Chapter 10: General Discussion

Fernando Antezana (WHO): The history of humankind provides powerful messages for us about the central importance of food in sufficient quality and quantity for the development of civilisation. Since populations began aggregating in towns and cities, their livelihood has depended directly upon access to a safe and adequate supply of food. When supplies have been restricted due to climatic factors, war, or civil unrest, the overall quality of life and sense of collective security have diminished. Now, at the dawn of the new millennium, we face the real opportunity of ending malnutrition within the relatively short period of two decades. This would ensure that the world’s most vulnerable populations are not deprived of one of the most fundamental rights of human beings, namely the right to adequate nutrition.

We are pleased with the draft report of the Commission and, in particular, commend the authors for embedding in their report many of the core components of WHO’S new global health policy ‘Health-for-All in the 21st Century’. Through the global consultative process, based strongly on the views of Member States, NGOs, and a wide range of other national and international bodies, it is not surprising that of the ten global targets defined in the new policy, the first target emphasises both equity and nutrition.

The Commission report gives emphasis to equity and to the close links between many recent international instruments dealing with human rights. It also implicitly recognises that there is an ethical imperative to provide food for all. While not explicitly mentioned, the report also implies the need for a gender perspective in dealing with many aspects of food policy. WHO urges that a more explicit gender approach be incorporated into the development of food and nutrition policy.

The Commission report gives particular emphasis to integrating and amplifying the United Nations’ efforts in respect of nutrition policy. It highlights the need for intersectoral action in order to achieve food security. Similarly, the new global health policy calls for health to be placed at the centre of concerns for sustainable human development. From a nutritional point of view, this implies looking for particular synergies in the goals and actions of the agricultural, energy, transport, educational, and health sectors. The emphasis on agriculture is appropriate. In addition, we would recommend that the Commission consider closer interaction between energy use and production, bio-diversity loss, and production of food. At a household level, many countries still use biomass as their major fuel for cooking. This is associated with increased risks of acute respiratory infections, bums, and poisoning. Safer means of energy use and indeed, safer kitchens, should also be a component of improving food security.

WHO supports the strategies recommended for enlarging the crop mix in food systems. WHO also supports potential gains for health through the use of new biotechnologies. Clearly, a careful evaluation of their long-term health impact will be required. As with all forms of new technologies, a major challenge will be to ensure that the benefits are made rapidly available to the poorest sectors of society and to the poorest countries. Already the agricultural sector has played a vital role in improving the productivity and quality of food worldwide.

Data are emerging from several developing countries to indicate that the rate of nutritional transition is occurring rapidly. This implies that children who are malnourished will, in their forties and fifties, suffer from obesity, diabetes, and a range of cardiovascular diseases and cancers.

Our collective response needs to ensure that the ischaemic heart disease epidemics of the developed world are not repeated throughout the developing world. Rather, greater emphasis needs to be given to preventative and promotive measures that include appropriate regulatory and fiscal strategies aimed at promoting healthy diets. The goal should be to introduce those policies that make healthy eating an easy choice.

This includes for example, using the successes of Finland and Norway in developing a combination of pricing and regulatory policies that favour fruit and vegetables over meat and dairy products. The experience of Poland is also important in this respect. By the latter part of the 1980s, the rate of ischaemic heart disease continued to rise significantly. Subsidies on meat and dairy products were dramatically reduced to increase government revenue. The result has been that fruit, vegetables, and fish products have become relatively more affordable with a concomitant rapid and sustained decline in ischaemic heart disease death rates. In contrast, many countries continue to subsidise high fat products and fail to support marketing approaches that would make a wider range of healthier foods available to the poorest sectors of the community.

In addition to nutrition policy, the control of non-communicable diseases will require stronger linkages between those involved in tobacco control and nutrition. Tobacco use, a high-fat diet, stress, physical inactivity, and hypertension work together to increase the risks of ischaemic heart disease. Tackling one factor in isolation may not reduce the overall impact of these conditions.

