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THE WORLD BANK /IFC I MIGA

OFFICE MEMORANDUM DATE: May 26, 1992

TO: All PHR Divisions

FROM: Alan Berg~ EXTENSION: 33433

SUBJECT: New & Noteworthy in Nutrition (No. 17)

Highlights: More on the AIDS scare (page 1) ... Half a billion dollars in nutrition operations for India (page 3) ... Global nutrition picture looking up (page 6) ... Empirical study on the effect of better nutrition on school performance gives high marks (page 7) ... New research shows strong contracep­tive effect of breastfeeding (page 8). This issue is organized as follows:

Nutrition and AIDS Operations The Larger Picture Nutrition and Educability The Population Link

Nutrition and AIDS

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1 2 6 7 8

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New on Micronutrients 8 Highlights of Seminars &

Symposia 10 Worth Noting 12

1. Update On AIDS and Breastmilk. Last November we reported on a study in Rwanda showing that between a quarter and a half of the Rwandan mothers who became HIV positive after delivery passed the infection to their infants through breastfeeding. The study raised several questions in the Bank -- and concerns. Now the April 25 Lancet reports on a study in 19 European centers that followed the children of 701 HIV-infected mothers for 18 months, with findings pointed in the same direction -- and a 14.4 percent transmission rate. Multivariate analysis shows the odds of transmission were more than twice as great in breastfed vs never-breastfed children. Chances are higher in children born before 8 1/2 months gestation, possibly because of inadequate immunity at that age. The bottom line of the European collaborative study: "The balance of evidence suggests that mothers with established infection can transmit HIV infection through breastmilk, although the relative importance of this route remains to be defined."

2. Official Position. The week after the study appeared in Lancet, WHO and UNICEF convened a consultation of experts, and on May 4 WHO issued a statement that acknowledges that some HIV transmission does occur through breastfeeding. The statement stresses, however, that "a baby's risk of dying of AIDS through breastfeeding must be balanced against its risk of dying of other causes if not breastfed." The consultative group concluded that "where infectious diseases and malnutrition are the main cause of infant deaths and the infant mortality rate is high, breastfeeding should be the usual advice to pregnant women, including those who are HIV-infected." The reason: a baby's risk of HIV infection through breastmilk is likely to be lower than the risk of death from other causes if it is not breastfed. In settings where the main cause of death during infancy is not infectious diseases and the infant mortality rate is low, "the consultation concluded that the usual advice to

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pregnant women known to be infected with HIV should be to use a safe feeding alternative for their baby rather than breastfeed."

3. More to Worry About. Wet nursing by surrogate mothers is still common in parts of the world. And even more common is the village mother who commonly picks up whatever child in the vicinity is crying and suckles it. With the advent of AIDS -- and the possibility of HIV being transmitted via breast milk -- both practices pose a dilemma that is only beginning to be considered.

4. Food for AIDS Victims. The Bank's first project with an explicit sub-component to provide food to AIDS-afflicted families -- this for Rwanda will be taken up by the Board on June 17. (See paragraph 18.)

Operations

5. Latin America & Caribbean. The on-again, off-again MCH and Nutrition Project in Arzentina is back on track, thanks to a strong job by UNICEF in mobilizing a team of some two dozen Argentine experts -- in many cases the tops in their fields there. Working away in the same building where Evita Peron once held forth, the team has come up with one of the most detailed proposals of its kind yet received by the Bank. The main remaining concerns for an otherwise technically strong project relate to organization and management. Problems we are up against are reflected in the fact that the Ministry of Health has had six different Ministers and six different Secretaries in the last two years. (Task Manager: Pepe Andreu, LA4HR.) UNICEF's partnership with the Bank in this undertaking offers an excellent model for operations elsewhere. In short, the Bank was involved in the early stages in making arrangements (including government financing) for the preparation team. UNICEF mobilized the experts and effectively supervised the preparation process. The result: the Bank is receiving a first-rate proposal, far advanced of what normally is seen at appraisal.

6. In the upcoming $18.4 million IDA Credit for the Honduras Health and Nutrition Project, now in yellow cover, the Bank for the first time will be providing support for food coupons. We have directly financed food supplements in the past. And we have previously financed large-scale experimental studies that included food coupons and a number of the supportive services required for food coupons. The project is the outgrowth of a pilot nutrition program (financed under the Bank-assisted Social Investment Fund) that successfully targeted food coupons to 177,000 needy children and women in primary schools and health centers. Evaluations attributed to the food coupons a dramatic impact on both growth in school enrollment and use of health centers, as described in New & Noteworthy No. 15. (Task Manager: Anna Maria Sant'Anna, LA2HR.)

