Chapter 1: Overview

The 25^th Session of the ACC/SCN was held in Oslo, Norway on March 30 to April 2, 1998, hosted by the Government of Norway. The subject of the symposium, held traditionally on the first day of the Session, was Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle.

This topic was inspired by debate during the 24^th SCN Session held in Kathmandu the year before. The symposium took as its starting point the notion that to accelerate action, malnutrition needs to be tackled throughout the lifecycle by ensuring adequate food, health, and care. Good nutrition during pregnancy reduces the likelihood of low birth weight and improves pregnancy outcomes. Promotion of growth and development in the young infant and child leads to a well-nourished school-aged child who can participate more fully in the educational process. Adolescent nutrition, especially for girls, is important for their growth, development and wellbeing, and eventually for their children’s.

This report presents the proceedings of the symposium. This overview summarises the content of the individual presentations, as well as the main issues discussed during the plenary. The Honorary Chair of the symposium was Dr Gro Harlem Brundtland, now Director-General of the World Health Organization. She was assisted in this task by Professor Kaare Norum, Director of the Institute for Nutrition Research in Oslo, and a member of the SCN’s Commission on the Nutrition Challenges for the 21st Century.

Introductory remarks were made by Dr Hilde Frafjord Johnson, Minister of International Development and Human Rights in Norway. Following the opening session, Dr Richard Jolly, Chair of the SCN, introduced Dr Brundtland, who gave the keynote address. Following the opening session, Professor Philip James, Chair of the SCN’s Commission on the Nutrition Challenges for the 21st Century and Director of the Rowett Institute in Aberdeen, presented the main themes of the Commission’s work. Subsequent presentations were given by Suttilak Smitasiri (Mahidol University, Thailand), Per Pinstrup-Andersen (International Food Policy Research Institute, Washington, DC), and Alan Lopez (WHO). At the end of the day, Dr Jolly introduced Ms Isatou Jallow Semega-Janneh of The Gambian Ministry of Health who gave the second Abraham Horwitz Lecture.

Dr Hilde Frafjord Johnson welcomed participants to Norway and to the SCN’s 25^th Session. She drew attention to the fact that the goal set at the World Food Conference in 1974, to eradicate hunger within a decade, was not achieved. The subsequent World Food Summit held in Rome in 1996 called for governments to take prime responsibility for action in their countries. Dr Johnson spoke of an ‘enabling environment’ for development that includes the functioning of the world trade system, efforts to provide effective debt relief, and appropriate macro-economic reforms lead by the Bretton Woods Institutions. She spoke of the feminisation of poverty, stressing that a poverty-oriented policy in development is a gender-oriented policy. Dr Johnson noted that the Norwegian government has identified education and health as top priorities in their cooperation with developing countries. An important aspect of this work is taking a human rights approach, whereby people are fully active in the development process and have established rights.

Given that this was the 25th Session of the SCN, Dr Richard Jolly in his opening address offered remarks on the origins of the SCN, which first met in 1977. From its beginnings, the SCN has involved agencies of the United Nations, bilateral agencies and non-governmental organisations. He gave tribute to Professor Nevin Scrimshaw who, some twenty years before the SCN was created, saw the need for the agencies to collaborate on technical issues of nutrition. Dr Jolly highlighted the many accomplishments of the SCN, noting especially the work of Dr Abraham Horwitz and Dr John Mason, past Chair and Technical Secretary. Under their leadership, the SCN issued a series of reports on the world nutrition situation and important lessons learned from successful community nutrition action programmes. This work provides a very rich source of material to draw upon in mobilising accelerated action into the next century.

When introducing keynote speaker Dr Gro Harlem Brundtland, Dr Jolly noted Norway’s commitment to development assistance, which far exceeded the 0.7% target for many years. Dr Jolly wished Dr Brundtland every success in her new role of leadership for health in the United Nations. In her keynote address, Dr Brundtland posed the question: how can we best stimulate positive change in political processes? The Hot Springs discussions of some 55 years ago identified poverty as the first cause of hunger and malnutrition. However, the fundamental objectives set out then have not been achieved: namely orderly management of domestic and international investment, and sustained international economic equilibrium. However, with more democracy in the world today, we have more opportunities to implement sound policies.