With respect to food safety, the Commission report briefly indicates how we face a range of new threats and problems. Never before has so much food been produced so far from the place where it is consumed. The globalisation of the food trade has profound implications for how we ensure food safety and security across borders. At the global level, the Codex Alimentarius provides an outstanding example of international cooperation between FAO and WHO in developing and ensuring food standards for the protection of all. Moreover, the provisions in the Agreement on the Application of Sanitary and Phytosanitary Measures, which entered into force with the establishment of the World Trade Organization on 1 January 1995, acknowledge the work of the Codex Alimentarius Commission as the reference for national food safety requirements. Countries that are members of the World Trade Organization may no longer reject foods that meet Codex standards, guidelines, and recommendations without providing justification. Despite this, it is likely that food safety issues will become even more important in trade disputes over the next few years as the pace and volume of food trade increase.

Issues of food safety have already emerged as being of the highest political concerns across a wide range of countries. Within Europe, I do not need to emphasise this further than mentioning BSE. In the Americas, contaminated raspberries and strawberries have resulted in important trade disputes between the USA and countries of Latin America. In Japan, concerns about food safety have similarly resulted in major efforts to strengthen the national capability. African countries have experienced the negative effect of how food safety standards can be abused. While several European Union countries initially rejected fish from cholera infected countries in Africa, the public health basis for this did not exist and the Codex Alimentarius was able to provide a balanced view of the true nature of the threat. Also, measures exceeding those outlined in the International Health Regulations resulted in the loss of approximately US$ 770 million for Peru when its trading partners boycotted its products during the 1991 South American cholera epidemic, which began in Peru.

WHO and a range of other agencies are working to strengthen food safety in an exciting project entitled ‘healthy markets’. The intent is to bring together our knowledge and skills about improving basic hygiene and work with those in the market places of all countries, starting in the developing countries, to show that simple cost-effective measures can be taken to improve the quality of food consumed.

Within health systems, nutrition is highlighted as a priority for action. The focus on life span approaches to health is echoed in the Commission report and strongly emphasised in the new global health policy. The lifespan approach to health starts from conception of a child in utero. Increasing evidence suggests that the quality and quantity of food provided from birth and, in fact, the mother’s level of nutrition during pregnancy, have a profound impact on a child’s subsequent health. Getting the balance right in the first few years of life will be a major challenge. Furthermore, with the realisation that breastmilk may transmit HIV from mother to child, WHO is examining the scientific evidence to ensure that it provides the most appropriate and the safest policy recommendations to countries.

It is not only the quality and quantity of food that are important. The social context and quality of caring that occurs in the family also has implications for subsequent health and development of children, young adults, and adults. Thus, we urge that the important interaction between social determinants and adequate nutrition be given closer attention in future research and policies. The overall quality of caring that occurs in the household influences the intellectual, physical, and emotional development of children.

In addition to care, WHO’S new global health policy calls for a stronger commitment to essential public health functions. These are as essential for nutrition services as they are for all other aspects of care. To highlight only two public functions here: information systems and human resources. Health information and surveillance systems provide the means of alerting countries to impending crises and evaluating the success of interventions. The sensitivity of nutritional indicators to macroeconomic climatic factors and diseases demands that they be at the core of surveillance systems and be based upon globally-derived and scientifically-based standards. In this context, the new WHO growth references will, for the first time, be based on data collected from a cohort of children who were breastfed and born to nonsmoking mothers.

Services are built with competent people in strong institutions. The policy highlights the need for a stronger, reinvigorated approach to human and institutional capacity for health. Improved morale, better training, and continuing education apply to all those involved in nutrition services. Importantly, the policy emphasises that basic skills in key public health disciplines such as epidemiology, health economics, and public health law will benefit all content areas, including nutrition.

In conclusion, I would like to commend the Commission on its draft report, and particularly the emerging issues and concepts it highlights. I would like to end by reiterating the importance of issues such as food security at household level, food safety, the Codex Alimentarius, the globalisation of food trade and the WTO, and essential public health functions.