7. A new request is just in from the Government of Bolivia for a Child Development and Nutrition Project. Xavier Coll, LA3HR, will be Task Manager ... Another Xavier Coll project, a $10.3 million IDA Credit to Guyana for a Health, Nutrition and Water and Sanitation Project, was approved by the Board on April 21. Designed to help mitigate adverse effects of adjustment,

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the project includes food distribution programs closely linked to growth monitoring and nutrition education.

8. The Bank is readying for negotiations a $70 million Health and Nutrition Project loan for Ecuador. An impetus for the nutrition portion comes from the country's Minister of Health Plutarco Naranjo, a noted nutrition authority. Again, growth monitoring is linked to food supplements for those children whose growth is faltering which, in turn, are linked to nutrition education of their mothers. (Task Manager: Bernardo Kugler, LA4HR.) A main source of funding for Ecuador's expanding nutrition effort is an earmarked tax on exported shrimp.

9. South Asia. With the $194 million IDA Credit for India's Integrated Child Development Services II Project, scheduled to go to the Board June 23, nutrition operations totaling half a billion dollars for four projects in India in the last 24 months will be underway. The new project will concentrate on the very poor states of Bihar and Madhya Pradesh, where levels of moderate and severe malnutrition (particularly in Bihar) are among the highest in the world. Infant mortality in these two states is 3 1/2 times that of Kerala. The outstanding Appraisal Report will be of interest to all Bank staff working on nutrition. (Task Manager: Ellen Schaengold, SA2PH.)

10. Recently published by Cornell University, a fresh view with independently collected data of the Bank-assisted Tamil Nadu Integrated Nutrition Project says "the true impact of TINP is greater than the earlier significant impact claimed in the government evaluation report." The work, part of a newly-completed doctoral dissertation on the project by Meera Shekar, concentrates on the monitoring and information system which, she says, "represents one of the best examples worldwide of efficient use of information for program management." Hers is one of several dissertations and other major studies being undertaken on the Tamil Nadu project.

11. Seeds for the FY94 Nutrition Project in Pakistan are being planted with the Second Family Health Project, currently being appraised. The proposal calls for the number of technical nutrition staff to be increased, provincial nutrition strategies to be updated, and nutrition activities/ education to be integrated into MCH centers and basic health units. (Task Manager: Christopher Walker, SA3PH.)

12. The Bank's new Food Policy Review for Bangladesh suggests that "the time has come to allow the private sector to play a larger role in stabilizing foodgrain prices and ensuring food security in Bangladesh. The public sector can then work more effectively and efficiently to respond to catastrophic events such as cyclones and floods, and to target assistance to those at greatest nutritional risk." Also advocated is the expansion and diversification of self-targeted food distribution programs aimed at reaching more women and children during the lean season/high disease incidence periods, and greater governmental accountability for food aid. (Task Manager: Ellen Goldstein, SAlCl.)

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13. Middle East & North Africa. The million-and-a-half Iranian widows whose husbands were casualties of the war with Iraq provide an easily identifiable group for targeting nutrition and other services, according to K. Subbarao, PHRWD, recently back from Iran. But generally he reports unexpectedly little malnutrition there and high awareness by mothers of what needs to be done for their children. A role of the mission (led by Jim Parks, MNlCO) was to help build a social safety net for the economic adjustments currently underway.

14. As with an increasing portion of adjustment projects, the number of children suffering from moderate and severe malnutrition will be a main indicator for tracking changes in welfare to be monitored under the second Structural Adjustment Loan for Morocco, approved April 30. (Task Manager: Ali Khadr, MNICO.)

15. East Asia & Pacific. The proposed $70 million loan for the Philippines Urban Health and Nutrition Project was pre-appraised in April and is on schedule. (Task Manager: Stan Scheyer, ASTPH, with Cathy Fogle, EAlPH.) Unlike most countries, malnutrition in urban Philippine areas is much more pronounced than in rural areas, with the national capital area of Manila among the worst.

16. Cambodia is about to become active again in Bank lending, and clearly there are nutrition problems there. However £AlPH staff report the extreme difficulty of working in that country; for instance, each of the four political factions has at least one Minister of Health. A first project will likely take the form of Social Dimensions of Reconstruction, with strong emphasis on early childhood. Like Iran, a main audience will be the very large number of war-widowed women now heading households in Cambodia. (Task Manager: Oscar Echeverri, EAlPH.)

