. And the
gains for humanity from doing so - in greater creativity,
energy, productivity, well-being and happiness - are
immeasurable.

Why time is of the essence

A child's organs and tissues, blood, brain and bones are
formed, and intellectual and physical potential is shaped,
during the period from conception through age three.

Since human development proceeds particularly rapidly for the
first 18 months of life, the nutritional status of pregnant
and lactating mothers and young children is of paramount
importance for a child's later physical, mental and social
development. It is not an exaggeration to say that the
evolution of society as a whole hinges on the nutrition of
mothers and children during this crucial period of their
lives.

The healthy newborn who develops from a single cell - roughly
the size of the period at the end of this sentence - will
have some 2 billion cells and weigh an average of 3,250
grams. (18) Under optimal conditions, the infant will double
its birthweight in the first four months of life; by its
third birthday, a healthy child will be four and a half times
as heavy.

Brain cells proliferate at the rate of 250,000 a minute,
beginning in the third week of gestation. (19) By the time of
birth, a child will have 100 billion neurons, linked by
synapses, the complex nerve junctions that begin forming in
the 13th week of gestation. (20)

Proliferating most rapidly after birth, in large part because
of the stimulation and care a child receives, millions upon
millions of these junctions will be forged by the time a
healthy child reaches the age of two and a half. Physical,
mental and  cognitive development depend on these
communication links between neurons. Without them, messages
would dead-end, muscles would not flex, and the complex
processes of thought and learning would not be possible.

Growth during the foetal stage depends on how well nourished
a woman was before pregnancy, as well as how much weight she
gains while she is pregnant. Gains in weight are essential
for the development of new maternal and foetal tissues, and
for maternal body maintenance and energy.

Since the foetus relies entirely on the mother for nutrients,
pregnant women not only need to gain weight but also must
maintain an optimal intake of essential nutrients such as
iron and iodine.

But fulfilling these interlocking food, health and care needs
can be a struggle for many women in the developing world,
where economic, social and cultural factors may be a barrier
to good nutrition.

Currently about 24 million low-birthweight babies are born
every year, which is about 17 per cent of all live births.
Most are born in developing countries, where the main cause
of low birthweight is not premature birth, as it is in the
industrialized world, but poor foetal growth.

Low-birthweight babies, defined as weighing less than 2.5
kilograms, are at greater risk of dying than  infants of
average weight. If they  survive, they will have more
episodes of illness, their cognitive development may be
impaired, and they are also more likely to become
malnourished. Evidence is also mounting that low birthweight
predisposes children to a high risk of diabetes, heart
disease and other chronic conditions later in life.

The measures that are essential for an expectant mother -
care and rest, a reduced workload and a well-balanced  diet
that affords ample energy, protein, vitamins, minerals and
essential fatty acids - are equally important when a woman is
breastfeeding her child.

Breastfeeding perfectly combines the three fundamentals of
sound nutrition - food, health and care - and is the next
critical window of nutritional opportunity after pregnancy.
While not all children are breastfed, it remains an important
protection for children.

Because breastmilk contains all the nutrients, antibodies,
hormones and antioxidants an infant needs to thrive, it plays
a pivotal role in promoting the mental and physical
development of children.

Breastfed infants not only show better immune responses to
immunizations, but their intake of breastmilk also protects
the mucous membranes that line their gastrointestinal and
respiratory tracts, thus shielding them against diarrhoea and
upper respiratory tract infections. (21)

In countries where infant mortality rates are high or
moderately high, a bottle-fed baby in a poor community is 14
times more likely to die from  diarrhoeal diseases and 4
times more likely to die from pneumonia than a baby that is
exclusively breastfed. (22)

Breastfeeding also has cognitive benefits. In one study,
breastfed subjects generally had IQs that were about 8 points
higher than children who had been bottle-fed, and higher
achievement scores as well. (23) Nutritionists theorize that
the effect may be the result of the growth-promoting
long-chain fatty acids of breastmilk. It may also be related
to the fact that breastfed infants have fewer infections and,
as healthier infants, they take a greater interest in their
environment and thus learn more than ill infants.

However, for mothers infected with HIV, breastfeeding's
enormous value as a bulwark against malnutrition, illness and
death must be weighed against the 14 per cent risk that they
may transmit the virus to their infants through breastmilk -
and the vastly greater risk, especially in poor communities
with inadequate water and sanitation, that feeding their
children artificially will lead to infant deaths from
diarrhoeal dehydration and respiratory infections.

During the second half of a child's first year, synaptic
growth in the prefrontal cortex of the brain, the seat of
forethought and logic, consumes twice the amount of energy
required by an adult brain. Much of this synaptic growth is
believed to result from the caring stimulation that an infant
and young child receives - the nurturing, feeding and
learning play in which parents engage their children.

After about six months, for optimal growth and development, a
child needs to be fed frequently with energy-rich,
nutrient-dense foods. The failure to make such investments at
the right time can never be remedied later. An adequate
intake of micronutrients,  especially iodine, iron, vitamin A
and zinc, remains crucial.


Spotlighting the causes

An understanding of the complex and subtle causes of
malnutrition is important to appreciate the scale and depth
of the problem, the progress achieved to date and the
possibilities for further progress that exist.
Malnutrition, clearly, is not a simple problem with a single,
simple solution. Multiple and interrelated determinants are
involved in why malnutrition develops, and a similarly
intricate series of approaches, multifaceted and
multisectoral, are needed to deal with it.

Immediate causes

The interplay between the two most significant immediate
causes of malnutrition - inadequate dietary intake and
illness - tends to create a vicious circle: A malnourished
child, whose resistance to illness is compromised, falls ill,
and malnourishment worsens. Children who enter this
malnutrition-infection cycle can quickly fall into a
potentially fatal spiral as one condition feeds off the
other.

Malnutrition lowers the body's ability to resist infection by
undermining the functioning of the main immune-response
mechanisms. This leads to longer, more severe and more
frequent episodes of illness.

Infections cause loss of appetite, malabsorption and
metabolic and behavioural changes. These, in turn, increase
the body's requirements for nutrients, which further affects
young children's eating patterns and how they are cared for.

Underlying causes

Three clusters of underlying causes lead to inadequate
dietary intake and infectious disease: inadequate access to
food in a household; insufficient health services and an
unhealthful environment; and inadequate care for children and
women.

Household food security

This is defined as sustainable access to safe food of
sufficient quality and quantity - including energy, protein
and micronutrients - to ensure adequate intake and a healthy
life for all members of the family.

In rural areas, household food  security may depend on access
to land and other agricultural resources to guarantee
sufficient domestic  production.

In urban areas, where food is largely bought on the market, a
range of foods must be available at accessible prices to
ensure food security. Other potential sources of food are by
exchange, gifts from friends or family and in extreme
circumstances food aid provided by humanitarian agencies.

Household food security depends on access to food -
financial, physical and social - as distinct from its
availability. For instance, there may be abundant food
available on the market, but poor families that cannot afford
it are not food secure.

For the poor, therefore, household food security is often
extremely precarious. Agricultural production varies with the
season and longer-term environmental conditions. Families
selling crops may find themselves paid fluctuating prices
depending on a variety of factors beyond their control, while
those who need to buy food may encounter exorbitant prices.

Families living on the edge of survival have few
opportunities to build up sufficient stocks of food, or to
develop alternatives that would cushion them in times of
hardship. So while poor families may have adequate access to
food for one month, what is essential is access that is
consistent and sustainable.

Women have a special role to play in maintaining household
food security. In most societies, they are solely responsible
for preparing, cooking, preserving and storing the family's
food - and in many societies they have the primary
responsibility of producing and purchasing it. For house hold
food security to translate into good nutrition, this often
overwhelming burden of work must be  redistributed or reduced
so that other needs of children, also related to nutrition,
can be met.

Health services, safe water and sanitation

An essential element of good health is access to curative and
preventive health services that are affordable and of good
quality.

Families should have a health centre within a reasonable
distance, and the centre's staff should be qualified and
equipped to give the advice and care needed. According to the
United Nations Development Programme (UNDP), access varies
widely, but in as many as 35 of the poorest countries 30 to
50 per cent of the population may have no access to health
services at all. (24)

In Africa, the programme known as the Bamako Initiative was
launched in 1987 to address the crisis in health care that
came on the heels of budget cuts and economic decline in the
1980s. It is a strategy for improving health services by
moving their control, management and even some of their
financing out of central jurisdiction and into communities.

Now in place in a number of countries in Africa, the
Initiative's principles are being adopted and adapted in
other regions as well. The results are promising: The supply
of basic drugs in health centres is more consistent, and
management committees, composed of village residents, help
ensure that people pay reasonable fees for basic services and
that the funds generated are well used.

Nevertheless, the fact remains that many people do not have
access to health care and may be further deterred from
seeking timely and appropriate care by user fees for health
care services.

The additional challenge of creating a climate where
preventive health and nutritional care components are also
integrated into the Bamako model is harder to realize.
Because they are less tangible to communities, preventive
health and nutrition services are also often less in demand
than curative care. Prevention, nonetheless, is vital and
cost-effective.

In terms of environmental health, the lack of ready access to
a safe water supply and proper sanitation and the unhygienic
handling of food as well as the unhygienic conditions in and
around homes, which cause most childhood diarrhoea, have
significant implications for the spread of infectious
diseases.

Moreover, when food is handled under unhygienic conditions
and the environment is unhealthful, littered with animal and
human wastes, young children are also more prone to infection
by intestinal parasites, another cause of poor growth and
malnutrition (Panels 5 and 20).

Also, women and children are usually responsible for fetching
the water needed for domestic use, a task that drains
considerable time and energy. Depending on how much the
distance to the water source is shortened, it has been
estimated that women could conserve large reserves of energy,
as many as 300 to 600 calories a day. (25)

Progress has been made in improving access to safe water. But
more than 1.1 billion people lack this fundamental
requirement of good nutrition. (26)

As for sanitary waste disposal, the world is actually losing
ground, with the rate of coverage falling in both urban and
rural areas. Only 18 per cent of rural dwellers had access to
adequate sanitation services at the end of 1994, (27) and
overall some 2.9 billion people lack access to adequate
sanitation. (28)

Caring practices

Experience has taught that even when there is adequate food
in the house and a family lives in a safe and healthful
environment and has access to health services, children can
still become malnourished.

Inadequate care for children and women, the third element of
malnutrition's underlying causes, has only recently been
recognized and understood in all its harmful ramifications.

Care is manifested in the ways a child is fed, nurtured,
taught and guided. It is the expression by individuals and
families of the domestic and cultural values that guide them.

Nutritionally, care encompasses all measures and behaviours
that translate available food and health resources into good
child growth and development. This complex of caring
behaviours is often mistakenly assumed to be the exclusive
domain of mothers. It is, in fact, the responsibility and
domain of the entire family and the community, and both
mothers and children require the care of their families and
communities.

In communities where mothers are supported and cared for,
they are, in turn, better able to care for young children.

Among the range of caring behaviours that affects child
nutrition and health, the following are most critical:

*    Feeding: As we have seen, exclusive breastfeeding for
about six months, and then continued breastfeeding with the
addition of safe, high-quality complementary foods into the
second year of life, provides the best nourishment and
protects children from infection.

The introduction of complementary foods is a critical stage.
A child will be put at increased risk of malnutrition and
illness if these foods are introduced much before the age of
six months, or if the preparation and storage of food in the
home is not hygienic.

On the other hand, a child must have complementary foods at
the six-month point, since breastmilk no longer meets all
nutritional needs. Delaying the switch-over much beyond six
months of age can cause a child's growth to falter.

From about 6 months to 18 months of age, the period of
complementary feeding, a child needs frequent feeding - at
least four times daily, depending on the number of times a
child is breastfed and other factors - and requires meals
that are both dense in energy and nutrients and easy to 
digest.

The foods a family normally eats will have to be adapted to
the needs of small children, and time must be made available
for preparing the meals and feeding children.

Good caring practices need to be grounded in good information
and knowledge and free of cultural biases and misperceptions.
In many cultures, for instance, food and liquids are withheld
during episodes of diarrhoea in the mistaken belief that
doing so will end the diarrhoea. The practice is dangerous
because it denies the child the nutrients and water vital for
recovery.

Other behaviours that affect nutrition include whether
children are fed first or last among family members, and
whether boys are fed preferentially over girls. In a number
of cultures and countries, men, adult guests and male
children eat before women and girls.

The level of knowledge about hygiene and disease transmission
is another important element of care. It involves food
preparation and storage, and whether both those who prepare
the food and those who eat it wash their hands properly
before handling it.

Ideas concerning appropriate child behaviour are also
important. If, for instance, it is considered disrespectful
for a child to ask for food, feeding problems can occur.

*    Protecting children's health: Similarly rooted in good
knowledge and information is the caring act of seeing that
children receive essential health care at the right time.
Early treatment can prevent a disease from becoming severe.

Immunizations, for example, have to be carried out according
to a specific schedule. Sound health information needs to be
available to communities, and families and those caring for
children need to be supported in seeking appropriate and
timely health care.