Ernest Loevinsohn (CIDA): Being reminded of the nutrition goals for the years 2010, 2015, and 2020 made me consider the chain of broken promises that have already been made to the hungry children and malnourished mothers of the world. This is an unhappy tradition that goes back at least to the early 1970s with the World Food Conference and perhaps even earlier. At the World Food Conference they said that “today we proclaim a bold objective, that within a decade no child will go to bed hungry.”

I think we want to do more than proclaim bold objectives; we want to perform bold actions. Certainly the malnourished people whom we are trying to serve would prefer that. One of the most important areas for bold action is in advocacy with decision-makers.

There are two stages in advocacy: the first is clarifying what we want to advocate for, and the second is the actual persuasion. In terms of the first stage, we need to determine what our priority messages are. How do we prioritise? I would suggest that we focus on the empirical evidence of which nutrition interventions are first, efficacious, second, cost-effective, and third, doable.

In terms of the persuasion stage: the regional meetings that the Commission report proposes will have an important role, but to be effective persuaders, we have to think in terms of each decision-maker. Whom do they have to listen to, and whom do they want to listen to? In short, how can we reach them? We need from the Commission a concrete programme for lobbying, that is realistic in terms of available resources.

There is one particular area that I would like to highlight where we might get some early successes from lobbying. That is the food aid business. This includes donors shipping food from their countries to developing countries, donors who spend money to buy food in developing countries, and most importantly those countries who have food distribution or subsidy programmes for their own populations.

You can spend a long time with people in the food aid field without hearing much about nutrition. This is a little odd, since this multi-billion dollar effort is being paid for by taxpayers under the heading of doing something about hunger. There is a lot of potential to get “more gain for the grain” from food aid. In the UN system we could start with the World Food Program. There are some very encouraging signs, as the Executive Director of WFP has said that she wants a focus on malnutrition with a view to “ending the inheritance of hunger”. She wants to concentrate on women first. But there is still some way to go in terms of implementing her vision on the ground, and some lobbying there might be a good way to proceed. For our part in Canada, we are trying to stay true to our pledge to make nutrition central to what we do in food aid, and to measure results using nutritional indicators - anthropometric and other.

Of course food aid is just one example of the opportunity for nutrition lobbying. To summarise, if we are going to have an effective programme of advocacy on nutrition, firstly, we have to prioritise our messages based on the empirical evidence. Secondly, we need a practical advocacy plan from the Commission,

Some of you may be familiar with Benjamin’s Law: When all is said and done, a lot more is said than done. What I would like from the Commission is a focus on action - on specific effective action - so that when their work is done, we can say that this was a shining exception to Benjamin’s Law.

Bill Clay (FAO): FAO endorses the concept of a gender perspective. A gender perspective in nutrition is needed. The theme of the World Food Day in 1998 was ‘women feed the world’. We strongly emphasise the need to recognise that nutrition wellbeing is important - not only in its own right, but also in making a contribution to the future generation and to society at large. All too often, women have been seen simply as vehicles for producing, caring for, and feeding children. Without sufficient attention given to the other human development considerations, there is a clear need to recognise the context and causes of childhood malnutrition. How these can best be addressed starts with the recognition of the importance of women in nutrition. It is only through good nutrition and health of women during pregnancy and of children during early childhood that the next generation will achieve its fullest physical and mental potential.

It is not acceptable that hundreds of millions of children are already condemned at the moment of birth to physical handicaps, higher propensity to disease and to impaired intellectual abilities. Low birth weight begins the cycle of hunger. This cycle must be broken. Reducing malnutrition is of major economic significance and better nutrition is a fundamental investment for economic development.

FAO considers that a gender perspective on nutrition must recognise the crucial role that women play in securing, preparing, and serving food for themselves and others. The International Conference on Nutrition Plan of Action stated that ‘women need to constantly balance the reproductive, nurturing, educational, and economic roles, which are so important to the health and nutritional wellbeing of the household and of the entire community’. Women are the main providers of meals, care, and nutrition information in the household, and they have a fundamental role in ensuring improved nutritional status for all. The importance that gender has on individual, family, and community nutrition and wellbeing was further emphasised during the World Food Summit (WFS). A specific objective of Commitment One of the WFS Plan of Action is ‘to ensure gender equality and empowerment of women’. This has been instituted as a guiding principal underlying FAO’s programmes. It has also strengthened the overall FAO efforts to promote community-based household food security and nutrition programmes.