17. The Bank's new Country Economic Memorandum for Indonesia, now in green cover, will note that survey data from the 1980s show significant increases in average caloric intake and reductions in the prevalence of moderate and severe malnutrition among young children. These advances are attributed to growth in food production and rural employment and better management and distribution of food supplies. Another factor, according to the report, was the intersectoral program which used monthly village meetings to monitor children's growth and promote nutrition education. Also noteworthy is the decreased incidence, since the late 1970s, of blindness and other problems linked to vitamin A deficiency. Again Government programs, including nutrition education and vitamin A capsule distribution, contributed to the observed improvement. (The report's nutrition analysis by Sandy Lieberman, EA3PH.)

18. Africa. Nutrition objectives served as an organizing principle for the development of the Bank's second food security project, which goes to the Board June 17 for Rwanda. An addition to the components described in New & Noteworthy No. 15 are the development and implementation of a charter to ensure prudent use of food aid. Although food will be made available to destitute groups (including singling out AIDS-afflicted families), great

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lengths are being taken to try to avoid excessive dependency on food aid. Through food aid, the Yorld Food Program is picking up a third of total project costs. (Task Manager: Jacques Baudouy, with Qaiser Khan, AF3PH, and Kees Tuinenburg, AFTSP.)

19. Nutrition looms large in the Social Action Program drawn up by a mission earlier this month in Ethiopia. In addition to feeding into the Policy Framework Paper, now under preparation, the team report (which is recommended reading, both for its quality and approach) will serve as the basis for a poverty/food security project and a health and nutrition project in the lending program. (Heading the 14-member team: Jack van Holst Pellekaan, AF2AG, and Jill Armstrong, AF2PH.)

20. Expansion of a UNICEF-sponsored community nutrition initiative is featured in the ~ Population Project, approved by the Board April 30. Also included is support for micronutrients, growth monitoring and nutrition education and rehabilitation of the severely malnourished. (Task Manager: Ed Brown, AFSPH.) ... Also for Niger, improvement of nutrition is among the main messages in the functional literacy component of the Agricultural Services Project approved by the Board March 31. (Task Manager: Jiri Cerych, AFSAG.)

21. York proceeds on a capacity-building project for food security in Mozambique, with the anticipation that it will go to the Board in September. (Task Manager: Neeta Sirur. AF6PH.) ... The Nigeria Nutrition Project, with collaborative preparation by UNICEF and USAID and funding support from UNDP, moved a step closer to realization after a successful preparation mission earlier this month. (Task Manager: Dave Radel, AF4PH.) ... Under the aegis of the Sao Tome and Principe Health and Education Project, approved by the Board on April 28, a high-priority nutrition study will be implemented as a preliminary step towards understanding the determinants of deteriorating nutrition on the islands. (Task Manager: Socorro de Paez, AF4PH.)

22. Europe and Central Asia. Recognizing that real incomes of Albanians will be reduced when prices are increased to levels consistent with economic incentives and budgetary resources, Bank staff has proposed to the just-elected Government administration a program that combines a broad safety net with a narrower, deeper one. The broad net is an implicit subsidy on wheat. The multi-tiered deeper one is a system providing a monthly voucher (worth ten kilos of bread) for each family with children under three years of age, a double voucher for each such family living in the seven poorest districts, and a still larger voucher for families with severely malnourished children or whose children fail to gain weight for two successive months. The latter will be combined with intensive nutrition education of the mothers. Harold Alderman's (AGRAP) analysis provides a 'best-practice' model that should be studied by all staff dealing with safety net needs in other countries. (Newly elected Albanian President Sali Barisha, by the way, is a physician who evinced considerable interest in nutrition to an earlier Bank mission.)

23. The Poland Health Services Development Project, approved by the Board on May 7, includes the preparation of an education and counselling

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program to address unhealthy diets. Rising mortality due to cardiovascular diseases and cancers characterizes the deteriorating national health status, and preventive nutrition strategies are seen as key to reversing the trends. (Task Manager: Mary Young, EMTPH.)