Therapeutic treatment for a severely malnourished child in
the hospital is far more expensive than preventive care.
According to a 1990 US Department of Agriculture study,
nutrition investments for pregnant women were very
cost-effective: Every $1 spent on prenatal nutrition care
yielded an average savings of about $3 in reduced medical
costs for the children during the first two months after
birth. (29)

A study in Ghana has also found savings in health care costs:
Children receiving vitamin A supplements made fewer clinic
visits and had lower hospital admission rates than children
not receiving the supplement.

*    Support and cognitive stimulation for children: For
optimal development, children require emotional support and
cognitive stimulation, and parents and other caregivers have
a crucial role in recognizing and responding to the actions
and needs of infants.

The link between caring stimulation and malnourished children
is also important: Several studies have found that
malnourished children who were given verbal and cognitive
stimulation had higher growth rates than those who were not.
(30)

Breastfeeding affords the best early occasion to provide
support and stimulation. It enables mothers and their infants
to develop a close emotional bond that benefits both. All
children need - and delight in - the kind of play and
stimulation that is essential for their cognitive, motor and
social development.

Verbal stimulation by caregivers is particularly important
for a child's linguistic development. Ill or malnourished
children who are in pain and have lost their appetite need
special attention to encourage them to feed and take a
renewed interest in their surroundings during recovery.

In addition to improved nutrient intake, optimal cognitive
development also requires stimulation of, and regular
interaction with, young children. The quality of these
actions can be enhanced through education of parents and
other caregivers. Child-to-child programmes, for example, can
provide simple resources to older children to improve the
care, development and nutritional well-being of their younger
siblings.

Policy makers need to recognize the significance of such
measures and actions and take them into account when devising
policy and programmes.

But the timing must be carefully planned: Many early child
development activities concentrate on children who are age
three and older when the focus should be on children up to
the age of three and should link care, good feeding and
psychosocial activities.

*    Care and support for mothers: As long as the unequal
division of labour and resources in families and communities
continues to favour men, and as long as girls and women face
discrimination in education and employment, the caring
practices vital to the nutritional well-being of children
will suffer.

Women, on average, put nearly twice the hours of men into
family and household maintenance. In Bangladesh, India and
Nepal, for example, girls and women spend three to five hours
more a week than boys and men in tasks such as carrying fuel
and growing and processing food. (31)

They then spend an additional 20 to 30 hours a week
performing other unpaid household work. If the burdens they
carry are not better and more equitably distributed, both
they and their caring role will suffer.

The elements of care most critical for women during pregnancy
and lactation include extra quantities of good-quality food,
release from  onerous labour, adequate time for rest, and
skilled and sensitive pre- and post-natal health care from
trained practitioners.

The AIDS pandemic has introduced new and volatile
considerations and aspects of care into already sensitive
areas of human behaviour and interaction. High priority
should be given to improving access to services that help
minimize the risk of HIV transmission to women before, during
and after pregnancy, as well as to their partners (Panel 6).

Cultural norms and misconceptions affect the care women
receive during pregnancy. In some culturally conservative
communities in parts of Asia, for example, fish, meat, eggs
and fat are not part of the diets of pregnant women because
it is feared they will make a baby too large and difficult to
deliver. Research shows, however, that better maternal diet
can improve the birthweight of children in many cases without
causing significantly increased head circumference of the
newborn, which is the factor most likely to put small women
at risk (Panel 7).

The adjustment of workload is another aspect of the care
accorded women during pregnancy - and one with powerful
ramifications.

A survey in one village in the Gambia, for example, found
that even during periods of relatively low seasonal
agricultural activity, women gained on average just 5.5
kilograms during pregnancy - only about half of the
recommended weight gain that women need to sustain their
developing foetus. (32)

Reductions in a woman's workload during pregnancy, combined
with more food of good quality, improve the nutritional
status of a woman and her unborn child and reduce the risk
that the child will have a low birthweight.

In Viet Nam, when men assumed some of their pregnant wives'
responsibilities during the third trimester of pregnancy,
women rested more, and their infants weighed more at birth.
In Indonesia, infants born to women who received a food
supplement did not weigh more at birth, but they  developed
better during the first year of life.

The fact that women are usually the primary caregivers does
not mean that men, families and communities are exempt from
care-giving  responsibilities.

The often oppressive and demanding patriarchal environment in
which millions of women live must give way to an equal
partnership in which women enjoy autonomy and the sense of
accomplishment that comes from building skills and
capacities.

At the same time, girls need to be free from pressures to
marry early. A study in West Africa, for example, found that
nearly 20 per cent of girls in rural areas of the Gambia and
Senegal and 45 per cent of girls in Niger marry before the
age of 15.

Figures such as these underscore the great need for girls and
women to be involved in major personal decisions, including
not only their marrying age but also how closely the births
of their children will be spaced.

Adolescent pregnancy is a major risk factor for both mother
and infant, as the girl may not have finished growing before
her first pregnancy, making childbirth dangerous.

The infant of a very young mother may have a low birthweight.
Higher risks of toxaemia, haemorrhage, anaemia, infection,
obstructed labour and perinatal mortality are all associated
with childbearing in adolescence.

A number of measures are essential, therefore, to enable
women and girls to develop their skills and abilities. These
include ensuring their access to family and community
resources, such as credit, and to education and information.

Basic causes

It is often said that poverty at the family level is the
principal cause of child malnutrition. While it is true that
a lack of resources and malnutrition often go hand in hand,
this statement tells only part of the story.

Many poor families do in fact receive adequate nutrition, and
malnutrition is found in many better-off families.
The broader explanation lies with in a fuller understanding
of the different types of resources necessary for good
nutrition, and of the factors that affect families' ability
to access and control these resources.

The three components of nutrition - food, health and care -
interact closely in their influence on family life. Often
efforts to fulfil one precondition for good nutrition compete
for the same resources required to fulfil another condition.

For example, if a woman has to spend excessive time in
producing food to achieve household food security, her
ability to provide adequate child care can be compromised.
The result may be malnutrition in her young child.

Political, legal and cultural factors at the national and
regional levels may  defeat the best efforts of households to
attain good nutrition for all members.

These include the degree to which the rights of women and
girls are protected by law and custom; the political and
economic system that deter mines how income and assets are
distributed; and the ideologies and policies that govern the
social sectors.

For example, where it is known and appreciated by everyone in
society - men and boys, women and girls, teachers and
religious leaders, doctors and nurses - that women in the
late stages of pregnancy need rest and protection from
overwork, families are more apt to receive the social support
they need to ensure this protection.

In places where there is a tradition of non-discrimination
against women in law and custom, women are more likely to
have good access to resources, including credit, and to the
decision-making power that can enable them to make the best
use of services for themselves and their children.


There is no doubt that while economic poverty is not the only
kind of poverty that eventually affects nutrition, it is
still an important factor.

Overcoming entrenched poverty and underdevelopment requires
resources and inputs that few developing countries,
particularly the poorest, can muster, either on their own,
through existing levels of private external investment and
loans, or through current patterns of official assistance and
loans.

In 1995, for example, aggregate resource flows to the
developing world from all sources totalled $232 billion,
including $59 billion in official development loans and
grants and $156 billion in private resources. Middle-income
countries were the biggest recipients of the private
investments and loans: Two thirds went to them and one third
to low-income countries. The two regions of the world with
the highest rates of childhood malnutrition - sub-Saharan
Africa and South Asia - received only $1.6 billion and $5.2
billion respectively.

And although bright spots exist in terms of investment and
trade in sub-Saharan Africa, the problems of the continent's
economies remain stark, including relatively low levels of
internal demand and the import quotas industrialized
countries impose on African manufactured goods.

At the same time, developing countries overall owed more than
$2 trillion in external debt in 1995. Sub-Saharan Africa, for
example, paid $13.6 billion in debt servicing in 1995 -
nearly double what it spent on health services. And
developing countries bear by far the greatest proportion of
the global burden of disease, which drains their human and
economic resources.

One potentially optimistic note in this dismal picture of
declining aid flows and increasing debt is the new 'Heavily
Indebted Poor Countries (HIPC) Debt Initiative' launched by
the World Bank and the International Monetary Fund in 1996.
This initiative is designed to assist poor countries to
achieve sustainable levels of debt based on an established
track record of implementing social and economic reform and
on the condition additional resources are channelled to basic
social services. Bolivia, Burkina Faso and Uganda will
benefit from the initiative only in April 1998 or later. More
generous and timely  debt-relief  would enable these counties
and others that will hopefully soon qualify to release
resources to reduce malnutrition.

If the basic causes of malnutrition are to be addressed,
greater and better targeted resources and improved
collaboration, participation and dialogue are needed.
Awareness and information must be generated: between sections
of national governments; between governments; with all
development partners, donors, UN agencies, non-governmental
organizations (NGOs) and investors; and above all with those
whose circumstances are rarely under stood or noticed, the
poor themselves.

Action against malnutrition is both imperative and possible.
The world, as the next part of this report explains, has
already accumulated a wealth of experience and insights on
which progress can be built.

Approaches that work

To succeed, the fight against malnutrition must be waged on
many fronts.

Actions as diverse as improving women's access to education,
fortifying staple foods with essential nutrients, enhancing
the spread of practical information and increasing government
social-sector spending have all led to improved nutrition in
a number of countries. The challenge is in devising overall
strategies that address specific nutrition problems.

The range of factors necessary for nutrition improvement was
explored in a recent study by the United Nations,(1) which
confirmed that there is no one formula to follow but that
certain elements are essential.

For example, the empowerment of women is of central
importance to improving nutrition of both women themselves
and their children. This includes legislative and political
efforts to combat discrimination against and exploitation of
women and measures to ensure that women have adequate access
to resources and care at all levels of society. Improving
education for girls and women is also vital.
The United Nations report had this is to say about the
following  specific factors involved in improving  nutrition.

* Nutrition and economic growth: 

Most countries in which nutrition has improved over the last
two decades also enjoyed relatively high rates of economic
growth over a sustained  period. Nonetheless, the
relationship is not completely straightforward.

In countries where economic growth has resulted in increased
household income and resource access for the poor, the
nutritional pay-off has been large. In Indonesia, for
example, economic growth from 1976 to 1986 was accompanied by
a 50 per cent rise in the income of the poorest 40 per cent
of the people. Improvements in nutrition have been relatively
constant throughout the economic boom, although they could
have been even better.

Household food insecurity - one of the key underlying causes
of malnutrition - is often the pivotal point in the
relationship between economic growth and nutritional status.
Poor households spend a large proportion of their income on
food. While poor households do not always use income
increases to raise their calorie consumption significantly,
in many countries greater income has led to in creased
consumption of higher-quality foods that tend to be rich in
protein and micronutrients - the vitamins and minerals needed
in very small but regular amounts to assure nutrition.

But while economic growth must be understood as a frequent
contributor to nutrition improvement, it is not a necessary
condition for it. A number of countries, such as the United
Republic of Tanzania in the case described below, have
achieved widespread nutrition improvement without significant
overall economic growth.

* Nutrition and the status of women: 

A major conclusion of the United Nations report is that in
countries where nutrition improvement has lagged behind
economic growth, social discrimination against women is
common. In Pakistan, for example, widespread discrimination
against girls and women is behind high levels of illiteracy
among women and girls, a very high fertility rate and lower
female life expectancy. Child malnutrition rates in Pakistan
are among the highest in the world, as is the proportion of
low-birthweight infants, at 25 per cent.

Some experts place the major blame for the very high child
malnutrition and low birthweight throughout much of South
Asia on such factors as women's poor access to education and
low levels of employment, compared with other regions.

On the other hand, women in Thailand, where nutrition has
improved remarkably in the last two decades, have very high
literacy, high participation in the labour force, and a
strong place in social and household-level decision-making.

* Nutrition and social-sector spending: 

Investment in health, education, sanitation and other social
sectors - especially with emphasis on access of women and
girls to these services - is among the most important policy
tools for improving nutrition.

As a child survival and development measure, UNICEF has
championed the 20-20 Initiative - the allocation of at least
20 per cent of government spending to basic social services
to be matched by 20 per cent of donor funding in these areas.
The value of such investment is becoming increasingly
apparent. For example, there is evidence from Sri Lanka and a
number of other countries that increases in spending on
public health services are more strongly associated with
reduced infant mortality and better nutrition than are
overall increases in income.


After Zimbabwe achieved independence in 1980, explicit
policies were followed to redress the lack of access of many
communities to basic services. As a result, there were vast
improvements in health services and immunization, family
planning and a range of educational services for the poor -
all of them important determinants of the improvements in
nutrition that the country has enjoyed.

The approaches described above are all essential - and driven
by the right of children and women to adequate services and
resources.

Actions that are more directed to nutrition improvement as a
principal outcome - improving the quality of staple foods
through fortification, improving local-level nutritional
surveillance capacity, protecting women's right to
breastfeed, sharing information on better complementary foods
- may have a more rapid and focused  effect on nutrition.

A number of these more direct approaches that have worked are
described below.

Dramatic results from small beginnings

In villages across Tanzania, a seemingly modest process began
in the early 1980s when villagers, many of them in poor and
remote areas, began to track the weight of their children.
With financial support from the Government of Italy and
day-to-day technical support from UNICEF, the Child Survival
and Development (CSD) Programme began in five districts in
the Iringa region, eventually reaching more than half the
population of the country.