Women need to be able to participate fully in the decisions that affect their nutritional wellbeing and welfare. This begins by ensuring that girls receive a fair share of their parent’s time, attention, affection and resources, including food and nurturing. Girls must not be denied access to quality education, health care, and social opportunities as they mature and become productive members of society. Their contribution to family and community must be valued appropriately. FAO fully endorses these propositions and commits itself to working with its member countries and other development partners to promote the nutritional wellbeing of women and to strengthen their capacity to promote the nutrition and welfare of the next generation.

We appreciate the emphasis that the Commission places on poverty and social discrimination as being at the core of the most serious nutrition problems throughout the world. We also recognise that we cannot wait for poverty and food insecurity to be eliminated before taking action to improve nutrition. We endorse the need to provide specific actions to meet the nutritional needs of special groups. Even so, this does not diminish the importance of agriculture and economic development in eliminating hunger and malnutrition. Nor does it minimise the fundamental importance of addressing food and income issues. The major resources available in many poor countries are their agricultural potential and their human population. Investment in both is necessarily mutually reinforcing.

Expanding agricultural development, including fisheries, forestry, and livestock leads to increased community and national wealth as well as improved individual incomes. It is this wealth creation that can improve the conditions for more sustainable access to food and to support the schools, the clinics, the social services and the physical infrastructure necessary to sustain lasting improvements in nutrition. Without such development, the poor and undernourished will simply be consigned to receiving handouts. Dignity, hope, and self-reliance will be lost.

It is important to recognise the extensive problems of iron deficiency anaemia and other micronutrient deficiencies. Small-scale farming systems are important to income generation. Regarding the concept of dietary diversity, we should not be overly focused on crop diversification and minor crops at the homestead or local level. While home gardening can be an important aspect of diet diversity, a balance needs to be maintained in advocating other agricultural systems that generate income, and with well-functioning and efficient markets to enable consumers to diversify their diets through trade at the local level. These aspects become even more important in urban and peri-urban areas and among the landless rural dwellers. Dietary diversity can be achieved through additional purchases as needed. In brief, consuming a diversified diet is not dependent on each household producing a diverse bundle of commodities.

The issue of global trade liberalisation, especially in agricultural commodities, is also a very important and complex issue. For example, higher world market prices for food imports, which may result in a reduction in production subsidies in developed countries, should benefit developing country food producers, but may not necessarily have immediate benefits for consumers in those countries. FAO is working in this area with regard to the Uruguay Round follow-up. This includes providing technical assistance to developing countries to enable them to be equal and well-informed partners in the process.

Rolf Aspestrand (UNDP): Poverty reduction is the highest priority of the United Nations Development Programme (UNDP), and, as has been stated several times here, nutrition has an important role in the process of poverty alleviation. This also links to UNDP’s work on building national capacity in the area of nutrition at country level. UNDP has governance programmes, where the links with the national governments can be strengthened, and we have to work on that. In the area of good governance, the UNDP has recently published a policy document ‘Human rights: integrating human rights with sustainable human development’. This new document looks at the links between human rights and development, and includes food security and nutrition.

It has been pointed out by Dr Brundtland, Professor James, and the Minister of Development in Norway, Dr Hilde Frafjord Johnson, that we need to coordinate our efforts and act together as one body. We should not have the situation where one country receives 3000 development projects and has to try to please 30 different agencies. That is not constructive. In this respect, UNDP is happy to support the coordination of agencies through the resident coordinators. UNDP also supports the country-level monitoring of human development progress. You may be familiar with the Human Development Report and its human development index.

I also would like to mention the follow-up to the 2020 Conference that was held in Oslo in 1995. The 2020 concept was introduced in the Human Development Report in 1995 and is something that the Norwegian government strongly supports. The first follow-up conference was in Hanoi, Viet Nam, in October 1998. The concept - trying to set aside 20% of the national budgets for basic social services, and having the donor agencies allocate 20% of their budgets on basic social services, is also something that UNDP supports.