The Larger Picture

24. For a Cbange. Good Nutrition News. In anticipation of December's International Conference on Nutrition, FAO staff are crunching out numbers on nutrition levels in the developing world. And, if the preliminary data are anywhere close to being correct, they surprise -- and offer promise. Both in percentages and absolute numbers, the figures on undernutrition are down. Dr. B.P. Dutia, until recently Assistant Director-General of FAO, reported at an ACC Sub-Committee on Nutrition meeting (the UN body of nutrition representatives from international and bilateral agencies) in Rome week­before-last that the proportion of people who are "dietary energy deficient" dropped from 36 percent in the period 1969-71 to 26 percent a decade later to 20 percent in 1988-90. Percentages are down in all regions except Africa. The drop, he told the SCN, has been sufficiently substantial so that, even with growth in population, absolute numbers also have fallen during these three periods -- by FAO's reckoning, from 941 million to 844 million a decade later, to 786 million in the period 1988-90. This is still obviously an unacceptably large number, but one revealing that encouraging progress has been made. (The most significant declines are in the Far East where percentages are down from 40 percent in 1960-71 to 28 percent ten years later, to 19 percent in the most recent look.) ... In another study, this by the SCN Secretariat, preliminary findings for a new World Nutrition Situation report estimate that in the last 15 years the global prevalence of underweight children declined from about 41 percent to 35 percent. Again, the decline shows up in all regions but sub-Saharan Africa.

25. Massive Drou&ht Vnfoldin~. The sub-Saharan African food problem is exacerbated this year by the worst drought of the century in Southern Africa, an area infrequently visited by serious drought. Be prepared this fall to see on your television sets extensive coverage of thousands of matchstick-limbed children. Total production of maize, the most important staple crop in Zimbabwe, is only 20 percent of normal. The drought could not have come at a worse time. Zimbabweans already had tightened their belts a notch because of the increased prices associated with structural adjustment, and the next crop will not make it to the table until next January. Complicating the process is that, as a normally food-surplus (and food-exporting) country, Zimbabwe has had virtually no experience since its independence in 1980 in fighting massive drought. In addition to reallocating up to $39 million from the existing project portfolio, the Bank is responding with a $100 million Emergency Drought Recovery and Mitigation Credit. This is scheduled to go to the Board next month, and is probably the Bank's best project response to date to an African food emergency. The project will finance seed for the next plantings (since so much of available seed has been eaten) and related inputs and transportation. Food-for-work for half a million already eligible farmers also is included (Task Manager: Eric Rice, AF6CO.) ... The Bank also is responding to other affected countries in the area by increasing amounts in

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adjustment projects scheduled to go to the Board in the next 4-6 weeks -­Zambia by $100 million, Mozambique by $10 million, and Malawi by $25 million. To speed disbursements, reshaping also is going on of existing health, nutrition, and water projects in these countries.

26. Bygone Micronutrient Diseases Reappearing. This year's most compelling and depressing presentation at the annual ACC Sub-Committee on Nutrition meeting was that on refugee nutrition. The nutrition status of refugees and displaced persons is appalling, all the more so because one assumes their needs are being met by the UN High Commissioner on Refugees, the World Food Program, NGOs and host governments. Malnutrition rates are high and often get worse in the camps. Called "veritable museums of micronutrient deficiencies," the camps contain diseases such as pellagra, scurvy and even beriberi, which were thought to have largely disappeared decades ago. The main value of the discussion was bringing to light that nobody is now accountable for the unnecessarily poor nutrition state of refugees. SCN made a series of recommendations to its parent body, the UN's Administrative Committee on Coordination (made up of the heads of UN agencies) to correct this situation.

27. Sharpening the Focus. We now know for sure that in nutrition if we don't focus on the very young child, we miss the boat -- although Bank projects don't always reflect this. If preventing stunting is the aim of a food supplementation program, it is the six-to-eighteen month old babies who deserve top priority, reported Professor George Beaton of the University of Toronto at the annual SCN meeting in Rome. (Some Bank projects still give equal attention to all children up to six years.) Growth itself is, of course, only a marker -- but we now know it marks long-term effects. Beyond eighteen months, one can still prevent failure of linear growth but probably at a much smaller rate, he said ... On the issue of whether small size is genetic, Professor Beaton noted the big difference in growth of children in Guangzhou in southeastern China compared with those of the same genetic stock in Hong Kong not far away.

Nutrition and Educability

28. Eating to Learn. An important empirical study on the effects of nutrition on primary school performance shows that nutrition strongly affects both grade attainment and achievement. The research, on students in rural northeast Brazil by Eric Hanushek of the University of Rochester and Joio Batista Gomes-Neto and others from the Federal University of Ceara, finds that current nutrition status (that places the student within 60 percent of normal skinfold thickness) is worth almost six (of an average 30) points in achievement growth compared to those who are more deficient. While many in the nutrition community have long suspected such a relationship, little previously available evidence confirmed it or indicated the magnitude of effects. The results also provide direct support for school feeding programs beyond the hypothesized effect on attendance (by promising a meal to students, they can be bribed to attend school). The evidence here is different. It suggests that well-nourished children indeed learn more.

