EPILOGUE NUTRITION: THE GLOBAL CHALLENGE Eighteen years have passed since the World Food Conference was held in Rome, a conference which reviewed the alarming food and nutrition situation in the world and suggested ways and means of improving it. WHO has been seriously concerned about the rapidly deteriorating nutritional situation of large populations all over the world, but especially that of children in the developing countries. Together with other United Nations organizations, WHO has joined in efforts made to deal with the unprecedented food crisis and acute famine affecting millions of people. Let us take a closer look at the situation in Asia today. Except for a few isolated pockets, acute hunger is hardly a problem, but chronic undernutrition , which can have serious socioeconomic and health consequences, is still prevalent in some developing countries: The past few decades have seen very rapid socioeconomic, agricultural and health changes in various countries of Asia. In many countries there has been a rise in gross national product, a slowing down of population growth, an increase in agricultural production and hence an increase in the amount of food theoretically available per person, and a broadening of health care coverage. At the same time, however, increased migration to the cities, greater emphasis on producing non-food crops, and in some countries floods or droughts and economic recession have begun to erode the progress made during the period. A positive factor has been the general presence of political stability in the majority of countries in Asia. Lasting peace and stability will help to ensure brighter prospects for a secure food supply. However, food shortage is by no means the only cause of malnutrition. A large number of environmental and other factors influence man's biological vulnerability to malnutrition. These can and should be addressed effectively through the health sector. WHO strives to ensure that the health component of food and nutrition problems receives proper attention. The responsibility of health agencies for the control of malnutrition should be self-evident. It is the duty of those responsible for public health to see that adequate attention is paid to food quality and safety, i.e. to ensure the availability of the nutrients needed to prevent malnutrition, and of food that is free of toxic chemicals and harmful biotoxins or pathogens. Furthermore, in many countries, health authorities have given priority to 191
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measures to alleviate the "non-food factors" that contribute to malnutrition, such as lack of good-quality drinking water, poor environmental sanitation and a high incidence of communicable diseases. In terms of lives saved, perhaps the most significant measures taken in this regard have been the formulation of the Expanded Programme on Immunizat ion and the promotion of oral rehydration therapy. Education on nutrition has lagged behind but the acceptance of primary health care by all countries of the world as a result of the Declaration of Alma-Ata has led to a resurgence of interest in this topic. As part of the general efforts to attain health for all, WHO is promoting adequate nutrition, and striving to eliminate malnutritio n while alleviating its adverse effects on health. The practical implication of this approach is that the health sector has two vital roles to play in preventing and managing malnutrition. The first is a direct role, consisting of promoting health activities designed to improve the nutritional status of individuals, families and communities, on the basis of scientific nutritional concepts. These include growth monitoring, improvement of maternal health and promotion of breast-feeding, to mention but a few. Secondly, the health sector has an important indirect role to play in regard to the multiple external causes of malnutrition and factors contributin g to it. It seeks to promote healthy nutrition by advising the non-health sectors on the possible consequences of their activities on nutrition and health. Although the World food Conference emphasized the need for national policies and programmes to improve nutrition, progress has not been very encouraging. In Asia, too, governments have not been very enthusiastic. Some argued that the projected rapid socioeconomic development, of which there have been a number of impressive examples in the Regions, would mean that nutrition would take care of itself. History has proved the fallacy of such an argument and the poverty and nutrition situation, already bad in many cases, has stagnated or even deteriorated. In many instances, per capita income has fallen and public expenditure on health, education and other basic services has been curtailed. Various types of structural adjustment policies have been put into effect in an attempt to deal with the economic crisis. In many instances their primary purpose has been to restore the foreign exchange balance, with little consideration for the deterioration of the nutritional status of the poor. Although successful economic adjustment may eventually have a beneficial effect on nutrition, the shortterm effect of a number of policy measures may be to cause irreversible damage to human capital. We should be concerned both with preventing damage from short-term adjustment policies and with ensuring that subsequent economic development is designed to produce sustained improvement in nutrition. In looking at nutrition at the macro level, it is not my intention to minimize its importance in primary health care, or of adequate food in the family. These are of paramount importance. What is lacking,
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above all, is intersectoral coordination. To my mind, this is a result of national and international policies of isolation. Nobody else can be blamed but those of us who have a stake in the nutrition of our people. It is a myth to think that countries can progress without international cooperation. The same holds true at the national level where ministries of health, agriculture, education, etc. try to work in isolation. I appeal to those who work in different sectors to come together, irrespective of their field of activity or speciality, and take a closer look at the basic problems relating to nutrition. There are many areas needing our attention. In Asia, we have the paradoxical situation in which children are undernourished while many adults suffer from health problems associated with overnourishment. I should like to share some reflections on this twofold challenge, starting with a brief overview of how nutrition has "evolved" over the years. If we look back in history, we can clearly see that a major shift has taken place in mankind's approach to the main factors-poor diet· and illhealth-that have traditionally accounted for most malnutrition. With the possible exception of knowledge that certain diseases can be foodborne, most people have been blithely unaware over the centuries that what they eat