The result was the virtual disappearance of severe
malnutrition - and striking reductions in mild and moderate
malnutrition. The lives of thousands of children were saved.
These improvements were accomplished against the backdrop of
previously high mortality and malnutrition rates among young
children that began to climb in Tanzania following the
economic decline in the 1970s and 1980s. Of crucial
importance was the Government's continued commitment, even
during this difficult  period, to policies worked out with
the full participation of communities and families. This
approach that was to prove one of the greatest strengths of
the CSD Programme.

A community-wide picture

A major feature was community-based growth monitoring, which
allowed the parents and other community members to assess the
nutritional well-being of their own and other children in the
village. The results could then be compared with figures for
neighbouring villages and those throughout the country.

These assessments provided a baseline at the start of the
programme and were repeated every three months thereafter to
follow the progress of individual children. When the results
for all the children in the village were added together, they
provided a concrete measure of nutritional well-being and
development for the whole community. These quarterly weighing
sessions sparked the participation not only of fathers and
mothers, but also of the whole community in analysing why
children were malnourished and why some seemed to thrive
while others did not.

An improved understanding of the factors involved in the
nutritional well-being of their children in turn helped the
villagers to plan and initiate actions that would contribute
to better growth and overall child health.
Subsequent weighing sessions helped parents and villagers
evaluate the results and effectiveness of the actions taken
and consider new or modified actions. In this way, continuous
cycles that combined assessment, analysis and action - the
'triple A' approach - were established, helping spark
successive nutrition improvements in the programme villages
(Fig. 8; Panels 9 and 10).

The steps the villagers took were aimed at increasing feeding
frequency; encouraging better use of basic health services;
training health workers, including skilled birth attendants
and healers; improving the home treatment of diarrhoea and
other illnesses; strengthening household technology to
improve the porridge made for young children; reducing
vitamin and mineral deficiencies; supporting activities such
as small animal husbandry and home gardening; and improving
sanitation.

From bystanders to participants

The simple tool of growth monitoring allowed the villagers to
make better use of their own creativity and resources, to
express their requests for external support more clearly and
to become less dependent on such support.

One thing the Tanzanian CSD Programme did not do was increase
the production or availability of basic food. While food is
obviously essential for good nutrition, the success of the
Tanzanian approach suggested that an overall lack of food at
the household level was not the major cause of malnutrition
in young children and pregnant women in the villages. Less
tangible, but singularly important, was the transformation
that many communities underwent. From passively enduring
economic decline and marginalization, villagers became active
participants for change, formulating and carrying out
policies that led to better lives for their children and
themselves. A major feature of this transformation was the
emergence of women as central players, making decisions at
both the community and household levels, with local support
in the form of start-up financing for their income-generating
activities.

Two other factors underpinned the success of the programme:
universal education, including adult education, and a high
level of political mobilization in Tanzanian villages that
provided an organized system of communication.

Despite setbacks, durable progress

The Tanzanian experience was hardly perfect. When decisions
are made through a repetitive, collective pro cess, false
starts and mistakes are inevitable. Gains also have been
difficult to sustain in some areas. But durable progress has
been made: Communities have actively taken up the fight
against malnutrition, and they have collected and analysed
information themselves. The sense of power and commitment
gained through such a process is not quickly relinquished.

About 10 years after the first successes in Iringa were
reported, a comparable approach is now achieving very similar
results in Mbeya, another part of Tanzania (Panel 11).
Virtually the same community-based approach that had proven
successful in Iringa and elsewhere in Tanzania was introduced
in Mbeya. The improvement in the nutritional status of
children there, again carefully monitored and documented,
independently confirms the validity of this approach.

Nor is the community learning approach used in Tanzania by
any means unique. In the heart of the Sahel, villagers in the
Maradi region of Niger, with support from UNICEF and
bilateral donors, have also begun to record their children's
weight on a regular basis. These villagers face many
obstacles that communities in Tanzania did not have - little
rainfall and a very short growing season, much less
experience with participatory development, less support from
the central level and a history of  village-level
decision-making that explicitly excluded women. But
malnutrition has been significantly reduced, and the scale of
their activities seems on track to rival that of Tanzania
(Panel 12).


In Thailand, another success story

On the other side of the globe, Thailand has achieved
stunning improvements in the nutrition of millions of its
children through a combination of approaches, aided by a
booming economy. The Thai Government estimates that
malnutrition of under-five children fell from about 51 per
cent in 1982 (measured as a proportion of  underweight
children) to about 19 per cent in 1990, and that severe
malnutrition virtually disappeared during that period. At the
local level, growth monitoring and promotion (GMP) coverage
increased nationwide from about 1 million children to about
2.6 million.

GMP was combined with supplementary feeding activities in
some locations. In addition to this increased attention to
nutrition, a number of  policy and programme measures
contributed to reducing malnutrition and poverty. Targeted to
poorer regions, these included: school lunch programmes;
surveillance of 'basic minimum needs' indicators;
village-level planning to ensure that priority needs were
met; rural job creation; and support for small-scale food
producers. Community participation, in varying degrees, was
part of all Thai programmes.

There is general recognition that more needs to be done in
Thailand, but these remarkable gains are a solid foundation
for the future.


Protecting, promoting and supporting breastfeeding

Virtually all of the community-based programmes that have
resulted in reductions in malnutrition have focused on
improvements in infant feeding, especially the protection,
promotion and support of breastfeeding.

While community-based support for breastfeeding is a major
achievement, even the efforts of communities well aware of
the central importance of breastfeeding can be foiled by
larger economic and institutional pressures.

The blitz of inappropriate advertising and promotion by
manufacturers of breastmilk substitutes - mostly infant
formula - has been a central challenge in the fight to
protect and promote breastfeeding. While infant formula is an
important product for the minority of children who for some
reason are not, or cannot be, breastfed, sales and
promotional activities around it have sometimes been based on
untrue claims of its value compared with that of breastmilk.


Promotional activities, such as providing free or subsidized
supplies of infant formula, bottles and teats in maternity
wards, have also undermined the best intentions and the
confidence of new mothers to breastfeed.

In 1981, the World Health Assembly, which consists of the
health ministers of almost all countries, responded
vigorously to inappropriate promotional efforts of the
infant-food industry by adopting the International Code of
Marketing of Breastmilk Substitutes, drafted by WHO, UNICEF,
NGOs and representatives of the infant food industry.(2)

The Code establishes minimum standards to regulate marketing
practices by setting out the responsibilities of companies,
health workers, governments and others and provides standards
for the labelling of breastmilk substitutes. Among its
provisions are that health facilities must never be involved
in the promotion of breastmilk substitutes and that free
samples should not be provided to pregnant women or new
mothers.

Progress has been relatively slow in translating the Code's
minimum provisions into national laws. As of September 1997,
only 17 countries had approved laws that put them into full
compliance with the Code. Training and development of model
legislation are now accelerating action in this area. Support
from the Government of Sweden has enabled UNICEF to provide
greater technical assistance on Code implementation and other
legal aspects of breastfeeding support.

A recent report, Cracking the Code, by the Interagency Group
on Breastfeeding Monitoring, based in the United Kingdom,
highlights the work that remains to be done. It documents
widespread violations of the Code by multinational companies
in four countries: Bangladesh, Poland, South Africa and
Thailand.

The Baby-Friendly Hospital Initiative

As a complement to community-based efforts to protect,
promote and support breastfeeding and to promulgate the Code,
UNICEF and WHO in 1991 began an intensive effort to trans
form practices in maternity hospitals.

The Baby-Friendly Hospital Initiative (BFHI), as the effort
is called, brought a structured programme to breastfeeding
support and, in just six years, has helped transform over
12,700 hospitals in 114 countries into centres of support for
good infant feeding. These baby-friendly hospitals are havens
of protection for breastfeeding, where women and children are
not subject to advertising and promotional activities for
infant formula or feeding bottles, and where they can receive
effective and well-informed  help for a sound start to
breastfeeding.

BFHI has a simple but thorough approach. Through a WHO-UNICEF
training programme that has been translated into the official
languages of the United Nations and into many others, the
professional staffs of maternity hospitals are trained in
lactation management and support. Staff members, along with
the directors or managers of their health facility, make a
commitment to fulfil the initiative's 'Ten steps to
successful breastfeeding' (see sidebar). These include
pledging to ensure that women and newborns can remain
together all the time and that women must be free to begin
breastfeeding promptly after birth and to continue exclusive
breastfeeding on demand during their hospital stay.

Step 10 calls for setting up breastfeeding support groups
that new mothers can rely on. Hospitals can be awarded
'baby-friendly' status only when specially trained
independent evaluators have ensured that all 10 steps are
met.

It is hard to overestimate the success of BFHI. More than a
million people are working to implement its programme, and
the overall pace of hospital certifications has not slowed.
Patterns of declining breastfeeding, particularly in urban
areas, have been reversed in country after country  following
BFHI implementation (Panel 13).

The success of the initiative can also be measured in the
health of young children. In Panama, the Ministry of Health
reported a 58 per cent reduction in respiratory infections
and a 15 per cent decline in diarrhoea in infants in just one
year in a single baby-friendly facility, the Amador Guerrero
Hospital. In north-eastern Brazil, Acari Hospital credits
BFHI with dramatic cost savings from decreased
hospitalization of infants and reduced case fatality among
them. In the first two years of BFHI implementation at the
Central Hospital of Libreville in Gabon, it was estimated
that there was a 15 per cent reduction in cases of neonatal
diarrhoea, a 14 per cent reduction in dehydration and an 8
per cent reduction in mortality.

*    Successes outside the developing world

BFHI is not just for non-industrialized countries.

An evaluation in the Republic of Moldova, once part of the
former Soviet Union near the Romanian border, showed an
average reduction in all neonatal infections in four
baby-friendly hospitals from about 18 per cent to 7.5 per
cent in two years of the programme. The neonatal infection
rate in the hospital that had been certified as baby-friendly
the longest dropped from 23 per cent to 3.4 per cent. Rates
of breastfeeding initiation in the country rose appreciably,
and rates of continued breastfeeding at 6 and 12 months were
significantly higher over the period of implementation of the
programme.

Similar results are being reported from Asia and Latin
America, and some countries are in the process of conducting
extensive evaluations of BFHI's impact. In the United States,
there is an active BFHI programme, and 11 hospitals have been
declared baby-friendly.

BFHI was conceived by a small group of experts with vision
and leadership and was tested, modified and then introduced
globally. But it could not have succeeded without the
engagement of local institutions and communities. Local NGOs
have played a significant role in the promotion and
sustenance of BFHI in many countries. And an international
NGO, the World Alliance for Breastfeeding Action (WABA),
founded in 1991, has helped solidify actions in support of
the initiative and breastfeeding beyond the hospital through
its work in networking, information sharing and advocacy.

National breastfeeding committees, though often established
prior to BFHI, were energized by the initiative's concrete
achievements. Paediatric and obstetric professional as so
ciations have endorsed the programme and have been educated
by it.

BFHI has also helped establish breastfeeding firmly on the
political agenda. The challenge for the future is to use the
political energy behind BFHI to ensure that breastfeeding
promotion and support extend beyond hospital walls and that
breastfeeding support groups become a constant priority for
communities and governments.

*    Complementing breastfeeding

Good infant feeding includes not only support for
breastfeeding but also ensuring good complementary feeding
practices for children more than six months old whose
nutritional needs can no longer be fully met by
breastfeeding, though sustained breastfeeding well into the
second year of life remains important (Panel 14).


The CSD Programme in Tanzania brought about a number of
significant improvements in household-level preparation of
good-quality complementary foods, including porridges with
reduced viscosity designed to increase consumption by young
children.

Until recently, however, there has not been good scientific
consensus on a number of questions related to the additional
food needs of older breastfed children. WHO and UNICEF
recently brought together a group of internationally renowned
scientists and programme practitioners familiar with these
problems, and a consensus report will soon be published that
will offer technical guidance for improving complementary
feeding.


Targeting specific nutritional deficiencies

In assessing nutrition problems and implementing programmes
to attack them, it is not possible to separate protein-energy
malnutrition from vitamin and mineral deficiencies.
Integrated community-based programmes that have achieved
reductions in overall malnutrition have usually done so by
addressing both micronutrient and protein-energy
deficiencies. But among the kinds of malnutrition identified
at the 1990 World Summit for Children, progress has been more
rapid in reducing some deficiencies than others.

Grains of salt: Reducing iodine deficiency disorders

The reduction in iodine deficiency, the world's leading cause
of prevent able mental retardation, is a global success story
by any standard. This achievement, which began to show
significant results beginning in 1992, involved a coordinated
international effort to change diets in a subtle but
important way - an approach that has had an impact on
probably more people worldwide than any previous nutrition
initiative.

A diet deficient in iodine exerts its saddest and most
significant effect on the developing embryo, starting at
around 12 weeks after conception. In adequate iodine results
in insufficient thyroid hormone, which in turn leads to a
failure of normal growth of the brain and nervous system. The
result is all too often a child born with a lifetime
disability.

The practice of using iodized salt as a safe, cheap and
effective way to combat iodine deficiency disorders (IDD) had
a long track record by 1992. It was introduced in Switzerland
in 1922, in the United States in 1924, and in the Andean
countries of South America in the 1950s and 1960s.