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29. More is LeSS. A study of school feeding in Argentina found that in some cases giving some food is worse than giving none. The analysis by Ernesto Cohen and Pablo Vinocur suggests that poor families, thinking that their children are being fed at school, give them less when limited food at home is being distributed to others in the family. So if school feeding programs are deficient in calories, malnutrition is higher than if no food is available at school.

30. Food for Teachers. The Dominican Republic has asked the Bank for help on a nutrition program for school teachers, providing them with school lunches so that they will have more pep in their teaching. Karen Lashman, LA3HR, reports that salaries are now apparently so low that teachers can't afford enough to eat. Resulting lethargy, she says, shows in the teaching.

Tbe Population Link

31. New on Breastfeedini and Fertility. A significant new research finding in the April 18 Lancet has implications for Bank staff planning population projects. In the first clinical efficacy study of its kind, exclusive or near-exclusive breastfeeding was found to be a remarkable 99.5 percent effective as a family planning method over a six-month period. Researchers from Georgetown University and the Catholic University of Chile found that only one of 384 Santiago women using the lactational amenorrhea method in a breastfeeding promotion program became pregnant, and that was in the sixth month. (Earlier estimates, based only on analysis of pre-existing data, did not project this high-a-level of effectiveness.) So Bank projects designed with aims to limit fertility may be missing a major bet if they do not in appropriate settings (see paragraph 2) explicitly include components for breastfeeding promotion. The women in the study were advised to depend on exclusive or near-exclusive (allowing one supplemental feeding per week) breastfeeding as the only contraceptive, so long as they had no vaginal bleeding (after 56 days post-partum). Interestingly with this breastfeeding method, only nine percent of the group restarted menses by the end of three months and only 19 percent by the end of six.

32. Not-so-new on Breastfeeding and Fertility. "While women are suckling children, menstruation does not occur according to nature, nor do they conceive." --Aristotle, De Generatione Animalium. Book V, circa 350 BC.

New on Micronutrients

33. Iron. The odds of low birthweight are tripled and of preterm delivery doubled for women with iron-deficiency anemia, according to a notable new finding by Theresa Scholl and others in the May issue of Tbe American Journal of Clinical Nutrition.

34. An interagency Group for Control of Iron Deficiency, created last year with World Bank support, reported on the preliminary results of a survey of iron supplementation efforts in 40 countries -- showing that, while iron tablet supplementation exists on paper in MCH programs in virtually all countries, its implementation is largely ineffective.

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35. The social marketing work of The Manoff Group in Indonesia found that consumer views about consuming iron pills is directly related to the color of the pill. Traditionally, the pill has been white or gray. But the perception of its value was much more positive when the pill was changed to red -- a color associated with good blood.

36. The first large-scale fortification of milk with iron is currently planned for Argentina, as part of the Maternal Child Health and Nutrition Project now under preparation. Although the technology was developed in Chile some years ago, it was never implemented on a sizable scale.

37. In Brazil, fortification with ferrous sulphate of drinking water in a preschool day-care institution in Ribeirao Preto reduced anemia of the children markedly, according to Jose Dutra de Oliveira, head of the research group at the medical school there.

38. Vitamin A. Vitamin A supplementation looks more important every day. Reports of its importance for young children have been flowing for several years, but the findings have been clouded with questions of methodology and other uncertainties. Now, in response to an ACC Sub-Committee on Nutrition urging for an independent review of experience to date, the picture is clearer. An interim report of a Canadian (CIDA)-supported meta­analysis of seven trials with adequate data noted "considerable confidence that in populations with clinical evidence of vitamin A deficiency, vitamin A supplementation can be expected to have an effect on young child mortality." Although further refinement of the study is expected, co-chairs George Beaton and Reynaldo Martorell report "it seems extremely unlikely that the major finding will change." ... The April 4 Lancet, reporting on a micronutrient meeting earlier this year in Bellagio, says that a meta-analysis of the six controlled community-based prophylaxis-mortality trials on vitamin A published in the past decade shows that vitamin A led to an overall reduction in child mortality of 34 percent.

39. The two usual techniques for determining vitamin A levels in children are both invasive: drawing blood or doing a scraping from the eyeball

so both obviously create problems. Now, vitamin A expert Al Sommer, Dean of the School of Public Health at Johns Hopkins, notes that a quick indicator of the severity of vitamin A deficiency in a community is a look at whether or not there is high case-fatality due to measles. This otherwise-mild childhood disease often is fatal with low vitamin A.