Barbara Underwood (IUNS): The IUNS is taking a 21^st century look at its function and trying to define ways in which the nutritional science community might enter more actively into these processes of carrying out an agenda appropriate to the global concerns in nutrition in the next millennium. Philip James, Julia Tagwireyi, and Ricardo Uauy are all on this IUNS Council, and Ruth Oniango is a member of a special committee considering how IUNS can be repositioned to more effectively meet the challenges of the next century. I simply want to say that the nutritional science community, through the IUNS - which represents some 69 different countries - stands ready to assist in carrying out what I think is a visionary agenda for the 21^st century.

Nevin Scrimshaw (UNU): There have been many UN and SCN documents on the world food and nutrition problem over the years - some of them have been very useful - others have been so loaded down with caveats and details that they are of little value. I think it is clear that we do now need a balanced, updated, contemporary, constructive statement for planning of nutrition activities into the next century. The UNU feels that the Commission has produced this kind of a document in draft. If the report became loaded down with the details that every agency wanted, we would have an ‘over-decorated Christmas tree’. It would then lose its value.

Inge Nordang (Norway): In light of the interesting speech made by the Norwegian Minister, Dr Hilde Frafjord Johnson, there is really not much more to add. One of the most outstanding issues in this symposium is the poverty issue. This has been an underlying problem in the agendas of all the major UN conferences and summits through the 1990s. It is necessary to go into the poverty processes and look at what is behind the poverty mechanisms. We should not always try to attack the symptoms only. I find it interesting to look at marginalisation as a major poverty mechanism at different levels. When trying to find remedies, the key word is ‘empowerment’. This has been very elegantly shown in several of the presentations. We have seen what is happening in Africa as a result of social marginalisation leading into poverty.

There is also the issue of women, which is at the centre of this Symposium. In most societies, women are marginalised. We have also been discussing geographical marginalisation, for example, Per Pinstrup-Andersen pointed to the importance of geographical marginalisation. If you want to do something about poverty, then you have to attack that.

Richard Osborn (UNFPA): The United Nations Population Fund is a small operation, which focuses largely on supporting reproductive health services for women. As a fund, we respond to what national governments bring to us by way of requests for programmes. In my capacity as the senior technical officer at UNFPA, I don’t recall a single programme coming to us with a component on nutrition as having an impact on maternal health. So when we look at our programming, which begins with adolescence, carries on through the reproductive years and the major period of child bearing, we find no evidence of concern for nutrition being brought to us. We are simply not presented with demands for inclusion of these variables within our programme.

Why has this occurred? On what basis would we advocate to governments that they should be concerned about nutrition? What data are available? Before coming to this meeting, I looked at the Cochrane database that is now available on disk from the WHO reproductive health library. In one review of the impact of social support, the conclusion is that pregnant women should be informed that programmes offering additional support during pregnancy are unlikely to prevent the pregnancy from resulting in low birth weight or pre-term infants, and are unlikely to improve other important outcomes. In a review of protein energy supplementation and pregnancy, the conclusion is that balanced energy protein supplementation modestly improves foetal growth, but is unlikely to be of long-term benefit to pregnant women or to their infants. There seems to be a stronger base when we look at some of the areas such as iodine supplementation where there has been a positive impact. But in short, looking at the available scientific database, I do not have information on which I can advocate to governments. I cannot rely on observational data alone. There is clearly a need for appropriate scale, well-defined clinical trials to provide the evidence on which we can base policy and programmes. I cannot advocate without an appropriate database of clinical trials.

Within my own organisation, although we talk a great deal about gender, we are still really referring to women’s programmes, i.e., it is not role-related specific behaviours that are being programmed. We should not merely focus on the early stages of the life, but we should also consider that the elderly are an increasingly important group.

In closing, I would like to remind you that 1999 is the fifth anniversary of the Cairo Population Meeting. One question that I would like to ask to you, is when I am putting together the agenda and laying out the outline for what will be the Secretary-General’s report to the special session of the General Assembly, should there be mention of nutrition in the area of population - in particular, in reproductive hearth? If the answer is yes, then I really need better information and a better set of arguments than I can find available in my current literature.