Among the goals adopted at the World Summit for Children, the
virtual elimination of IDD was regarded by UNICEF as one of
the most achievable. Universal salt iodization - all salt
destined for both human and animal consumption - was the
obvious strategy to advance the attack on IDD.

Getting the job done, a continuing effort, is a process that
uses the 'triple A' approach - assessment, analysis and
action - on a global scale.

In some countries, the problem of iodine deficiency was
known, but rigorous assessments - using such indicators as
goitre prevalence and urinary iodine excretion - were needed
to convince policy makers and salt producers of the need for
action. The next step was to analyse these results, along
with the workings of commercial salt networks and the
organization of the salt industry. Using advocacy and
attention to legal detail, it was also necessary to pass
appropriate legislation to ensure correct levels of salt
iodization, and to protect iodized salt producers by
eliminating non-iodized salt from the market.

Actually getting iodine into salt supplies was another
matter. The task was addressed in ways that ranged from
relatively easy adaptations by resource-rich major industrial
salt producers that supply whole countries, to providing
support for small producers to enable them to iodize salt
without loss of income. Quality control and evaluation of the
impact of salt iodization remain continuing challenges.
Thanks to support from many quarters, all of these steps have
been realized in a short time in an  extraordinary number of
countries. UNICEF estimates that nearly 60 per cent of all
edible salt in the world is now iodized, and among countries
in the world with recognized IDD problems, all but seven have
passed appropriate legislation to ensure universal
iodization.

Of the countries that had IDD problems in 1990, 26 now iodize
over 90 per cent of their edible salt or import that
proportion if they are not salt producers. Another 14
countries iodize between 75 per cent and 90 per cent of their
salt. As late as 1994, 48 countries with established IDD
problems had no programmes at all. Of these, 14 now iodize
more than half their salt  (Fig. 9).

At the level of children and their families, these results,
though still incomplete, are improving lives by the
thousands. It is estimated that up until 1990, about 40
million children were born each year at some risk of mental
impairment due to iodine deficiency in their mothers' diets.
By 1997, that figure was probably closer to 28 million (3) -
still too many, but representing a clear and rapid decrease.

The number of children born each year with cretinism is
difficult to estimate, but in 1990 it was on the order of
120,000. It is probably about half that now.

It is impossible to measure the impact of IDD on
miscarriages, which are rarely well reported in health
statistics, but the improvements are surely noticeable by
affected women and their families. In highly iodine-deficient
areas, infant mortality was long known to be elevated, but
recent research now indicates that increasing the iodine
intake of young infants to adequate levels may improve their
survival to a far greater degree than previously expected,
probably through improvements in their immune systems.

The gains in salt iodization came about largely because of
the work of an alliance of responsive and knowledgeable
partners. WHO, in collaboration with UNICEF and the In ter
national Council for the Control of Iodine Deficiency
Disorders (ICCIDD), not only helped raise awareness of the
importance of IDD but also worked to ensure scientific
consensus and information on standards for: levels of salt
iodization, the safety of iodized salt in pregnancy, and
indicators for monitoring and evaluation. UNICEF, WHO and
ICCIDD also provided technical and financial support for many
steps of the process.

Kiwanis International, a global ser vice organization,
provides funding support and continues to educate its
grass-roots membership about IDD (Panel 15).

The Government of Canada was a major player in all stages of
this work, supporting UNICEF programmes in many countries and
supporting the Ottawa-based Micronutrient Initiative, which
in turn has extended technical support and funding to field
programmes, including the development of monitoring
guidelines. In 1995, UNICEF estimated that over 7 million
children were born free of the mental impairments of IDD
largely because of the Canadian contribution.

Partly because of Canada's early and unambiguous support to
combating IDD, other donors and governments in affected
countries were drawn into the battle. The approximately $20
million invested by the Government of Canada catalysed other
investors. Total investment by public- and private- sector
partners in this effort since 1986 is now estimated to exceed
$1 billion.(4)

In country after country, advocacy for salt iodization
legislation has brought together teachers, consumer groups,
women's groups and health professionals. Primary
schoolchildren by the millions are armed with test kits that
enable them to check whether the salt in their homes is
iodized - and to get a valuable chemistry lesson in the
process. In Indonesia, for example, the enormous challenge of
salt iodization in a country of almost 14 thousand islands,
with highly decentralized salt production, is being overcome
by a coalition that includes millions of the country's
schoolchildren and teachers.

The elimination of IDD as a public health problem is, of
course, not complete, and momentum must not be lost. But the
effort has already had results beyond these tangible benefits
in the lives of individuals.

The fight against IDD has brought to the attention of policy
makers and communities the importance of good nutrition in
ensuring the physical and mental development of children and
populations. It has opened the door to accelerated work on
other nutrient deficiencies with public health significance.
It has demonstrated the value of public- and private-sector
partnerships in pursuit of a well-defined goal in favour of
children.

The success of the drive for universal iodization of salt
shows that the diets of children, women and families
worldwide can be changed in small but very beneficial ways in
just a few years as a result of concerted global, national
and local action. It is imperative that this experience be
built upon in attacking some of the other nutritional
deficiencies that can begin impairing the development of a
child even before birth.

Capitalizing on vitamin A's benefits

Although the value of vitamin A for protecting children
against blindness has been known for decades, vitamin A's
amazing ability to strengthen resistance to infection and
reduce the chances of children dying has only recently won
general acceptance by the scientific and medical
establishment.

Following a dramatic report from Indonesia in 1986 of a 34
per cent reduction in pre-school child mortality with vitamin
A,(5) seven additional large studies were carried out over
the next seven years. Most of these studies, involving more
than 160,000 African and Asian children, reported large and
significant reductions in mortality when children were given
additional vitamin A through supplements or fortified food
products. When these results were combined statistically in
1993, it was firmly established that  vitamin A
supplementation could  reduce child mortality by about 23 per
cent where there is a risk of deficiency.(6) These
conclusions, strengthened further by evidence that the
vitamin has an even greater life-saving  effect on children
with measles, brought widespread acceptance that measures to
prevent vitamin A deficiency could have an enormous impact on
child survival.

Adequate vitamin A status does  little to prevent children
from being infected but has a major effect on reducing the
severity of illness, especially persistent diarrhoea,
dysentery, measles and malaria (Panel 18). Vita min A's power
to reduce the severity of illness was clearly evident in
Ghana, where periodic distribution of the vitamin led to a
reduction in local clinic attendance by 12 per cent and
hospital admissions by 38 per cent.(7) Vitamin A can thus
have a double-barrelled effect: It not only reduces the
severity of illness and saves lives but also may ease the
demand on often overworked health workers and facilities.

The effect of the discovery of vitamin A as a child survival
tool led to renewed global interest in updating knowledge
about the extent and public health significance of vitamin A
and other micronutrient deficiencies. Numerous surveys of
clinical and sub clinical vitamin A deficiency have led to an
estimate that in 1990 there were over 100 million young
children in the world at risk from the deficiency because of
inadequate diets, although today the immediate risk for many
of these children has been diminished by effective
interventions, including regular vitamin A supplements.

Some countries still lack good assessments, but vitamin A
deficiency, its underlying causes and its consequences for
health and survival are much better understood now than ever
before.

The age-old condition of maternal night-blindness has finally
come to be recognized as a major public health problem. Long
ignored by both afflicted women and the medical
establishment, maternal night-blindness is now recognized to
be widespread, with an estimated 1 million to 2 million
pregnant women affected at any given time in South Asia
alone. Women describe how they are able to see adequately
during the day but after sunset are unable to move about and
carry out their household chores. They consider it a common
problem of pregnancy that goes away once the child is born.
But recent work in Nepal shows that women with
night-blindness during pregnancy are six times more likely to
have been night blind in a previous pregnancy (8) and that
the condition is a marker for a constellation of risk
factors, including dietary vitamin A inadequacy and
deficiency; iron deficiency anaemia; protein-energy
malnutrition; increased morbidity during pregnancy; and
mortality up to two years after diagnosis (Panel 1).

Combining a variety of approaches

Several approaches exist to prevent vitamin A deficiency,
each with its own strengths and limitations, but which can be
highly effective if applied in complementary ways. These
include vitamin A supplements (commonly administered in
capsule form), fortification of food and gardening or other
methods to improve diets.

Vitamin A can be boosted through homestead gardening or
adapting food preservation or preparation methods that can
enhance retention. And fortifying food with vitamin A has
become increasingly feasible as fortifiable foods penetrate
the markets of the poor in a number of countries. These
food-based approaches combine increased vitamin A supply with
nutrition education that promotes the consumption of vitamin 
A-rich foods by young children and women.

Periodic supplementation that provides high-dose vitamin A
capsules - both to children from 6 months to 5 years and
beyond, and to mothers as soon after childbirth as possible -
has proved to be a very valuable intervention, offering
immediate help to children who are at risk of vitamin A
deficiency in situations where food-based options are
limited. Experts  estimate that periodic high-dose 
supplements for young children have the potential of
eliminating 90 per cent of blindness and other ocular
consequences of vitamin A deficiency and about 23 per cent of
mortality in early childhood wherever the deficiency is
common.

Successes in supplementation

It is a major global achievement that by mid-1997, some 30
years after the first vitamin A supplementation programmes
began in India, the policy of providing children with
periodic high-dose supplements has been adopted in all but 3
of the 38 countries where clinical vitamin A deficiency still
existed, and in all but 13 of the additional 40 countries
with documented subclinical deficiency.


At least 35 countries also routinely provide vitamin A
supplements with immunizations during 'national immunization
days'. And many countries link vitamin A supplementation to
regular immunization activities or to periodic deworming of
children, as in India and Mauritania.

Overall, UNICEF estimates that more than half of all young
children in countries where vitamin A deficiency is known to
be common received high-dose vitamin A capsules in 1996,
compared to about one third in 1994 (Fig. 10). This includes
such large countries as Bangladesh, India, Nigeria and Viet
Nam. Between 1993 and 1996, UNICEF purchased nearly a
half-billion high-dose vitamin A capsules that were
distributed in 136 countries, helping to bring or keep 
vitamin A deficiency under control. At roughly 2 cents per
capsule and perhaps 20 to 25 cents per delivered dose, few
other child health or nutrition interventions are as
cost-effective  in reducing mortality and disability
throughout life as vitamin A  supplements.

Breastmilk nearly always provides enough vitamin A to protect
a child from severe deficiency, even if this means that the
child's mother becomes deficient. However, both mothers and
infants can be protected against deficiency if mothers
receive a high dose of vitamin A soon after they give birth.
Some 50 countries have adopted a policy of routine high-dose
supplements for women soon after childbirth, which protects
their children for about six months. New information on the
impact of vitamin A deficiency on women's health makes
post-partum  supplementation an even greater priority (Panel
1).

*    Sugar fortification: A sweet success

Several countries have chosen another route to improved
vitamin A status of their populations: fortifying the sugar
supply.

Guatemala has led the developing world in fortifying sugar
with vitamin A since the mid-1970s. Despite nearly a decade
of civil disturbance and a lapse in fortification for several
years in the early 1980s, an evaluation of 82 villages in
1990 concluded that sugar fortification had brought vitamin A
deficiency under control among Guatemalan children.

Sugar is also being fortified in parts of Bolivia, Brazil, El
Salvador, Honduras and the Philippines, and Zambia is
planning to begin fortification in 1998, with other countries
likely to follow or to find other staple foods to fortify
with vitamin A. The Philippines, for example, has
successfully tested and fortified a local, non-refrigerated
margarine with vitamin A and is testing the impact of
fortifying the wheat flour used in its national bread, pan de
sal.

The success of fortification depends on a number of factors:
Those at risk of the deficiency must consume the fortified
food regularly and in great enough quantities to make a
difference, the fortification must not alter the palatability
of the product for consumers and it must not put the product
out of their financial reach. If these conditions are met,
this can be a very effective approach, as the Guatemalan
experience has shown. Supplementation may be an important
complementary strategy for fortification if fortified foods
do not reach all affected individuals.

Countries also need to ensure that sugar fortification
programmes do not promote increased consumption of sugar but
are aimed at informing consumers that whatever sugar they do
consume should be fortified.

*    Improving diets to boost vitamin A

In many countries, vegetable gardening around the home and
food preservation and preparation methods that enhance the
vitamin content of the diet have been promoted as a means of
improving vitamin A intake. In West Africa and Haiti, for
instance, drying of mangoes has extended  access to this
important vitamin A source beyond the months of the mango
season.

In Bangladesh, home gardens of fruits and vegetables have
been adopted by families of low socio-economic status in one
fifth of the country in recent years, the result of
systematic introduction of village nurseries, the
availability of low-cost seeds, and reliable extension
services. This work has been supported by the NGO Helen
Keller International. Initial evaluations suggest that this
programme has curbed the incidence of night-blindness,
especially in families that grow and consume a variety of
vegetables. This is one of relatively few such projects where
careful evaluations have made it possible to  assess the
impact of activities on  vitamin A status.

There is evidence that eating a variety of foods rich in
carotene - the precursor form of vitamin A found in fruits
and vegetables - coupled with some vitamin A from animal
sources - can alleviate moderate to severe vitamin A
deficiency in children and women.