40. A study in Indonesia by a Cornell group that supplemented women with massive doses of vitamin A three weeks post partum and followed the effects on them and their infants, concluded that the concentration of vitamin A in breastmilk was sustained up to eight months. Children breastfed by mothers without vitamin A supplement had half the vitamin A stores. As a megadose of vitamin A may result in malformation of the fetus, it can be safely given to women only within four weeks after delivery when non-pregnancy is assured.

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41. In the Terai region of Nepal, the University of Michigan tested the impact of three types of treatment for vitamin A deficiency: mass-dose capsules, mass-dose capsules combined with public health, and nutrition education. All three treatments were effective in reducing severe vitamin A deficiency. Importantly, the study shows that nutrition education, encouraging the eating of vitamin A-rich foods, alone can do the job. And changing a food habit in this direction provides the best chance for sustainability. (The vehicle for the nutrition education was an adult literacy program using vitamin A needs as the theme. In the space of two years, at the cost of $1.20 a child, night blindness was cut by two-thirds.)

42. Iodine. Independence in Eastern Europe poses challenges for iodized salt, and presumably other fortified foods. It is apparent that the pre-liberated Eastern Bloc countries did better at preventing iodine deficiency diseases through effective iodization of salt than some Western European countries. Hungry and Poland already have slipped seriously since liberation.

43. One of the problems in promoting an iodine campaign in Burkina Faso is that goitrous necks are seen as a sign of beauty. reports Bruna Vitagliano, AF5PH, upon her recent return from a meeting with rural NGOs trying to improve the iodine deficiency situation in that country.

44. Kenya, which has one of the model salt iodization programs in Africa, iodizes only its domestic salt, not that for export. An interesting wrinkle on this is that in Uganda, black-marketed salt smuggled from Kenya is actually better than the salt legally imported from Kenya because the former is iodized. Not all is rosy, however, says Ken Bailey of WHO. On occasion, smuggled Kenyan salt is adulterated with white sand.

45. The Bank has contributed $250,000 in support of a just-launched Global Micronutrient Initiative, in collaboration with CIDA, IDRC and UNDP, to help countries develop strategies for addressing micronutrient malnutrition and prepare appraisable proposals. So far $3.5 million has been raised overall by IDRC. The Executive Director of the Secretariat to be housed in Ottawa is being recruited. Nominations of or by Bank staff for an entrepreneurial person, not necessarily a scientist, can be communicated to Judy McGuire, PHRHN.

Highlights of Recent Seminars and Symposia

46. "We can do something about nutrition problems without doing something about development." This was one of the main conclusions from a three-year study for the Rockefeller Foundation, reported by Cornell University's Professor Per Pinstryp-Andersen to the April 2nd day-long nutrition symposium sponsored by ASTPH. The director-designate of IFPRI also reported that his study shows that, while unlike certain other sectors, "the content of nutrition programs is not generalizable, the process of arriving at that content~ generalizable."

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47. At the same symposium, summing up 20 years' experience with economic development and its changing emphasis over the years, economist David Klaus (EAlPH) asked: "if we have to pick any one thing that may be the real key to development, could it perhaps be the nutrition of pregnant women and pre-school children? If babies and very young children suffer irreparable mental and physical damage before they are even five years old," he asked, "will any other investments or policy reforms be able to overcome this handicap, for the individuals concerned and for the country as a whole?" Pointing to the current Bank emphasis on education projects, he said, "by the time we reach children through a primary education project, it may be too late." He argued that" ... we ought to start by putting our own house in order and giving far more attention to nutrition when planning country development strategies and interventions than we do at present." He advocated making nutrition a key element in Bank country dialogue, that a country's nutrition status and policy (if any) be integral to country strategy papers and that impact on nutrition be part of discussions in reports on all adjustment loans.

48. Jayshree Balachander, who until recently administered the Tamil Nadu Integrated Nutrition Project, gave a pair of seminars April 16 and 17 at which she emphasized the payoff to prompt management actions. One concept pioneered by the project was the establishment of an "empowered committee" to streamline decision-making. At regularly scheduled meetings, collective on­the-spot decisions (generally reserved for higher-ups and taking much longer) can be taken by representatives of several departments involved in the project. The "empowered committee" concept has been adopted for four other Bank-assisted projects in India and is being considered in Sri Lanka. (By the way, the special supplement in the last issue of New & Noteworthy --excerpts from the Government of India's response to the Tamil Nadu Project Completion Report -- prompted questions about the scale of that project. Tamil Nadu I covered 9,000 villages and about 1.2 million mothers and children. Tamil Nadu II, now underway, expands the project statewide -- to 20,000 villages.)