Richard Jolly (SCN Chairman): I think you have issued us with many challenges and your very first reference to there not being a single project asking for support for maternal nutrition is a very thought-provoking comment.

Roger Shrimpton (UNICEF): I would like to give some reflections on the Symposium. UNICEF, as a humanitarian and developmental agency, is guided by the Convention on the Rights of the Child, and I would like to talk about rights-based approaches to programming as an overall theme and give some examples of how programmes can be implemented from a practical perspective in the field. There are five issues that I would like to talk about: breastfeeding, local government implementation of nutrition goals, governments and rights, prioritisation, and follow-up.

The eloquent presentation by Isatou Jallow Semega-Janneh was a wonderful reminder for all of us of how important breastfeeding is. We should all remember, of course, that breastfeeding is a right for all children as stated in the Convention of the Rights of the Child, which has been signed by all governments. It is an important obligation of all governments to protect, promote, and secure breastfeeding.

I wanted to talk also about local government as a way of achieving goals. The presentation by Suttilak Smitasiri described the ways by which nutrition goals were achieved in Thailand. The ‘what’ needs to be achieved and decided at the national level, but ‘how’ that is achieved was worked out at the local level. Suttilak described the importance of looking for the ‘windows of cultural opportunity’ that are there, but these differ according to the setting. So ‘how’ you achieve goals is something that needs working out at the local level. Often intersectoral responses are needed not just health sector responses. Recently I read in an editorial of the British Medical Journal, that the British government is taking a new approach to health. It recognises that achieving health goals cannot be done only through the health sector, and that the basic causes must be addressed. The British policy proposes something very similar to the approach used in Thailand, which is that at the local government level, local government, health care providers, and civil society should work out the process indicators. So there are commonalities across various societies about how you can achieve these goals - that are not just sectoral goals but that are society-based.

Thirdly, I would like to talk about governments and human rights. I would like to explain how a rights-based approach was developed in Indonesia for achieving maternal mortality reduction. By getting the Indonesian government to agree on the implementation of the Convention on the Rights of the Child, and the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW), as a priority in its work with UNICEF, we developed a two-pronged strategy. One arm of this was a mother-friendly hospital movement, and the other was a mother-friendly sub-district movement. This reminded me very much of the breastfeeding community initiative presented by Isatou. Now, throughout Indonesia, there are movements at the district and sub-district level. By putting CEDAW into that sort of context and by getting local governments to understand what CEDAW is and to appreciate their obligations to achieve what is in CEDAW, are ways of addressing the gender perspective through the life cycle. As organisations, if we can increasingly refer to the conventions on human rights and especially the Convention on the Rights of the Child, and the Convention on the Elimination of all Forms of Discrimination Against Women, and perhaps less to our global seminars and our global goals, which are important sectorally, this will help us come together also at the country level. UNICEF strongly supports efforts to increase coordination of agencies at the country level through UNDAF (United Nations Development Assistance Framework) process. We believe that the combination of a rights-based approach and the UNDAF process will help agencies work together better in the pursuit of common nutrition goals.

I also wanted to say something about prioritisation. I have worked as a nutritionist in the field for 25 years. I continually hear the reference by some people to bullet approaches as being not sustainable, and to food-based approaches, as if these were things were an either/or. This is not helpful if you work in programmes. If one takes a rights-based approach to nutrition and there is an immediate need, then there is a need to go in with an immediate response, which would be appropriately a supplement. A rights-based approach would endorse that. Food is also part of a rights-based approach, but those responses perhaps take longer. So recognising immediate, underlying and basic causes, and the need to have all of those responses ready, is important. It should not be an either/or in relation to supplements, food fortification, or food-based approaches.

Finally, UNICEF is considering developing approaches to reduce low birth weight. We have begun some discussions with the World Food Programme to see how we might work together on that. This is an important area and we are prepared to begin developing programmes in Southern Asia, especially in Bangladesh. The UNICEF country programme in Bangladesh has low birth weight reduction as a priority because Bangladesh has 50% low birth weight, and as such, is the leading country for low birth weight in the world.