The absence of more evidence that gardening projects improve
vitamin A status may be because of the low avail ability of
some carotenoids in plant foods for the body, the lack of
complementary fats and animal foods in the diet, or
inadequate evaluation methods. In addition, it is not clear
which vegetables or fruits are most effective in improving
vitamin A status. This question is an important research
challenge.

Promoting increased consumption of vitamin A through animal
foods may be possible in some countries. A recent project in
Central Java (Indonesia), supported by Helen Keller
International, the Micronutrient Initiative and UNICEF,
promoted the consumption of eggs, which are affordable, to
reduce vitamin A deficiency. As a result, egg consumption
increased and vitamin A status improved significantly among
young children in this project (Panel 16). Helen Keller
International also successfully promoted increased
consumption of vitamin A-rich liver by children in Niger,
where animal products are relatively accessible in some
regions.

*    Responding to anaemia

Iron deficiency anaemia is probably the most prevalent
nutritional problem in the world. Over half the women in
developing countries and a large percentage of young children
suffer from it,(9) and progress in reducing its prevalence
and impact has been slower than might be hoped. As with
vitamin A, several approaches have been pursued.

The consequences of anaemia for pregnant women and their
newborn children are often disastrous. The condition puts
women at higher risk of death because of the greater
likelihood of haemorrhage in childbirth and other factors,
and their newborns face a high risk of poor growth and
development. Many countries have adopted policies to ensure
that women who seek prenatal care have access to daily iron
supplements to help them meet the very high needs of
pregnancy and childbirth. UNICEF is a major supplier of
iron/folate tablets. A total of 2.7 billion were provided to
122 countries from 1993 to 1996.

However, since many pregnant women enter pregnancy already
anaemic - and it is difficult to resolve pre-existing anaemia
during pregnancy - more attention is being paid in some
countries to improving the iron and folate status of girls
and young women before their first pregnancy. There is
evidence from small-scale trials that in cases where it is
difficult to reach young women with daily iron/folate
supplements, ensuring weekly or twice-weekly supplementation
may still be effective in building iron stores.(10) In
Malaysia, weekly supplementation over several months resolved
the anaemia in over 80 per cent of adolescent girls in a
community where anaemia was highly prevalent. Similar results
have been reported from other countries.

Fortification of foods with iron is also an effective means
of addressing anaemia. Wheat flour and flour products are the
most common vehicles for iron fortification in places where
they are widely consumed and centrally processed,
particularly in Latin America and the Middle East (Panel 17).

In 1993, Venezuela began fortifying all wheat and maize flour
with iron and B vitamins. A 1996 evaluation showed large
reductions in the prevalence of anaemia in children and
adolescents following the fortification, even though during
this period the country was suffering from a general economic
decline.(11)

At a meeting in 1996, countries of the Middle East and North
Africa made a joint commitment to fortifying wheat flour with
iron as a principal strategy for anaemia reduction in the
region, where wheat is a staple.

Anaemia is made worse by some illnesses, particularly
hookworm infection. Malaria is also a major cause of anaemia,
although this is not directly related to iron losses. In
several countries, deworming of schoolchildren has been shown
to reduce the prevalence and severity of anaemia.(12)
Preventing malaria and improving its curative treatment,
which are priorities of UNICEF and WHO for 1998 and beyond,
will undoubtedly go a long way to reducing anaemia in
children and adults alike.

Improving basic health services

The nutritional well-being of children around the world has
benefited greatly from the enormous achievements since 1990
in improving children's access to basic health services, both
curative and preventive.

The success of child immunization programmes has been a major
boost to child health. Immunization also protects vitamin A
levels, which plum met during acute measles infections. So,
the spectacular achievement of over 90 per cent immunization
coverage in 89 countries and over 80 per cent in another 40
countries by 1996 - including  a 79 per cent global measles
immunization rate (13) - means that for millions of children,
vitamin A levels undisturbed by measles episodes will
continue to help protect them from  illness.

Programmes to improve hygiene and sanitation are also likely
to be of crucial importance almost everywhere there is
malnutrition in impoverished communities. Improved water
supplies or support to food production may also be very
critical, depending on local circumstances. Analyses in
several countries have found that the strongest predicting
factors for malnutrition are lack of safe water, inadequate
sanitation and high fertility rates.

Each year over 1 million more children are saved from death
through the use of oral rehydration therapy (ORT).(14) ORT
promotion includes sup port for continued feeding during and
after diarrhoea as well as the use of oral rehydration salts
(ORS) to prevent and treat dehydration. Continued progress is
needed in diarrhoea prevention, treatment, nutritional
management and cure to ensure that growth lost during
diarrhoea episodes is rapidly caught up, but the achievements
so far have been of great nutritional benefit to millions of
children. Similarly, the gains already achieved in access to
safe water and sanitation facilities have translated into
nutritional benefits around the world. Millions more children
than before have been able to avoid plunging deeper into the
spiral of infection and poor dietary intake because so many
illness episodes are prevented or readily cured.

An especially important advance in the health world has been
the revitalization of basic health services through such
measures as the Bamako Initiative, the set of policy measures
launched by African governments in 1987 in response to the
rapid deterioration of public health systems in Africa in the
1970s and 1980s. Now operating in other regions, the Bamako
Initiative measures have meant that health centres in remote
areas - virtually abandoned in the 1980s for lack of basic
drugs and supplies - are again thriving and serving the
communities whose active involvement in their management has
helped resuscitate them. The results have been striking. In
addition to ensuring access to basic curative services, the
initiative has sustained increased coverage of immunization
and other preventive activities. In Guinea, for example, pre
natal care coverage went from less than 5 per cent before the
initiative to almost 80 per cent in the mid-1990s.

With WHO and other partners, UNICEF is committed to
accelerated action in malaria control, including the
promotion of insecticide-treated bednets and support for
improved drug use in malaria treatment. A combined programme
for prevention of both iron deficiency anaemia - through iron
supplementation, fortification and dietary improvement - and 
parasite-induced anaemia - through malaria control and
deworming - is one emerging approach for effectively
addressing these age-old problems.

Programmes featuring improved education and information

The programmes described above in Niger and Tanzania included
important education, information and communication
components. In some cases, this included reinforcing
classroom education, as in Niger, where literacy and other
non-formal instruction to women in participating villages
only served to highlight the need to improve formal education
for their children, especially their daughters. One donor
agency  involved in supporting community-based programmes in
Niger, in fact, encouraged the inclusion of formal  education
for girls as part of the activities meant to improve
nutrition.

School-based programmes in cases such as this, as well as
non-formal programmes for youth and adults, such as literacy
and parent education courses, are a useful complement and
sometimes a principal vehicle for other activities promoting
better nutrition. It is easy and usually very appropriate to
ensure that curricula used in these programmes include strong
nutrition components.

Schools, teachers and education programmes can serve as
mobilizers of community participation in many ways, such as
through village education committees and parent-teacher
associations. These can also serve as a resource for
nutrition and help organize relevant community-based
assessment, analysis and action as well as promote good
practices and share information concerning nutrition.

In the Lao People's Democratic Re public, for example, early
childhood development volunteers in the community and parents
are mobilized through participatory processes to  develop,
among other skills, better  nutrition practices, both
traditional and modern. The essential role of teachers and
schoolchildren in promoting the use of iodized salt and even
testing its quality in Indonesia was mentioned earlier. In
this case, messages about salt iodization and its  importance
have even been formally incorporated into teacher training
courses across the country.

Eight useful lessons

What have these success stories shown? While there is no
single prescription, these eight points bear noting.

1. Solutions must involve those most directly affected.

Malnutrition has many causes and manifests itself in several
ways. There is no single, globally applicable solution to the
overall problem, and there is no substitute for assessment
and analysis done with the full and active participation of
the families most threatened by nutritional problems and most
familiar with their impact and causes. People who suffer or
whose children suffer from malnutrition cannot be passive
recipients of programmes. If they are not the main players in
problem assessment and analysis, then actions to reduce
malnutrition are likely to be inappropriate or unsustainable.

2. A balance of approaches is necessary.

A central challenge for nutrition programmes, as well as
other development efforts, is finding a balance of approaches
that work. Processes involving assessment, analysis and
action - the triple A approach - are essential for
formulating appropriate 'bottom-up' solutions, particularly
with respect to the ways in which programmes are organized,
managed and monitored. But there are some aspects of
resolving malnutrition that can be appropriately formulated
at higher levels, using wide and more 'top-down' application
of appropriate strategies and technologies, based on the best
scientific knowledge and the most effective technologies
available.

UNICEF experience indicates that for many problems, a
combination of top-down and bottom-up actions may be best.
BFHI was formulated as a global strategy, but its success has
taken many forms, depending on the engagement of national and
local institutions and groups.

Vitamin A supplementation was suggested by the mortality
reduction it enabled in many places and endorsed globally as
a strategy, but its application has depended greatly on
existing health measures and the involvement of
community-based  institutions.
 
Salt iodization has been enhanced by consumer advocacy and
legislative change at the local and national levels and by
the fact that communities previously affected by IDD can see
and feel a difference.

The essence of a triple A approach is not necessarily to
establish new  cycles but, as much as possible, to build upon
existing ones. Assessment-analysis-action cycles are the
logical steps everyone tries to follow in order to cope with
their problems better. By understanding how nutritionally
useful mechanisms work and where the weaknesses are, a
nutrition programme can build upon and improve existing good
practices, rather than establishing new systems and
procedures that may be difficult to accept and adopt, and are
therefore difficult to sustain.

In the case of the Tanzanian CSD Programme, there were many
components but the main focus was to improve people's
capacity to assess the problem - through growth monitoring -
and thereby help them make better use of their resources.

3. Nutrition components work better in combination.

Because malnutrition is the result of so many factors, it is
not surprising that it has been attacked most effectively in
situations in which several sectors and strategies have been
brought to bear.

Combining improved infant feeding, better household access to
food overall and improved and more accessible health services
and sanitation is clearly more effective in reducing mal
nutrition where food, health and care are a problem than any
of these measures taken alone. In support of these various
approaches that work, relevant social services - health, 
education, communication and social mobilization - must be
more clearly focused on nutrition. This is not done by
creating new 'nutrition projects' in these areas, but rather
by incorporating nutrition components in ongoing
community-based activities. Experience shows the usefulness
of building such nutrition components into all programmes,
wherever possible.

The impact on nutrition of health, education and other social
services should also be monitored, with the results used both
for a better understanding of nutrition problems and as a
means to motivate policy makers, programme staff and
communities themselves to increase their efforts to reduce
malnutrition. Based on the monitoring of nutrition impact,
viable and successful programmes should be redesigned so as
to have the best effect.

Communication plays a special role in nutrition programmes in
arming parents, educators and other caregivers not only with
basic nutrition information but also with the ability to make
informed decisions and the skills and knowledge needed to
take action to support improved nutrition in their
communities.

Communication should be carried out simultaneously at various
levels to include parents, other family members, teachers,
volunteers and community leaders who can in turn teach and
support good practices. In addition, personnel of provincial
and district health offices, staff in agriculture, rural
development and education itself, media representatives,
researchers and persons in positions of power of any kind
must be reached and their help enlisted.

4. Progress hinges on continuing research.

All of these gains against malnutrition have depended upon
programmatically relevant research, but more is needed. Both
motivated researchers and processes to support such research
are needed. For example, it took the urging of United Nations
agencies and financing from the Government of Canada to
ensure an analysis of the mortality impact of vitamin A
deficiency.

There is a need for more research to improve programmes that
affect the hardest-to-reach people, and for determining the
effectiveness of feasible interventions - for example, how to
encourage increased consumption of green leafy vegetables.
Research institutions, both industry-based and academic, need
to include the poor and their day-to-day nutrition problems
on the research agenda.

5. Food production is important but not enough.

As was demonstrated in the Tanzanian programmes of Iringa and
Mbeya, nutrition can be improved even in rather poor
communities without increasing overall food availability.
Increasing food production is often necessary, but it is
never enough to ensure improvement in nutrition.

Programmes that aim to increase food production countrywide
or in parts of countries should not claim that nutrition will
be improved in young children and women unless other specific
and focused measures are implemented to better their 
situation.

6. Everyone has an obligation to child rights.

Children have a valid claim to good nutrition. The government
has an obligation and many other members of society and the
community, including parents, have duties to realize the
child's right to good nutrition. All of these groups need to
become aware of the nutrition problem, its causes and
consequences, the possibilities of solutions, and their
obligation to respect, protect, facilitate and fulfil child
rights. They need to know what to do and how to do it.
Advocacy, information, education and training are all
important strategies to create or increase this necessary
awareness.


7. Community and family-based involvement is vital.

Children's rights give them valid claims on society. In order
for poor people to carry out their duties towards children,
the poor must be recognized as key actors rather than as
passive beneficiaries.

All available resources, even those controlled outside the
community, should be used to support processes within
households and the community that contribute to improved
nutrition. Such processes involve decisions about the use of
resources and the monitoring of the impact of these
decisions.

As described above, households and communities learn how to
search for better solutions through the process of assessing
the existing situation, analysing the causes and acting as
available resources permit. Community- based monitoring is
important in the repeated assessment of the evolving
situation. Analyses by the community and by all supporters
outside the community are facilitated by an improved
understanding of the causes of the nutrition problem.