49. Harold Alderman's March 19 seminar on "Nutrition Considerations in Bank Lending for Economic Adjustment" brought out that programs for employment generation generally receive greater attraction than nutrition programs, both in structural adjustment loans and social funds. This presumably is because of the commonly-held belief that employment programs are "investment" and nutrition programs are "consumption." However, both approaches, the seminar corrected, have the potential to be either investment or consumption; it depends on the design.

50. BariY Popkin, Professor of Nutrition at the Carolina Population Center, presented here in April his new study on "The Nutrition Transition" in which he stressed that developing countries are following the dietary path of Western countries -- away from traditional low-fat, high-carbohydrate diets toward the typical high-fat Western diet that contributes to heart disease, cancer and obesity. In China, one of his focal countries, generating employment through pork production and concern for producing pork for added protein in the diet have overshadowed the role of pork consumption in raising saturated fat intake and increasing degenerative diseases there.

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51. Alan Piazza, EA2AG, noted in an April 10 seminar that although a seemingly relatively modest 8.6 percent of the Chinese population is regarded as nutritionally needy, in a country of 1.1 billion the absolute numbers of malnourished still are among the highest of any country. A new project including nutrition operations is being designed to concentrate on China's resource-poor areas, where half the children are malnourished.

52. A different perspective on the commonly-heard issue of consumer sovereignty for health and nutrition projects was voiced by frequent Bank consultant Henry Mosley of Johns Hopkins at the Annual Bank Conference on Development Economics on May 1. He noted that we should not go overboard with the principle of consumer sovereignty, as important as its aim, since to make sound judgments the consumer needs the full range of information -- and that rarely is the case.

Worth Noting

53. Highly Recommended: An unvarnished look at the inadequate response to malnutrition by the UN agencies (the Bank included) -- and what can be done to turn it around-- is the subject of this year's Martin J. Forman Memorial Lecture. The presentation by this year's honoree E.J.R. Heyward (retired Deputy Executive Director of UNICEF and frequent Bank nutrition consultant) promises to be one of the more consequential statements on international nutrition in some time. It will be delivered Monday, June 15, 7:00p.m., at the Hyatt Regency Hotel, Crystal City. Reception following.

54. Early Warning -- Slow Response. Establishment of early-warning food and nutrition surveillance systems, with an eye toward anticipating and acting on food shortages very early, has been a hallmark of a number of the food security and nutrition operations in recent years. But the delayed government response to the serious drought now unfolding in Southern African countries (paragraph 25) wherein some surveillance systems exist, raises serious questions about the direction of energies in developing such systems. (In spite of early warning signals of potential food shortages in Zimbabwe as early as last July, 194,000 tons of maize were exported through 1991. As a result, maize stocks fell from 643,000 tons in April 1991 to about 42,000 tons last month.) The meetings, the literature, and the new sub-discipline that has emerged working on nutrition surveillance have concentrated on sharpening methodologies. Perhaps more attention is needed on how decisions are made, by whom and what influences such people. Experience shows that when countries are determined to confront drought, for instance Kenya and Botswana, it can be done. The challenge is to better understand what brings about that determination. As reported at this year's ACC Sub-Committee on Nutrition meeting, "while many nutrition surveillance programs have developed improved assessment capabilities, very few do actually influence decisions for actions." The sense of the SCN was that nutrition surveillance often is conducted in isolation, undertaken for its own sake, and donor agency-driven. Also, even when good data have been collected, often there is little analytical capacity.

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55. Worthy Tbailand Events Not-in-the-News. The extensive news coverage this week about Thailand reminds that there has been a near-total absence of public attention drawn to the fact that severe malnutrition has almost been eliminated there in the last decade. And mild and moderate malnutrition have been reduced by over half, even in the most disadvantaged northeast region. While part of this achievement can be explained by rising incomes, in the northeast it has been primarily the combined product of carefully planned nutrition and health outreach interventions, coupled with coordinated programs in other economic and social sectors. The lessons to us for other countries from the impressive Thai nutrition experience have not been given enough attention, probably because we no longer lend to Thailand in the social sectors, according to Jim Greene and Richard Heaver, ASTPH, after a visit there. Success, they say, is attributed to the time taken to generate awareness among all levels of government, continuing political support, good management structures, and care given to both macro and micro planning. Community participation is important, including the development.of the near­universal growth monitoring program carried out by half a million village volunteers -- with a weighing participation rate of 80 to 90 percent in rural areas. What is now a national program had its roots in a nutrition component of a Bank-assisted project in the early-1980s. (This described in the 1987 World Bank-published book on nutrition.) Interestingly, despite the great progress in reducing rates of infant mortality and protein-energy malnutrition, micronutrient deficiencies remain a significant problem.