Dr Brundtland cited a policy in Norway as an example of a national action to alleviate a public health problem. A national nutrition and food policy was formulated in Norway in the seventies. This policy emphasised reducing fat intake and increasing intake of fruits and vegetables as priority actions. Advocacy was underpinned by economic and social polices that influenced household choices, as well as the production, distribution, and pricing of food. Despite some significant delays in implementation, this policy eventually resulted in a widespread change in dietary preference for low-fat milk, now widely available in food outlets throughout the country. Dr Brundtland highlighted the need for consistent effort to get good policies implemented, especially when there are strong interest groups working against the public health interest.

Dr Brundtland went on to stress the need for targeted policies to improve nutrition in developing countries, noting that economic growth and more equity will not necessarily improve nutrition. The importance of micronutrient interventions to health outcomes has not been sufficiently emphasised. Vitamin A interventions, known to have a dramatic effect on young child mortality, are but one example.

Dr Brundtland also discussed changes to be introduced into WHO’S work. She stressed that capacity building and health sector development will be part of all WHO programmes. The WHO will also speak out on the need to safeguard the role of health and social services. This message will be directed not just to the financial institutions, but also to governments. Finance ministers of all countries need to hear about the central role of health for development. Evidence-based health and nutrition policies will serve this task well, she said.

In closing, Dr Brundtland likened the Secretary-General’s team of UN agency heads as his cabinet, and the Secretary-General himself as a Prime Minister. Mandates of agencies need to openly discussed at this level, and integrated. Only with this kind of thinking will the goals that have been set out by the global conferences be achieved.

Professor Philip James began his presentation titled The Global Nutrition Challenge in the Millennium’ by explaining the origins of the SCN’s Commission on the Nutrition Challenges of the 21st Century and introducing its members. The Commission was established following the SCN’s discussions in Kathmandu one year ago. Its purpose is to identify the emerging nutrition challenges and to examine the role of the United Nations agencies in meeting these challenges.

Professor James began by presenting numbers and trends in preschool malnutrition, noting that some 157.6 million children are underweight worldwide, according to 1996 figures published by the ACC/SCN. According to simulations carried out by the International Food Policy Research Institute (IFPRI), by the year 2020, at current rates of progress, about 150 million children will still be underweight. Importantly, the definition of malnutrition conventionally used for these estimates hides the true impact of malnutrition on societies. This is because the majority of children may have depressed growth, even when only modest numbers are specified as malnourished, because they fall below a given cutoff.

Professor James then traced the origins of young child malnutrition to low birth weight, and to low body mass (BMI) in women and poor weight gain during pregnancy. Evidence from a review of randomised controlled trials of nutrition interventions during pregnancy shows that poor foetal growth responds to nutritional interventions. “We need to look at antenatal care in a completely new way in order to avoid the huge handicap that arises from low birth weight”, he stated.

In introducing the agricultural dimension, Professor James covered several points. Firstly, if being well-nourished ensured growth to an optimum height, in India for example, one-third more food would be needed. Secondly, reliance on only a small number of food crops introduces an element of vulnerability and risk in terms of sustainable development. Thirdly, seasonal fluctuations in the annual provision of food significantly affect adult and infant nutrition. This may have profound long-term implications on the development of societies.

Professor James also addressed the issue of dietary chronic disease. Me noted that in numerical terms, diseases of the circulatory system and cancers are now greater in the developing world than in the industrialised world. There is also a profound rise in rates of obesity in developing countries. Some of these problems, diabetes for example, have foetal origins and major implications for policy. Professor James summed up by saying “... with a coherent public health strategy... not simply adult education... the course of coronary heart disease can be changed.”

In conclusion, Professor James urged that coherent strategies need to be formulated in relation to the magnitude of the problem and the level of population risk. This has been done by the Institute of Medicine for three micronutrient deficiencies, and a similar approach could be developed for the range of malnutrition problems that societies face.

Dr Suttilak Smitasiri’s presentation on “Nutrition Challenges and Gender in Asia” focused first on the experience of Thailand in tackling undernutrition in children. The speaker drew attention to the high rates of underweight in children in Asia, and anaemia among pregnant women. Anaemia of pregnancy is especially widespread, over 80% in India and Bhutan.