Outside support includes advocacy, information, education,
training and direct service delivery. Government and NGO
staff may work outside the community, but should be in
frequent contact with the community, functioning as
facilitators. They should focus their support and dialogue on
community mobilizers: people who are a part of the community
and enjoy its trust and respect.

There is no pre-defined package of inputs or services that
can work. Instead, the community is constantly learning about
the best mix of interventions, a mix that can change 
significantly over time. Community development means that
desirable outcomes, such as good nutrition, are achieved
through participatory and sustainable processes. A
combination of top-down advocacy and mobilization and a
bottom-up demand for support will ensure that both community
and government feel ownership of successful changes.

8. Government policies must reflect the right to nutrition.

Some national policies affect nutrition directly, such as
salt iodization or immunization programmes, for example.
Others, like income and price policies, affect nutrition
indirectly.

With the ratification of the Convention on the Rights of the
Child, governments have the obligation to respect, protect,
facilitate and fulfil the rights enshrined in the Convention.
All policies should therefore be analysed in terms of their
real and  potential impact on the right to good nutrition.

The most important strategies for nutrition include those for
food, health, breastfeeding, education, and water and
sanitation, and national nutrition information systems should
be established to provide valid data about their impact.
Policies should be based on knowledge from relevant research
and be constantly evaluated for their real impact on
nutrition in communities. Nutrition information systems
should be as decentralized as the existing  administrative
systems, starting with community-based monitoring.


Bringing science to bear

Science and technology will never solve all of the problems
associated with the inadequate food and care and the lack of
health services and sanitation that lead to childhood
malnutrition. But the successes stemming from breakthroughs
being made and insights reached have stirred new hope for
healthier, more productive lives for both children and
adults. This section describes some of the crucial scientific
advances that are helping to shape specific interventions to
reduce malnutrition or that may do so in the future.

Some of this knowledge, such as the strengthening effect of
vitamin A on the immune system, is well established; other
knowledge is just emerging and is worth watching. Some of the
new science is likely to accelerate efforts to reduce
malnutrition, and at the same time generate new understanding
of how reducing mal nutrition in childhood or during the
prenatal period may lessen chronic disease in adulthood and
the onerous public health burden it causes. There are also
new tools to tackle the essential task of nutritional
assessment and new ways that agricultural science can be
brought to bear on the problem.

Nutritionally acquired immune deficiency

It is estimated that the immune systems of some 23 million
people worldwide have been damaged by HIV.(1) It is less well
known that malnutrition impairs the immune systems of at
least 100 million young children and several million pregnant
women,  none of them infected by HIV. But unlike the
situation with AIDS, the 'cure' for immune deficiency due to
malnutrition has been known for centuries: It is achieved by
ensuring an adequate dietary intake containing all essential
nutrients. Today, more is being learned about the specific
role of individual nutrients in the functioning of the immune
system, knowledge that will help in the design of
interventions that can improve the situation in the near
future. This knowledge also reinforces the importance of
striving to ensure that everyone in the world has access to a
diet that is adequate in both quality as well as quantity.

Scientists have known for some time that malnutrition and
infection are connected. A 1968 monograph by WHO, entitled
'Interactions of Nutrition and Infection', was one of the
first comprehensive statements of some of these links.

The threat that vitamin A deficiency poses to the lives of
young children has already been described. Within a few
years, the scientific community went from calling the fact
that vitamin A supplements could reduce child mortality "too
good to be true" to calling it "too good not to be true."But
the many ways vitamin A deficiency increases child deaths
were not well understood until recently. Now the results of a
dozen field studies, conducted in Brazil, Ghana, India,
Indonesia, Nepal and elsewhere, indicate that supplementing
the diets of children who are at risk of vitamin A deficiency
can reduce deaths from  diarrhoea. Four of the studies that
focused on diarrhoea showed that deaths were reduced by 35-50
per cent. The vitamin can also halve the number of deaths due
to measles (2) (Fig. 11).

In Bangladesh, breastfed infants whose mothers were given a
single oral high-dose supplement of vitamin A shortly after
giving birth had significantly fewer days of sickness 
because of respiratory infections and febrile illnesses
during the first six months of life than did infants born to
unsupplemented mothers from the same socio-economic group in
the same area.(3)

Zinc is another micronutrient that has long been known to be
essential for the growth and development of cells and for the
functioning of the immune system. However, because zinc
deficiency is extremely difficult to measure, little
attention was paid until recently to the possibility that it
might impair child health and development (Fig. 12).

Trials in Bangladesh, India and Indonesia have already shown
reductions of about one third in the duration and severity of
diarrhoea in children receiving zinc supplements and a 
median 12 per cent decline in the incidence of pneumonia.(4)
In these investigations, zinc supplements did the most good
for those children who started out the most malnourished.

A study recently completed in Lima (Peru) found that the
benefits of zinc supplementation on immunity can begin even
before birth. Re searchers from the Johns Hopkins School of
Public Health in Baltimore (US) and the Instituto de
Investigacion Nutricional in Lima have been adding zinc to
the iron and folate  supplements of pregnant women and
testing its impact on the health of their newborn children, 
including its effects on immune  system activity.  Initial
analysis shows that antibody levels just after birth are
higher in the children of zinc-supplemented  mothers than in
those receiving a placebo.

Zinc supplementation appears so effective in reducing the
incidence of diarrhoea and pneumonia in poor countries that
one scientist, Robert Black of Johns Hopkins University, has
suggested that zinc supplements are as significant a public
health intervention for diarrhoea reduction as improvements
in water and sanitation. And major new research indicates
that even the effects of malaria, a deadly enemy of both
children and adults, may be lessened by zinc and vitamin A
(Panel 18).

Iron deficiency can also damage the immunity of a growing
child, impairing the body's ability to kill invading
pathogens and leading to  increased illness in iron-deficient
populations.(5) In studies in Egypt, anaemic children had
longer and more severe episodes of diarrhoea than did their
iron-fortified peers.

Basic science is now able to explain why these astonishing
results occur. Thus far, zinc and vitamin A are the two
micronutrients that have proved to be the most closely linked
with the proper functioning of the body's front-line
defences. These two micronutrients help maintain the physical
barriers of skin and mucosa that prevent micro-organisms from 
invading the body, as well as enhancing the activity of
leukocytes such as NK (natural killer) cells and mac ro
phages - scavenger cells that engulf, then destroy, foreign
pathogens such as bacteria throughout the body.

Equally important, low dietary consumption of zinc and
vitamin A reduces the number and impairs the development and
function of two types of B-cells - key players in 'acquired 
immunity'. These produce antibodies and T-cells that, in
turn, are responsible for eliminating virus-infected  host
cells. They also produce biochemicals known as cytokines,
which further promote B-cell and macrophage activity. At the
same time, an adequate intake of zinc is now understood to be
necessary in order for both vitamin A and iodine to do many
of their vital jobs.

Nutrition and AIDS

The role of nutrition in preventing infection is now being
investigated as one possible way to help reduce the
transmission of AIDS. Vitamin A may form part of the arsenal
needed to combat HIV, which is expected to infect between 4
million and 5 million children by early in the next century,
most of them in sub-Saharan Africa. These children will
mainly be infected by their mothers.

The routes of mother-to-child trans mission of HIV, also
known as vertical transmission, are threefold: during
pregnancy, during labour and delivery, and through
breastfeeding.

Scientists have been exploring the possibility of reducing
vertical transmission in all three routes since 1994. They
have tried to block intrauterine transmission by giving women
doses of the antiretroviral drug Zidovudine during pregnancy.
The drug has been shown to reduce mother-to-child trans
mission of HIV - but at hundreds of dollars per course, it is
prohibitively expensive for most people in the developing
world. Less expensive methods of antiretroviral therapy
during pregnancy, such as administering Zido vudine for
shorter periods or using cheaper drugs, are now being tested
in Haiti, sub-Saharan Africa and South-East Asia.

Two other treatments during pregnancy are also under
investigation. These involve either intravenous therapy with
purified anti-HIV antibodies, or supplementation with vitamin
A. In a 1994 study of HIV-infected women in Malawi, it was
found that 32 per cent of those who were vitamin A deficient
during pregnancy had passed HIV on to their  infants. In
contrast, only 7 per cent of HIV-infected women with
sufficient levels of vitamin A did so. The study concluded
that vitamin A-deficient  women were thus four and a half
times more likely to infect their children.(6)

Also, a 1995 study from Kenya  reported that the
concentration of HIV in breastmilk is higher in vitamin
A-deficient mothers than in those with good vitamin A status.
Another study, also from Kenya, has shown that HIV-positive
women who are also vitamin A deficient were five times more
likely than non-vitamin A-deficient women to shed
HIV-infected cells in their reproductive tracts, a factor
that may be an important determinant of both sexual and
vertical transmission of AIDS. However, some experts have
suggested that these results may have come about not because
of the influence of vitamin A on HIV transmission, but
because poor vitamin A status and high rates of infection
occur  together for other reasons.

Based on the findings of the first studies - and to
demonstrate whether the connection between vitamin A and HIV
transmission is causal - four clinical trials were begun
recently to examine HIV transmission rates in women who have
received  vitamin A supplements during the second or third
trimester of pregnancy. Results from these studies, conducted
in Malawi, South Africa, Tanzania and Zimbabwe on a total of
nearly 3,000 HIV-infected women, are expected soon.

Using nutrition to reduce maternal deaths

Maternal mortality is a tragedy in  social, economic and
public health terms. WHO and UNICEF have noted that of the
585,000 yearly maternal deaths around the world, the vast
majority are preventable. About 80 per cent of these deaths
are the result of five direct obstetric causes: haemorrhage,
infection, obstructed labour, unsafe abortion and a
convulsive disorder in late pregnancy called eclampsia.(7)

As already noted, obstructed labour is more likely to occur
among women who were stunted in childhood (Fig. 13). It is
estimated that anaemia may be responsible for as much as 20
per cent of maternal mortality, particularly those deaths
from haemorrhage and possibly infection. Anaemia also 
increases the risk of morbidity and mortality associated with
any major surgical intervention, including Caesarean section.

Programmes already exist to  reduce anaemia in pregnant
women. More work is needed, however, not only to make
iron/folate supplementation pro grammes more effective, but
also to improve the treatment and prevention of malaria and
hookworm. Both of these are conditions that also contribute
to maternal anaemia.

Even if an adequate nutritional status were achieved in
adolescent girls and women before their first pregnancy, this
would never eliminate the need for good medical care in
pregnancy and childbirth. But some day it may help reduce the
tragic burden of maternal mortality and the need for certain
medical interventions. Some of the connections between
nutrition and maternal mortality suggested below are not yet
definitively demonstrated or part of programme activities,
but they hold great promise for the future. A few are
especially worth mentioning:

* Even given the many known benefits of good vitamin A 
status, it is nonetheless remarkable to find that improving
the vitamin A status of pregnant women whose intake of the
vitamin is low also dramatically reduces maternal mortality
(Panel 1). Deadly infections in pregnancy, as in childhood,
find a formidable adversary in vitamin A. The use of
low-cost, low-dose vitamin A capsules as well as improvements
in diet make it highly probable that this new research will
be easily incorporated into programmes.

* Zinc deficiency, increasingly recognized as widespread
among women in developing countries, is associated with long
labour, which increases the risk of death. Severe zinc
deficiency is also believed to impair foetal development in a
number of ways. Zinc is important for the synthesis of
hormones and enzymes essential to childbirth - especially
estrogen-dependent  functions such as expulsion of the
placenta and proper contraction of uterine muscles during
birth - as well as for immune-system development. A number of
studies around the world have found that zinc supplementation
has reduced complications of pregnancy. Several studies are
under way that will soon help define the impact of improved
zinc status on pregnant women.

* It has long been known that iodine deficiency in women
increases the risk of stillbirths and miscarriages. And there
is evidence that, in highly iodine-deficient areas, another
result of this deficiency may be increased maternal mortality
through severe hypothyroidism.

* A recent study in the United States showed that calcium
supplementation did not reduce the risk of hypertension in
pregnancy that could result in death, but a number of experts
have suggested that supplementation might reduce this risk in
areas where women are especially calcium deficient.

* Folate deficiency, now well known to induce neural-tube
birth defects if it is present during the first month of
pregnancy, may also represent a risk for maternal morbidity
and mortality, as well as increase the risk of low
birthweight.

The clear message emerging from these connections is that
improving women's nutritional status - by increasing their
intake of micronutrients as well as their overall food
consumption, and by taking steps to reduce their workload and
improve their  access to health care - may offer
considerable, low-cost benefits in reducing maternal deaths.
But there is still no international consensus on the benefits
to be gained by supplementation during pregnancy with
nutrients other than iron and folate.

The real challenge is to reach women well before they become
pregnant - indeed, to help adolescent girls achieve the best
nutritional status possible before they enter their
reproductive years. This would not only help reduce maternal
mortality but would also reduce the prevalence of low
birthweight, the risk of birth defects and the rates of
stillbirths and early infant mortality. All of these remain
scientific and programmatic challenges, along with the
imperative of ensuring that women's health is  positioned
high on the health and  development agendas of all countries.