56. Alma Ata Revisited. Although health conditions in Alma Ata -- the birthplace of the health-for-all movement --were found to be "poor, at best," no problem of undernutrition is apparent or immediately likely in the new nation of Kazakhstan, according to K. Subbarao, PHRWD. (At least from what he saw; several districts, inhabited by so-called "native populations," may be worse off but he was discouraged from going there.) With price liberalization, however, there is potential for malnutrition, he reports, unless measures are taken to provide food on a targeted basis to especially needy groups.

57. Food in the Time of Cbolera. Fear of cholera has reached a phobic pitch in parts of Latin America and in the process is apparently saving a lot of lives, albeit not directly from cholera. The new dedication to washing foods, cleaning up unhygienic conditions and paying more attention to safety of water has led to a reduction in diarrhea, severe malnutrition and the rate of infant mortality.

58. Urban A&riculture for Better Nutrition? The Infrastructure and Urban Development Department now has an unusual study underway to improve living conditions in urban areas, using food production as an entry point for nutrition improvement, employment generation and environmental enhancement. The study outline makes the point that urban agriculture (or "metropolitan intensive agriculture", as it is called) has significant capacity to contribute to health, particularly for low-income urban residents, by reducing real food costs. (The study, UNDP financed, is being undertaken by Jac Smit.)

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59. However, Irene Tinker of the University of California/Berkeley, in a recent discussion at the Bank, raised the disturbing question of whether (with intensified urban pollution, particularly lead levels) it may be unsafe in some settings to consume urban-grown produce. If her hypothesis is borne out -- she is looking into this the implication is that advice would have to be to discourage rather than to encourage urban gardens.

60. Available Materials. Two recent papers from the ACC Sub-Committee on Nutrition state-of-the-art series, one on Managing Successful Nutrition Programs, the other on Nutrition-Relevant Actions, are available for those who would like copies ... Published proceedings of Ending Hidden Hunger, the policy conference on micronutrient malnutrition co-sponsored by the Bank in Montreal last October, also are on hand. Included are papers on fortification, vitamin/mineral supplementation, dietary diversification, nutrient-specific overviews and several country experiences ... Marcia Griffiths, as part of a presentation at the recent Asia Region Nutrition Symposium, distributed an excellent table on the advantages and disadvantages of using different anthropometric indicators for growth monitoring. This, too, is available with us for those interested.

61. Popping Popeye. Traditional claims for the high iron value of spinach are spurious according to the British Medical Journal. The discovery that spinach is as valuable a source of iron as meat was made in Germany in the 1890s and this served as a boon for parental urging in much of Europe and North America. Popeye alone is said to have raised spinach consumption by 33 percent. Unfortunately, says BMJ, this all was fraudulent. German chemists reinvestigating the iron content of spinach showed that the original researchers had put the decimal point in the wrong place and made a ten-fold overestimation of its iron value.

62. Euphemism of the Month: From a LAC project paper, corruption being referred to as "uneven supervision of government finances."

63. Also ... The Bank's EDI Maternal Nutrition and Safe Motherhood regional seminar in Tanzania last week attracted 30 participants from seven countries ... Food subsidies and nutrition will be among the topics at the June 17-19 "Public Expenditure and the Poor: Incidence and Targeting" Conference in JBl-080. New research will be presented on who benefits from different patterns of government spending, as well as studies of various targeted interventions. (Further information from Kimberly Nead, ext. 37936.)

64. Loss to International Nutrition: The death of Professor Derrick Jelliffe of UCLA by way of Uganda, the Sudan, India, and Jamaica. Professor Jelliffe, a father of community nutrition and one of the earliest and most effective advocates of breastfeeding, alerted us more than anyone to the heavy promotional practices of infant formula manufacturers and their consequences -- for which he coined the likable phrase "commerciogenic malnutrition."

* * * * * Again, thank you to all who contributed items here. Copies of papers

mentioned can be obtained from Trish Coogan or Doreen Jones, ext. 33670.