Thailand is known for having dramatically reduced malnutrition in young children, from over one half to about 19% within one decade. What were the elements of this success? Dr Smitasiri pointed out that policies and programmes were created to reduce both poverty and malnutrition. Targeting poor areas, focused interventions, a primary health care structure that promoted community participation, and a strong emphasis on nutrition in rural income generation schemes were important elements. Advocacy and commitment at the highest political levels were also key. These aspects were galvanised by a small group of senior professionals with strong backgrounds in primary health care and management. This group was effective in merging nutrition work into the national poverty alleviation plan. Because of the massive scale of implementation, and high levels of volunteer recruitment at the village level, results were communicated widely, which helped to raise awareness.

How relevant is this experience to other countries in Asia? Dr Smitasiri outlined some of the contrasts between the situations of South Asian women and Thai women. In Thailand, women and men have both been involved in nutrition policy implementation. However, there are three important gender differences that might limit application beyond Thailand: 1) South Asia faces more difficulties in terms of food production and living standards, 2) South Asia has a wider economic and social gap between the ‘haves’ and the ‘have nots’, and 3) the role of women in South Asia is more limited than in Thailand and elsewhere in South-East Asia. Systematic efforts are needed to create a critical mass of leaders, especially women leaders in South Asia. Nutrition work needs to build upon a solid understanding of the potential for change.

The speaker noted in conclusion that “the Thai experience... can be considered by other Asian countries,” and despite the need for urgent action in South Asia, she cautioned that nutrition work should not dis-empower the poor.

In his paper “Achieving the 2020 Vision,” Dr Per Pinstrup-Andersen first expanded on the six priority areas of action required to realise the 2020 Vision set out by the IFPRI:

· strengthen the capacity of developing country governments to perform appropriate functions, such as maintaining law and order and assuming private sector competition in markets. “The efforts of the past decade to weaken developing country governments must be turned around”, he stated. Governments should facilitate food security by facilitating a social and economic environment that provides all citizens with the opportunity to assure their food security.

· invest more in poor people to enhance their health, nutrition and productivity, and to increase their access to remunerative employment. Female education is among the most important investments for assuring food security.

· accelerate agricultural productivity by strengthening agricultural research and extension systems. Agriculture is the lifeblood of the economy in most developing countries, providing up to three-quarters of all employment and half of all incomes. Agriculture has long been neglected in developing countries resulting in stagnant economies and widespread hunger and poverty.

· promote sustainable agricultural intensification and manage natural resources soundly. Local control over natural resources must be strengthened and local capacity for management improved.

· develop effective low-cost agricultural input and output markets. Policies and institutions that favour large-scale, capital intensive enterprises over small-scale labour-intensive ones should be removed.

· expand and realign international assistance. The current downward trend in international development assistance must be reversed, but aid effectiveness also needs to be improved. Recipient countries should develop a coherent strategy for achieving goals related to food security and poverty and should identify the best use of international assistance.

Dr Pinstrup-Andersen went on to discuss the role of women in achieving the 2020 Vision, noting that women account for 70-80% of household food production in Sub-Saharan Africa despite unequal access to land, inputs, and information. Overlooking the potential benefits from effective integration of women into development is costly to developing countries. It also results in fewer development gains per dollar spent on development projects. The human resource embodied in women is poorly utilised in the development process.

Extensive research done by IFPRI has shown that improvements in household welfare depend not only on the level of household income but also on its control. Women tend to spend their income disproportionately on food and other family needs. Thus women’s incomes are more strongly associated with improvements in child health and nutrition. Further, ensuring nutrition security of the household through a combination of food, health care, and child care is almost exclusively the domain of women. Technology is urgently needed to increase the productivity of women.

In conclusion, the speaker stressed that women are key to food security, and must be given equal access to productive resources and to education, health care, and other factors that increase their wellbeing and their human capital.

Dr Alan Lopez, in his presentation “Gender and Nutrition in the Global Burden of Disease”, began by explaining the origins of the Global Burden of Disease (GBD) project. Statistics on health status traditionally have enormous limitations that affect their practical value to policy makers. Health statistics tend to be partial and fragmented, and sometimes misused by advocates competing for scarce resources. Also, traditional health statistics do not allow policy makers to compare relative cost-effectiveness of different interventions. Working together, the World Bank and the WHO in 1991 commissioned a study of the Global Burden of Disease to provide a full assessment of global health conditions. The results of this work have been widely published. Two main findings arise from the mortality analyses:

· for several major developing regions (Latin America and the Caribbean, for example) more people die of non-communicable than communicable diseases. In China, for example, there are more than four times as many deaths from non-communicable than communicable causes;

· only in India and sub-Saharan Africa do communicable causes still predominate.