Breastfeeding: Good for mothers' health too

In addition to the nutritional status of adolescent girls and
women, there is another important connection between
nutrition and maternal mortality. A number of studies have
shown a strong link between the early initiation of
breastfeeding and reduced risk of postpartum haemorrhage.

Initiating breastfeeding immediately following birth, as most
women do in baby-friendly hospitals, stimulates the
contraction of the uterus and reduces blood loss. For this
reason, the continuing spread of the Baby-Friendly Hospital
Initiative should also contribute to the reduction of 
maternal mortality.

In recent years, research has also demonstrated that this
immediate post-partum benefit is by no means the only way in
which breastfeeding can improve women's health. A recent
large-sample study in the United States demonstrated that
women who breastfed their children had a lower risk of breast
cancer in the pre-menopausal period, and the longer they
breastfed, the lower the risk.(8) These results show that
protecting, promoting and supporting breastfeeding has
benefits for women that go beyond the remarkable effects,
already well understood, that protect their children from
illness and death.

Prevention of chronic diseases

Chronic degenerative diseases are largely regarded as
diseases of affluence. In industrialized countries,
improvements in living standards and health care have led to
increased life expectancy, allowing people to live long
enough to develop such chronic illnesses. Chronic diseases
are also associated with the sedentary lifestyle and
over-abundant diet prevalent in many industrialized nations.

Arguments are being made, however, that these chronic
diseases in large measure may also be diseases of poverty -
particularly poverty early in life and during foetal
development. The hypothesis is particularly intriguing in
light of the fact that ischaemic heart disease is projected
to be the world's leading cause of death and disability in
the year 2020.(9)

Professor David Barker and his colleagues at the Medical
Research Council (MRC) Environmental Epi dem i ol ogy  Unit
in Southampton (UK), first raised the "foetal origins of
adult disease" hypothesis over a decade ago, noting a link
between low birthweight and the incidence of cardiovascular
disease among middle-aged men and women born in the United
Kingdom.(10)

Since then, over 30 studies around the world have indicated
that low-birthweight babies who were not born prematurely
have a higher incidence of hypertension later in life than
those with a normal birthweight,(11) independent of their
social class and such adult risk factors as smoking, drinking
and overeating.

Low birthweight, as well as thinness at birth, has also been
correlated with glucose intolerance in childhood (12) and
non-insulin dependent  diabetes in later life.(13)

Professor Barker and his colleagues speculate that maternal
dietary imbalances at critical periods of devel opment in the
womb can trigger a re dis tribution of foetal resources,
affecting a foetus's structure and metabolism in ways that
predispose the individual to later cardiovascular and
endocrine diseases. The correlation between low birthweight
and later cardiovascular disease and diabetes may arise from
the fact that nutritional deprivation in utero 'programmes' a
newborn for a life of scarcity. The problems arise when the
child's system is later confronted by a world of plenty.(14)

In central India, an ambitious study has been funded by UK
Welhome Trust and coordinated by Dr. Ranjan Yajnik at the
King Edward Memorial Hospital Research Centre in Pune (India)
and Dr. Caroline Fall at the MRC Environmental Epidemiology
Unit. It is exploring the impact that a mother's nutrition
may have on the development of diabetes, high blood pressure
and coronary heart disease in her offspring when they reach
adulthood. The results could resolve some of the
uncertainties about causation of chronic illness, offering
nutritional information relevant to both developing and
industrialized countries.

The study has followed over 800 women through pregnancy,
monitoring foetal growth, maternal weight gain and
biochemical indicators of nutritional status.(15) The
nutritional value of the women's daily food intake -
including calorie, protein and micro nutrient content - was
measured and recorded. Within 24 hours of birth, both infant
and placenta were weighed and other body measurements
made.(16) Almost one third of the nearly 800 infants born
during the study were classified as low birthweight, under
2.5 kg.(17) An interesting early finding suggests that
birthweights are most strongly associated with the size of
the mother - not just her weight gain during pregnancy, a
well-known determinant of newborn size, but also her weight,
height, percentage of body fat and head circumference  before
conception. The weight and body mass index of many of the
women before pregnancy suggested chronic undernutrition. The
study also suggested that women's diet during pregnancy did
not appear to have influenced foetal size substantially, 
although regular consumption of two particular items - green
leafy vegetables and dairy products - was associated with
larger birth size. These early findings lend support to the
premise that building a sturdy baby depends on good nutrition
for the expectant mother throughout her life.

The children from the Pune study are growing up in a society
of increasing urbanization and prosperity. Urban dwellers in
India are already five times more likely to develop diabetes
than their rural relatives, (18) and those who have migrated
to industrialized countries like the United Kingdom die in
significantly larger numbers from coronary heart disease than
their indigenous white counterparts.(19)

In 1999, the first of the children in the study will be
tested for signs of glucose intolerance and insulin
resistance; these are early hints of diabetes that have
already been noted in children of low birthweight in
Pune.(20) Soon after, blood pressure monitoring will begin in
an effort to look for initial signs of hypertension. As the
study progresses, findings can be related back to birth size,
foetal growth and maternal diet before and during pregnancy.
From an undertaking of this magnitude, clear evidence may
emerge about the importance of improving maternal nutrition
as a means of preventing chronic later-life disease in
children - before these children have children of their own.

New ways to reduce malnutrition deaths in emergencies

The sheer extent of mild and moderate malnutrition makes
these conditions responsible for much more sickness and death
globally than does severe malnutrition. But a severely
malnourished child - usually defined as under 70 per cent of
the median weight-for-height reference or having oedema
(water retention and swelling) at least in the feet - is at
very high risk of death, and requires prompt and intensive
care in a health facility.

Until recently, health professionals dealing with severe
malnutrition in emergency situations or in large hospitals in
poor countries had been using an approach practised for
years. The protocol was to treat infectious conditions,
correct  rehydration and feed, at least in the early stages,
with high-energy milk - usually a combination of dried skim
milk, vegetable oil and sugar. In the last few years,
however, with the help of WHO and the benefit of the
experience of a number of NGOs specializing in this field,
the new protocol is improving the treatment of severe
malnutrition.

While the new protocol retains some elements of former
standard practices, there are significant changes. The milk
now recommended for the early stages of therapeutic feeding,
for example, is enhanced by the addition of both oil and a
vitamin and mineral mix, which addresses the  special
micronutrient imbalance that accompanies severe malnutrition.
Called F-100 because it gives 100 kilocalories per 100
grammes, the milk optimizes the chance for rapid weight gain
and the eventual recovery of a severely malnourished child.

Another important change is a new recommendation calling for
modification of the standard oral rehydration salts (ORS) to
address the special electrolyte needs of severely
malnourished children. The use of standard ORS has been known
to increase risk of heart failure and sudden death among
certain severely malnourished children. The revised ORS
reduces that risk. Known as ReSoMal (rehydration solution for
malnutrition), it contains more potassium and different
concentrations of elements from those in standard ORS.

The new protocol for the care of the severely malnourished
also emphasizes elements that have been known by nutrition
workers for some time, but perhaps not well enough to be
integrated into regular practice. These include the need for
rapid attention to clinical factors, such as low body
temperature (hypothermia) and low body sugar (hypoglycaemia),
as well as to less strictly medical factors such as meeting
malnourished children's great needs for emotional support,
intellectual stimulation and play. Experienced emergency
nutrition personnel working in places such as the Great Lakes
region of Central Africa and the Democratic People's Re
public of Korea have adopted this method and noted how
quickly it helps reduce mortality. One challenge is to ensure
that supplies of the appropriate high-energy milk and
rehydration solution are steady and sufficient (Panel 19).

New ways to measure malnutrition

Much of the new knowledge described above will contribute to
effective actions to reduce malnutrition and related
conditions. But even when actions are effective, assessing
their impact is often difficult. Measuring malnutrition
initially can also pose problems - and make it difficult to
place the issue on the policy and programme agenda.

There is thus a need for assessment and analysis techniques
that are low in cost, produce rapid results and are easy to
use and understand. Here are some of the promising new tools:


* A simplified way to look for vitamin A: Population-level
surveys of  vitamin A status have been a particular
challenge. In the past, when it was thought that the main
impact of vitamin A deficiency was damaged eyes and
blindness, population surveys of vitamin A status involved
examining children's eyes for early signs of damage. Now that
it is understood that this deficiency has lethal consequences
on a subclinical level - that is, at levels of deficiency
that do not yet show up as damage to the eye - more sensitive
methods of detecting its presence are needed.

Most of the national or regional vitamin A surveys that have
been conducted in recent years have used blood retinol as the
principal indicator of vitamin A status. There are some
difficulties with the interpretation of this indicator, and
it is expensive and difficult to collect and analyse the 
venous blood samples needed for these surveys.

A new technique that promises to be easier, cheaper and less
invasive is 'dark adaptometry'. This method, which has been
tested and found effective in several field situations,(21)
takes advantage of the fact that in very early stages of
vitamin A deficiency the ability of the pupil of the eye to
constrict under illumination is impaired. By flashing a
simple hand-held light at one pupil and covering the other,
the degree of impairment of the pupillary reflex can be
estimated. It is hoped that this simple method, which is
non-invasive, will become widely available soon.

* 'Dipsticks' for iodine deficiency: Iodine deficiency
disorders (IDD) can be assessed in populations by palpating
goitres, but this method requires a high level of training
and is less useful as goitres begin to disappear with better
access to iodized salt.

Since iodine excreted in the urine is a good indicator of
iodine consumed, IDD can be reliably detected by analysing
urine samples. Many countries have undertaken urinary iodine
surveys, which involve collecting samples, preserving them
carefully and sending them to a laboratory for analysis in a
central location.

A new technique may eliminate some of those steps and much of
the cost. A reagent-treated testing strip or 'dipstick' now
being developed will simplify the procedure by allowing the
iodine content of urine to be analysed and read directly on
the spot without transporting samples to a laboratory. It is
hoped that this tool will soon be available for field
surveys.


* Improved test kits for iodized salt: Simple iodized salt
test kits have helped make salt-testing a community affair.
Anyone can use the small plastic bottles of test solution
that cause salt to turn blue if it is iodized, and some
countries have distributed these kits to schoolchildren,
teachers and community workers. The test kits, however, have
a limited shelf life, and they do not distinguish very
sensitively among levels of salt iodization. Work is now
under way to improve the test kit in both these respects and
make it an even more useful assessment tool.

* Computerizing anaemia surveys: Thanks to computer chips,
assessment of anaemia at the population level is becoming
easier. There have been methods for some time to assess
peripheral blood (from a fingertip, for example) without
sending the samples to a laboratory, but some of them are
slow and inaccurate.

Portable electronic haemoglobinometers are now available,
however, that enable blood to be drawn easily from a finger
into a small cuvette that is inserted directly into a machine
that gives a digital read-out of the precise haemoglobin
level in a few seconds. The wider use of these machines in
population surveys will help to raise awareness of the
enormous magnitude of the anaemia problem.

New ways to enrich diets

There are many ways to enhance foods to improve the content
of the vitamins and minerals that are so important for the
well-being of children and their families. Food fortification
is one very important way of doing this, and has already
helped overcome  micronutrient deficiencies in many 
industrialized countries and some developing ones.

But many of the world's poorest people eat locally grown
crops that cannot be fortified. Agricultural scientists are
now demonstrating that staple crops can be modified in
several ways at the breeding stage, with great nutritional
benefit.

The grains and tubers on which the vast majority of people in
the developing world depend have certain inherent
shortcomings nutritionally. For one thing, these staples tend
not to provide all the minerals and vitamins needed to ensure
good nutrition. In addition, cereals, depending on several
factors, including the degree to which they are refined,
contain substances that impede the 'bioavailability' of some
important minerals - the ability of the body to absorb and
use them. The most important of these substances is known as
phytate, a molecule containing phosphorus. Micronutrients
usually come from non-staple foods - animal products,
vegetables and fruits. But the poorest populations often
cannot afford these foods and depend on the grains and tubers
they can afford. This fact helps explain the high prevalence
of some micronutrient deficiencies.

Agricultural research has turned to the science of plant
breeding to improve this situation. The goal is to develop
staple food crops that contain higher quantities of essential
micronutrients - or lower amounts of phytate. In this
connection, work is currently being done in the United States
to develop low-phytate grain foods for animal consumption.
Such grains hold nutritional promise for people as well,
according to the results of a recent study, which found that
human volunteers absorbed iron at a significantly higher rate
from foods prepared using a new low-phytate  strain of corn
than from an older higher-phytate strain.(22)

The Consultative Group on In ter national Agricultural
Research, made up of 17 internationally funded agricultural
research centres, is trying to raise farm productivity and
food consumption in developing countries. The group is now
coordinating a global effort to increase the micronutrient
content of five major staple food crops: rice, wheat, maize,
beans and cassava. The aim is to breed plants that load high
amounts of vitamins and minerals into their edible parts -
and also into their seeds, allowing them to enrich themselves
for subsequent harvests without changing their taste,
texture, or the ease with which they are grown.