might be hazardous to their health. The human species survived hand-tomouth on whatever it could manage to hunt, gather, harvest or hoard. Anthropological studies show that the diet which fueled the greater part of human evolution was low in fat and very low in sugar, but high in fibre and other complex carbohydrates. Some 200 years ago, when the industrial revolution brought radical improvements in methods of food production, processing, storage and distribution, people living in high-income countries found they could stop worrying about the threat of occasional hunger and could start indulging in preferred foods. Only during the past few decades, as people have benefited from greater control of infectious diseases and better access to food, have research findings confirmed the well-founded suspicion that dietary preferences may influence the onset of several major chronic diseases. For these reasons, if we are to promote healthy nutrition for all, we must take simultaneous action on two quite different, if overlapping, fronts. Many less-favoured nations remain handicapped by a formidable array of development constraints. These include a rapidly increasing population, unproductive agriculture, environmental degradation, inadequate roads and other means of communication, limited health service coverage, and-all too often-civil strife. Among the harmful consequences is the tragedy of many millions of thin and stunted children, who do not have enough protein and energy in their diets, who suffer from cretinism and other permanent brain damage because their diets and those of their parents are deficient in iodine, or who go blind or even die from lack of vitamin A. It is in just such environments that diarrhoeal diseases, frequently compounded by seasonal or chronic food shortages, take their heaviest toll in terms of malnutrition, ill-health and premature death. The reversal of this
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situation is a most urgent priority in the field of development. At the same time, there has been a significant drop in the prevalence of infectious diseases, while food availability and the quality of diets have improved for population groups all over the world. The result in many countries has been a sharp reduction in infant and child mortality and longer adult life expectancy. These and related factors have paved the way for a dramatic expansion of a different type of nutrition crisis: diet-related chronic disorders are now flourishing in environments where, not so long ago, infectious diseases were seen as the greatest menace to health. Chronic disorders are fast becoming major killers in low- and medium-income countries. Ironically, their prevalence is especially high among the urban poor who pursue the unhealthy dietary habits and lifestyles that, until recently, were considered to be the exclusive province of affluent groups. Such life-styles include unbalanced nutrient intake, lack of exercise, smoking, and alcohol and other substance abuse. One type of malnutrition is being exchanged for or-worse still-being superimposed upon another, with no net gain for human health in the process. Let us try to see healthy nutrition in its fullest dimension. Only then can we best identify and influence the multiple factors-ecological, social, economic and political-that determine nutritional status. It is in this spirit that WHO and F AO are organizing the International Conference on Nutrition (ICN) this December in Rome. For the first time in history, governments acting in an international forum will be asked to think beyond the present problems of hunger and survival and to focus on healthy nutrition, both as an essential component of the development process and as one of its most important outcomes. This means for making major improvements in human well-being everywhere in the world are virtually within our grasp. Our scientific knowledge is adequate, the technology has proved to be effective, and we have accumulated enough practical experience for its application. The implications are immense and call for broad, intensive and sustained efforts to increase public awareness of the relationship between food, environment and health. What is now needed is the political will and commitment to ensure that the appropriate level of human and financial resources is consistently available to apply these remedies. I believe that the will and the commitment will ultimately enable us to meet the global nutrition challenge. Hiroshi Nakajima, M.D., Ph.D. Director-General World Health Organization
Nutrition and Health, 1992, Vol. 8, pp. 191-194 0260-1061192 $10 © 1992 A 8 Academic Publishers. Printed in Great Britain
Downloaded from nah.sagepub.com at TEXAS A & M INTL UNIV on March 16, 2015
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measures to alleviate the "non-food factors" that contribute to malnutrition, such as lack of good-quality drinking water, poor environmental sanitation and a high incidence of communicable diseases. In terms of lives saved, perhaps the most significant measures taken in this regard have been the formulation of the Expanded Programme on Immunizat ion and the promotion of oral rehydration therapy. Education on nutrition has lagged behind but the acceptance of primary health care by all countries of the world as a result of the Declaration of Alma-Ata has led to a resurgence of interest in this topic. As part of the general efforts to attain health for all, WHO is promoting adequate nutrition, and striving to eliminate malnutritio n while alleviating its adverse effects on health. The practical implication of this approach is that the health sector has two vital roles to play in preventing and managing malnutrition. The first is a direct role, consisting of promoting health activities designed to improve the nutritional status of individuals, families and communities, on the basis of scientific nutritional concepts. These include growth monitoring, improvement of maternal health and promotion of breast-feeding, to mention but a few. Secondly, the health sector has an important indirect role to play in regard to the multiple external causes of malnutrition and factors contributin g to it. It seeks to promote healthy nutrition by advising the non-health sectors on the possible consequences of their activities on nutrition and health. Although the World food Conference emphasized the need for national policies and programmes to improve nutrition, progress has not been very encouraging. In Asia, too, governments have not been very enthusiastic. Some argued that the projected rapid socioeconomic development, of which there have been a number of impressive examples in the Regions, would mean that nutrition would take care of itself. History has proved the fallacy of such an argument and the poverty and nutrition situation, already bad in many cases, has stagnated or even deteriorated. In many instances, per capita income has fallen and public expenditure on health, education and other basic services has been curtailed. Various types of structural adjustment policies have been put into effect in an attempt to deal with the economic crisis. In many instances their primary purpose has been to restore the foreign exchange balance, with little consideration for the deterioration of the nutritional status of the poor. Although successful economic adjustment may eventually have a beneficial effect on nutrition, the shortterm effect of a number of policy measures may be to cause irreversible damage to human capital. We should be concerned both with preventing damage from short-term adjustment policies and with ensuring that subsequent economic development is designed to produce sustained improvement in nutrition. In looking at nutrition at the macro level, it is not my intention to minimize its importance in primary health care, or of adequate food in the family. These are of paramount importance. What is lacking,