Tom Marchione (USAID): I am impressed by, and would recommend the work of Roger Shrimpton in community participation and involving the local community in nutrition programmes. After a decade or so of state disempowerment, especially in developing countries, it certainly is appropriate, as Per Pinstrup-Andersen said, that the State needs to be re-empowered to fulfil its functions and provide the infrastructure necessary to have a viable programming environment. On the other hand, let’s not place too much emphasis on the Central State and not enough emphasis on the means of enabling and nurturing local programming, such as those we have heard about in Thailand and The Gambia, which are so impressive. The assumption that decision-makers are people at the heads of organisations seems to me to be myopic. It is important to get to decision-makers within communities, and we should think more in terms of a plan that enables this process. It might not have been so realistic to try to do this in 1955 or 1975, but I think that now, with the spread of democratisation and the freeing of civil society, we really have to think more in terms of how to facilitate and build on what is already happening.

George Kent (World Alliance for Nutrition and Human Rights): I appreciate very much UNICEF’s strong orientation towards the rights-based approach and have a few comments about what Roger Shrimpton said. One of my first concerns is that Roger began with a rather unconditional statement about breastfeeding being a right for all children. Those of us working on the issue find that problematic because it conflicts with the right of the mother to choose. We are trying to work out some language to resolve that conflict. Second, I am slightly concerned about the notion of interpreting participation in terms of having goals set centrally and then implemented locally. I think it is important to insist on participation from the localities in the formulation of the goals as well.

In the formulation of rights, my position is that the human right to food and nutrition implies a particular entitlement to some kinds of goods or services. Accompanying that are legal remedies such that if one does not get what one is entitled to, then there will be some mechanism in place for correcting the situation. Without that I think we are not talking about human rights and I think that needs to be spelled out more clearly.

Philip James (Commission): A recurring theme is the centrality of the issue of human rights. We have already discussed the way by which we approach this - what we need to do is move into the practical dimension of what this actually means. We need to spin that into effective mechanisms whereby those rights are displayed and acted on. There are fundamental issues of human rights, but how do we put that into a coherent framework that has logic in terms of action?

I was fascinated by what UNFPA said regarding the lack of a scientific basis. I believe that the scientific analysis is incomplete as displayed by the Cochrane reviews. This brings up a fundamental question. If observational data are no longer the basis for action, then are we demanding double-blind placebo-controlled trials before we get action? What level of evidence do we need before we actually specify a particular route of action?

Concerning the poverty dimension, quite often progress had been made without economic transformation. If we just go down the poverty agenda, we would be missing a huge opportunity given the evidence that material progress can be made, for example, in childhood malnutrition, without having an enormous increase in GDP. Certainly the Asian experience suggests that there is not a powerful concordance between economic gain and nutritional improvements.

Julia Tagwireyi (Commission): I come from a programme planning perspective. In looking at what the 21^st century holds, I have to personalise that experience. It is a challenge facing us at the country level. More of the same will not do because the context is changing so rapidly - especially in Sub-Saharan Africa. Those very communities that we have depended on for their activity and action at the community level - their coping strategies are diminishing so rapidly. The disease burden - particularly with AIDS - is going to affect all those things we are doing in the communities - it is in fact already doing so. It is reducing the little capacity we have in terms of technical people. That is a challenge for us in the 21^st century because we are dealing with communities that are getting fragmented because of the heavy disease burden - in particular, AIDS. Communities in many instances in Sub-Saharan Africa, are no longer able to cope - their coping strategies are diminishing daily. Governments and other stakeholders in countries may need to wake up to see how they can help their communities bolster their coping strategies so that they can continue to help themselves. I don’t think I am exaggerating - this is the reality that we are living with. We have to challenge ourselves and ask how we cope with this. We want improvement - we are all frustrated by the decline or stagnation in nutrition improvement. At the same time the situation has changed and the context is more difficult in terms of operating. Are we up to that challenge?