However, analysis of mortality outcomes does not give a full picture of a population’s health. The leading causes of disability are much different from the leading causes of death. The central role of disability in determining overall health status “has until now been almost invisible”, Dr Lopez stated.

The GBD team has shown that the leading causes of disability include, surprisingly, depression and other mental illnesses. Iron-deficiency anaemia is ranked second among leading causes of disability. Turning to the issue of sex differences, Dr Lopez underlined that women suffer disproportionately from their reproductive role. The burden of reproductive ill-health, almost entirely confined to developing regions, is so great that, worldwide, maternal conditions make up three of the ten leading causes of disease burden in women 15 to 44 years.

Where does malnutrition figure in these estimates? To deal with this question Dr Lopez presented data on exposures to hazards. Exposure to particular hazards can significantly increase an individual’s risks of developing disease. Policy makers need solid information on these risk factors to devise effective prevention strategies. The burden of disease or injury that can be attributed to past exposure to a given risk factor is an estimate of the burden that could have been averted if that risk factor had been eliminated.

Importantly, of the ten risk factors studied, malnutrition is the dominant hazard responsible for about 16% of the global burden of disease; poor water supply and sanitation are responsible for an additional 6.8% of the global burden. Malnutrition is a major cause of disease burden in Sub-Saharan Africa where it accounts for one-third of all disability life-adjusted years (DALYs) lost and in India where it accounts for 22% of DALYs lost. These estimates do not capture the effects of mild and moderate underweight in children, micronutrient malnutrition and other forms of undernutrition in other age groups. This important work is yet to be done.

The importance of taking into account malnutrition as an underlying cause of mortality was stressed during plenary discussion of Dr Lopez’s paper. Similarly, for Eastern Europe and countries of the former Soviet Union, the importance of overnutrition and poor nutrition to declining health and rising rates of premature mortality was underlined.

Ms Isatou Jallow Semega-Janneh spoke on “Breastfeeding: From Biology to Policy”, as the second Abraham Horwitz Lecturer. The theme of her presentation was exclusive breastfeeding. She began by reviewing aspects of the biology of breastfeeding, pointing out that “the full benefits of breastfeeding may not be realised if optimal breastfeeding, including exclusive breastfeeding, is not practised”. Citing data available from WHO’S Global Data Bank on Breastfeeding, the speaker noted that exclusive breastfeeding to the age of four months is quite rare despite very high initiation rates, especially in Africa. In describing barriers to exclusive breastfeeding, Ms Semega-Janneh notes that local perceptions of what constitutes optimal infant feeding may differ greatly from international recommendations.

The speaker then described an innovative community action project, called the Baby Friendly Community Initiative, which was carried out in The Gambia beginning in 1991. The Initiative focused on providing community support to exclusive breastfeeding. The rationale for this approach was that most deliveries in The Gambia occur at home and feeding practices, including breastfeeding, are influenced to a great extent by traditional beliefs at home.

The Ten Steps of the Baby Friendly Hospital Initiative were adapted to the community level. Messages on maternal nutrition, complementary feeding, environmental sanitation, and personal hygiene were also incorporated. Village support groups on infant feeding were created. These groups - made up of five women and two men-were trained to implement and monitor the Initiative. Traditional birth attendants were included in the support groups because of their key role in the communities. Training built on local and traditional knowledge. Village support groups were entirely responsible for information dissemination. During the lifetime of the Initiative, breastfeeding initiation rates (within 24 hours) increased from 60.2% to 99.8%. Similarly, exclusive breastfeeding became universal. Attitudes also changed and a local term for exclusive breastfeeding was adopted. Rest houses in the field were constructed for breastfeeding women. Because of the success of the Initiative, national expansion in The Gambia has been recommended.

The speaker then reflected on the importance of maternity protection for all working women, and explained how different aspects of maternal protection are covered in existing international instruments, such as the Innocenti Declaration and others. Ms Semega-Janneh concluded by challenging the SCN member agencies to “bring home the importance and benefits of breastfeeding to governments and their policy makers.”