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above all, is intersectoral coordination. To my mind, this is a result of national and international policies of isolation. Nobody else can be blamed but those of us who have a stake in the nutrition of our people. It is a myth to think that countries can progress without international cooperation. The same holds true at the national level where ministries of health, agriculture, education, etc. try to work in isolation. I appeal to those who work in different sectors to come together, irrespective of their field of activity or speciality, and take a closer look at the basic problems relating to nutrition. There are many areas needing our attention. In Asia, we have the paradoxical situation in which children are undernourished while many adults suffer from health problems associated with overnourishment. I should like to share some reflections on this twofold challenge, starting with a brief overview of how nutrition has "evolved" over the years. If we look back in history, we can clearly see that a major shift has taken place in mankind's approach to the main factors-poor diet· and illhealth-that have traditionally accounted for most malnutrition. With the possible exception of knowledge that certain diseases can be foodborne, most people have been blithely unaware over the centuries that what they eat might be hazardous to their health. The human species survived hand-tomouth on whatever it could manage to hunt, gather, harvest or hoard. Anthropological studies show that the diet which fueled the greater part of human evolution was low in fat and very low in sugar, but high in fibre and other complex carbohydrates. Some 200 years ago, when the industrial revolution brought radical improvements in methods of food production, processing, storage and distribution, people living in high-income countries found they could stop worrying about the threat of occasional hunger and could start indulging in preferred foods. Only during the past few decades, as people have benefited from greater control of infectious diseases and better access to food, have research findings confirmed the well-founded suspicion that dietary preferences may influence the onset of several major chronic diseases. For these reasons, if we are to promote healthy nutrition for all, we must take simultaneous action on two quite different, if overlapping, fronts. Many less-favoured nations remain handicapped by a formidable array of development constraints. These include a rapidly increasing population, unproductive agriculture, environmental degradation, inadequate roads and other means of communication, limited health service coverage, and-all too often-civil strife. Among the harmful consequences is the tragedy of many millions of thin and stunted children, who do not have enough protein and energy in their diets, who suffer from cretinism and other permanent brain damage because their diets and those of their parents are deficient in iodine, or who go blind or even die from lack of vitamin A. It is in just such environments that diarrhoeal diseases, frequently compounded by seasonal or chronic food shortages, take their heaviest toll in terms of malnutrition, ill-health and premature death. The reversal of this
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situation is a most urgent priority in the field of development. At the same time, there has been a significant drop in the prevalence of infectious diseases, while food availability and the quality of diets have improved for population groups all over the world. The result in many countries has been a sharp reduction in infant and child mortality and longer adult life expectancy. These and related factors have paved the way for a dramatic expansion of a different type of nutrition crisis: diet-related chronic disorders are now flourishing in environments where, not so long ago, infectious diseases were seen as the greatest menace to health. Chronic disorders are fast becoming major killers in low- and medium-income countries. Ironically, their prevalence is especially high among the urban poor who pursue the unhealthy dietary habits and lifestyles that, until recently, were considered to be the exclusive province of affluent groups. Such life-styles include unbalanced nutrient intake, lack of exercise, smoking, and alcohol and other substance abuse. One type of malnutrition is being exchanged for or-worse still-being superimposed upon another, with no net gain for human health in the process. Let us try to see healthy nutrition in its fullest dimension. Only then can we best identify and influence the multiple factors-ecological, social, economic and political-that determine nutritional status. It is in this spirit that WHO and F AO are organizing the International Conference on Nutrition (ICN) this December in Rome. For the first time in history, governments acting in an international forum will be asked to think beyond the present problems of hunger and survival and to focus on healthy nutrition, both as an essential component of the development process and as one of its most important outcomes. This means for making major improvements in human well-being everywhere in the world are virtually within our grasp. Our scientific knowledge is adequate, the technology has proved to be effective, and we have accumulated enough practical experience for its application. The implications are immense and call for broad, intensive and sustained efforts to increase public awareness of the relationship between food, environment and health. What is now needed is the political will and commitment to ensure that the appropriate level of human and financial resources is consistently available to apply these remedies. I believe that the will and the commitment will ultimately enable us to meet the global nutrition challenge. Hiroshi Nakajima, M.D., Ph.D. Director-General World Health Organization
Nutrition and Health, 1992, Vol. 8, pp. 191-194 0260-1061192 $10 © 1992 A 8 Academic Publishers. Printed in Great Britain
Downloaded from nah.sagepub.com at TEXAS A & M INTL UNIV on March 16, 2015