George Kent (WANHR): There seems to be a common sense of fragmentation to this effort. If we think about it in terms of a rights approach that implies a goals approach, and the goal is to end malnutrition, then the task is to have a strategic plan with an acknowledgement of the kinds of resources we have available. The problem with the resources that we have available is that they tend to go in different directions. There is not a single strategic plan. Imagine for a moment if we were to contract out this task - ending global malnutrition. Imagine what we might get if we put out a request for proposals for how to end global malnutrition. Imagine also that we would pay the contractor on a contingency basis. We will check on the contractor’s performance every three years and give an incremental payment as the work moves ahead. And there will be sub-contractors. We have the sub-contractors represented here, but there isn’t a master contract. Perhaps if we could think of the task as preparing the master contract. We don’t need the technical details of how the cement pourer has to formulate his/her cement - the cement pourer has that expertise and we can leave that to him/her. What we are talking about is performance contracting - you deliver a certain performance and we will hire you. I think we should hire bridge builders to figure out how to shape the task with the intermediate steps, with the sub-contracting and so on.

Richard Jolly (SCN Chairman): I’m not quite sure where governments and the community come into the analogy of the sub-contractors. I can see how the UN agencies are there, but there are a lot of gaps between the UN agencies, the countries, the people.

Urban Jonsson (UNICEF): There is something incredibly important that has happened over the last 12 months, and that is the UN reform. The need to work together and harmonise policies and strategies is the biggest challenge for the UN just now. And we have the mechanism to do this.

For years in the SCN Working Group on Nutrition, Ethics and Human Rights, we allowed ourselves to ask ‘do we really accept a human rights approach?’ Forget about the discussion-it’s over. It is not optional any more. It is very clear from the Secretary-General in the reform process, that the UN is an organisation based on human rights. There is no option any more. It is up to us to interpret that and operationalise it within the framework of the United Nations Development Assistance Framework. So in that sense, I think we really have an opportunity to do something extremely important within the UN. If we do it well, not only will we show the way for others, but it will bring nutrition higher on the UN agenda. We have somehow been training for this for the last 20 years, so we ought to be able to do our homework well.

There is an enormous amount of material on the care initiative. We have discussed poverty and nutrition. Let us not reinvent the wheel every time - sometimes we should do it, but not every time. There is a wealth of material and agreement on what the relationship is. Finally, I am very sad when I hear people saying that nothing happens and that there is no success. I think many of us would disagree with that. So many good things have happened, with so many interesting successes around the world. The SCN has been at the forefront in the nutrition world to document it over the last 12 years. Community-based programmes, country-level programmes - it’s a wealth of information, that almost makes us say ‘let’s declare victory’. We start to know what works. But then Julia says “more of the same is not enough”. What is “more of the same”? The same is not what we have identified in SCN as success because most governments do not adopt the right strategies. Let us not develop new strategies, but let us make governments adopt the right strategies. I don’t think we need much more time to think about what is right and what is wrong. We have done this over the last 10 years and we have a certain consensus. The problem is that the governments do not accept it. So there is another level in getting these strategies accepted.

Judy McGuire (World Bank): We have one example in the world of a very successful effort to get the UN agencies moving - that was the Rio conference, which was about the environment. The reason why they got action going had nothing to do with anything signed by UN organisations. It was because the NGO community got together and made a lot of fuss and put a lot of pressure on UN organisations, and made them accountable and made them do their jobs.

Lilian Marovatsanga (AGN): I come from a developing country where the problems are getting worse, and I am not convinced that when I leave this room I will be able to say what we have achieved so far. We have the solutions to most of the problems, but our own limitation is that when it comes to practical implementation, it seems to be crisis management all the time. There is no strategic planning in nutrition. We need to be business-minded and approach the problems in an organised manner. In Zimbabwe, between November and now, so much has happened because of the crash - a 70% devaluation of the dollar - creating a food crisis. There are now riots. We have seen this happen also in Indonesia. We should draw on lessons learned so that we can manage nutrition problems. We have to build the business aspect into the way in which we plan our programmes and this requires a strategic plan.