In developed countries, such crops have already been
successfully produced: high-zinc wheat, for example, is being
grown in Australia. Estimates are that it will take 6 to 10
years to breed comparable new plants in developing countries.
Scientists believe that they will not only improve the daily
dietary intake in the developing world but will also
significantly  increase crop yields because these micro
nutrient-dense plants have  better germination and more
resistance to infection at the vulnerable seed ling stage.

More effective action for nutrition improvement

The technical advances described in this report, whether new
research on nutrition and illness or better ways to detect
problems, are not magic bullets. They will contribute to
sustainable improvement in nutrition only if they sharpen the
ability of people, including the poor, to assess and analyse
the causes of malnutrition around them - and to plan and
carry out appropriate responses.

Recent advances in the fields of  social science and
communication will also help accelerate and sharpen people's
ability to take control of actions to reduce malnutrition.

Actions described here to improve child nutrition and thereby
improve growth, resistance to illness and cognitive
development need to be coupled with other highly effective
low-cost interventions that have already been proven to
prevent disease and improve child development.

Some of these have yet to be widely exploited. For example,
intestinal worms, which contribute to poor growth and
development, can be combated through routine deworming using
low-cost drugs that are both very safe and highly effective
(Panel 20). And child deaths from malaria can be reduced
through the use of insecticide-impregnated mosquito nets.
These measures have not received adequate global attention
and resources, even though every child has a right to their
benefits.

Actions to prevent malnutrition in young children also need
to be linked to efforts to promote early child development
through stimulating play and early learning, and by
strengthening interaction with parents and peers. The parents
of young children everywhere need regular contact with 
people who can help check their children's growth and
development and can provide advice and support on
breastfeeding and complementary feeding. In many communities,
parents and caregivers will also need both advice on and
access to supplements of vitamin A, iron, iodine and other
micronutrients. Support in these areas might best be provided
through established formal institutions - health centres,
clinics or pre-school centres (Panel 21). But where such
facilities do not exist or do not function, children cannot
wait for them to be built or staffed.

Communities must receive overall support in their efforts to
ensure that all families have access to basic preventive
actions to improve the nutrition of children and pregnant
women. This includes strengthened health services to prevent
and treat disease, and increased support to stimulate early
child learning, care and development.

None of the preventive and supportive actions to promote
child growth and development described in this report require
a doctor or nurse or a trained educator. Communities can be
helped to organize themselves to provide or administer these
services, and in most communities, groups that can take on
these responsibilities already exist. Communities can also be
helped to assess their own priority problems and can learn to
monitor the effectiveness of their actions, redesigning their
own programmes accordingly. Combined with the use of
effective low-cost technologies, the adoption of these
measures could result in rapid improvements not only in child
survival but also in child development, nutritional status
and learning capacity.

It has often been said that meeting this challenge is a
matter of political will. In a $28 trillion global economy,
the problem is surely not a lack of resources. But it may be
more useful to see the challenge as a matter of political
choice. Governments in poor and rich countries alike may
choose to allow children to be intellectually disabled,
physically stunted and vulnerable to illness in childhood and
later life. This is the price of doing little or nothing to
ensure good nutrition.

But governments could instead resolve to move to consolidate
lessons already learned about reducing malnutrition. They
could do everything possible to mount massive actions that
can clearly succeed and that can be implemented by
communities them selves. And they could encourage  research
on, and implementation of, new and better actions.

For the well-being and protection of children and the human
development of the world, the course of action is clear.

                          * * * *

References

The silent emergency

1.   Gillespie, Stuart, 'Increased Maternal Mortality Risk',
section 5.1 in Major Issues in Developing Effective
Approaches for the Prevention and Control of Iron Deficiency:
An overview prepared for the Micronutrient Initiative and
UNICEF, work in progress, September 1996 (first draft).

2.   Draper, Alizon, 'Child Development and Iron Deficiency:
Early action is critical for healthy mental, physical and
social development', The Oxford Brief, Opportunities for
Micronutrient Interventions, Washington, D.C., May 1997.

3.   World Bank, World Development Report 1993: Investing in
health, Oxford University Press, Washington, D.C., 1993, p.
77, col. 1.

4.   World Bank, Enriching Lives: Overcoming vitamin and
mineral malnutrition in developing countries, World Bank,
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Development Indicators 1997
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5.   Draper, Alizon, op. cit., p. 1.

6.   Maberly, Glenn F., 'Iodine Deficiency in Georgia:
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p. 1, col. 3.

7.   Martorell, Reynaldo, 'The Role of Nutrition in Economic
Development', Nutrition Reviews, Vol. 54, No. 4, April 1996,
p. S70.

8.   In accordance with international terminology recommended
by WHO, readings that are three or more standard deviations
from the reference median (based on a reference population of
American children) are referred to as 'severely
malnourished', while those between two and three standard
deviations are called 'moderately malnourished'.

9.   Young, Helen and Susanne Jaspars, Nutrition Matters:
People, food and famine, Intermediate Technology
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10.  UNICEF, 'Food, Health and Care', UNICEF, New York,
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11.  Draper, Alizon, op cit., p. 1.

12.  What Governments Can Do: Seventh annual report on the
state of world hunger, Bread for the World Institute, Silver
Spring, 1997, p. 8.

13.  Ibid., p. 10.

14.  Philip, W. et al., 'The contribution of nutrition to
inequalities in health', British Medical Journal, Vol. 314,
British Medical Association, London, 24 May 1997, p. 1545.

15.  'Children at Risk in Central and Eastern Europe: Perils
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16.  Fogel, Robert W., 'Economic Growth, Population Theory
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17.  Grantham-McGregor, Sally, 'A Review of Studies of the
Effect of Severe Malnutrition on Mental Development', The
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American Institute of Nutrition, Bethesda, 1995, p. 2235S.

18.  Cole, Michael and Sheila R. Cole, 'Prenatal
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19.  Nash, Madeleine J., 'Fertile Minds', Special Report,
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20.  Landers, Cassie, 'A Theoretical Basis for Investing in
Early Child Development: Review of current concepts',
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International Child Development Centre, Florence, 1989, p. 4.

21.  Hanson, Lars A. et al., 'Effects of breastfeeding on the
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22.  De Zoysa, I., M. Rea and J. Martines, 'Why promote
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Health Policy Planning, Oxford University Press, 1991,
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23.  Glick, Daniel, 'Rooting for Intelligence,' Newsweek,
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24.  UNDP, Human Development Report 1997, UNDP, New York, pp.
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25.  UNICEF, WATERfront, Issue 8, UNICEF, New York, August
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26.  UNDP, Human Development Report 1997, p. 29.

27.  United Nations, Progress made in providing safe water
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28.  UNICEF, The Progress of Nations 1997, p. 12.

29.  US Department of Agriculture study (1990) cited in Tufts
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30.  Landers, op. cit., p. 7.

31.  United Nations, The World's Women 1995: Trends and
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32.  Holmboe-Ottesen, Gerd, Ophelia Mascarenhas and Margareta
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Nutrition Policy Discussion Paper No. 4, United Nations, New
York, May 1989, p. 37.

Approaches that work

1.   Gillespie, Stuart, John Mason and Reynaldo Martorell,
'How Nutrition Improves', ACC/SCN State-of-the-Art Series,
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York, July 1996.

2.   'International Code of Marketing of Breastmilk
Substitutes', World Health Organization, Geneva, 1981, pp.
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3.   UNICEF, The Progress of Nations 1997, UNICEF, New York,
1997, p. 21.


4.   Micronutrient Initiative, Ottawa, facsimile dated 14
Oct. 1997.

5.   Sommer, Alfred et al., 'Impact of vitamin A
supplementation on childhood mortality: A randomised
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1169-1173.

6.   Beaton, G. H. et al., 'Effectiveness of Vitamin A
Supplementation in the Control of Young Child Morbidity and
Mortality in Developing Countries', ACC/SCN State-of-the-Art
Series, Nutrition Policy Discussion Paper No. 13, United
Nations, December 1993, p. 61.

7.   Ross, David A. et al., 'Vitamin A supplementation in
northern Ghana: Effects on clinic attendances, hospital
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1993, pp. 7-12.

8.   Katz, J. et al., 'Night blindness is prevalent during
pregnancy and lactation in rural Nepal', Department of
International Health, Johns Hopkins School of Hygiene and
Public Health, Baltimore, Journal of Nutrition, August 1995.

9.   Gillespie, Stuart, John Kevany and John Mason,
'Controlling Iron Deficiency: A report based on an ACC/SCN
workshop', United Nations, Geneva, February 1991, p. 4.

10.  Alnwick, David, 'More for Less in Combating Iron
Deficiency? Update on the Effectiveness of Weekly
Supplements', Research in Action, No. 2, UNICEF, New York,
November 1995, p. 1; Schultink, W. et al., 'Effect of daily
vs. twice weekly iron supplementation in Indonesian preschool
children with low iron status', American Journal of Clinical
Nutrition, Vol. 61, American Society for Clinical Nutrition,
1995, pp. 111-115.

11.  Layrisse, M. et al., 'Early response to the effect of
iron fortification in the Venezuelan population', American
Journal of Clinical Nutrition, Vol. 64, 1996, pp. 905-906.

12.  Stoltzfus, R. J. et al., 'Epidemiology iron deficiency
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157.

13.  United Nations, Progress at Mid-Decade on Implementation
of General Assembly resolution 45/217 on the World Summit for
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14.  Lewnes, Alexia, Oral Rehydration Therapy: Elixir of
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Bringing science to bear

1.   Piot, Peter, 'Fighting AIDS together', The Progress of
Nations 1997, UNICEF, New York, 1997, p. 23.

2.   Sommer, Alfred and Keith P. West, Jr., Vitamin A
Deficiency: Health, survival and vision, Oxford University
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3.   Roy, S. K. et al., 'Impact of a single megadose of
vitamin A at delivery on breastmilk of mothers and morbidity
of their infants', European Journal of Clinical Nutrition,
No. 51, Stockton Press, 1997.

4.   'Zinc for Child Health: Child Health Research Project
Special Report', Report of a meeting, Baltimore, Maryland,
17-19 Nov. 1996, Vol. 1, No. 1, June 1997, p. 8.

5.   'Improving Iron and Zinc Nutrition in Infancy and Early
Childhood: Proceedings of the Bali Consultation Meeting for
the Planning of Multi-Country Iron and Zinc Intervention
Trials', in Bali, Indonesia, 4-6 February 1997, UNICEF, 1997,
pp. 6-7.

6.   Semba, Richard D., 'Will vitamin A supplementation
reduce mother-to-child transmission of HIV?' Research in
Action, No. 5, UNICEF, New York, July 1996.

7.   Adamson, Peter, 'A failure of imagination', The Progress
of Nations 1996, UNICEF, New York, 1996, p. 8.

8.   Rasmussen, Kathleen M. and Michelle K. McGuire, 'Effects
of breastfeeding on maternal health and well-being', Food and
Nutrition Bulletin, Vol. 17, No. 4, United Nations University
Press, 1996, p. 366.

9.   Murray, Christopher J. L. and Alan D. Lopez (eds.), The
Global Burden of Disease, Harvard School of Public Health,
Cambridge, 1996, pp. 360-367.

10.  Barker, David J. P., Mothers, Babies and Disease in
Later Life, BMJ Publishing, London, 1994.

11.  Law, Catherine M. and Alistair W. Shiell, 'Is blood
pressure inversely related to birth weight? The strength of
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12.  Law, C. M. et al., 'Thinness at birth and glucose
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13.  Hales, C. N. et al., 'Fetal and infant growth and
impaired glucose tolerance at age 64', British Medical
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women, Diabetologia, 1993, 36:225-228; McCance, David R. et
al., 'Birth weight and non-insulin dependent diabetes:
Thrifty genotype, thrifty phenotype, or surviving small baby
genotype?', British Medical Journal, Vol. 308, 1994, pp.
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14.  Barker, op. cit.; Hales, C. N. and D. J. P.  Barker,
'Type 2 (non-insulin dependent) diabetes mellitus: The
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15.  The Smallest Babies in the World, video, MRC
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16.  A study of maternal nutrition and intrauterine fetal
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17.  'Proceedings of the Third Annual Workshop on the Fetal
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18.  Fall, Caroline, Ranjan Yajnik and Shobha Rao, personal
communication, 1997.

19.  McKeigue, P. M., G. J. Miller and M. G. Marmot,
'Coronary heart disease in South Asians overseas: A review',
Journal of Clinical Epidemiology, Vol. 42, No. 7, United
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20.  Among 201 four-year-old children born in Pune of known
birthweight, those who were 2.4 kg or less at birth had mean
glucose and insulin concentrations 8.1 mM (micromole) and 321
pM (picamole) respectively 30 minutes after an oral glucose
challenge; in comparison children born 3.0 kg or heavier had
a mean glucose concentration of 7.5 mM and a mean blood
insulin level of 289 pM. From Yajnik, M. et al., 'Fetal
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Indian children', Diabetic Medicine, Vol. 12, 1995, pp.
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21.  Congdon, N. et al., 'Pupillary and visual thresholds in
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1997, pp. 61-66.

22.  Mendoza, C. et al., 'Effect of Genetically Modified,
Low-Phytate Maize on Iron Absorption from Tortillas', article
submitted to Experimental Biology '97 (unpublished).


                          * * * *

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