The significance of the ICN
World declaration on nutrition
Plan of action for nutrition
Dr. Gopalan served as a member of the Advisory Group of Experts for the International Conference on Nutrition and is the President of the Nutrition Foundation of India, B-37, Gulmohar Park, New Delhi 100 049.
The International Conference on Nutrition (ICN) included official delegations of 159 countries as well as a considerable number of scientists and representatives of non-governmental organizations. Thus, the ICN was a truly representative meeting.
During the two years of preparation for the conference, eight regional meetings and two meetings of a specially designated advisory group of experts were held in order to finalize the agenda. A preparatory meeting in Geneva held three months before the main conference in Rome considered a draft World Declaration and Plan of Action for Nutrition which was debated in depth at the ICN in December. After such detailed discussions, the decisions finally reached in Rome reflect the considered collective views of the participants.
In recent years there have been major world conferences on food; on health (the Alma Ata Conference on Primary Health Care); on population; and on the environment. The ICN was, however, the first world conference on nutrition ever to be held. For this and other reasons, it is of special significance.
Considering that malnutrition is an age-old problem of humanity, it is strange that an initiative for organizing a global conference that could address the central issues contributing to present widespread malnutrition and consider strategies for the betterment of the nutritional status of the world's peoples had been so long delayed. The decision to hold the ICN, at long last, reflects the recognition (albeit belated) that ensuring optimal nutrition for the peoples of the world is a major and central objective of development.
It was appropriate that the ICN was jointly organized by two leading agencies of the UN system - FAO and WHO the former mainly concerned with problems related to food and the latter with problems related to health. Optimal health cannot be achieved in the absence of adequate nutrition. In the ultimate analysis, adequate nutrition can only be achieved through ensuring adequacy of food supplies at the household level. This joint effort by FAO and WHO symbolizes the imperative need for cooperation between the food and health sectors in the matter of implementation of meaningful nutrition policies at the national and international levels.
In their deliberations, the ICN participants recognized, in fact, the need for even broader intersectoral coordination. Thus, the conference drew attention to the role of poverty and lack of education as major factors underlying undernutrition in many parts of the world and emphasized that besides adequate food, important requirements for nutritional improvement include safe water, sanitation and education.
The joint organization of the ION by FAO and WHO is welcomed for another practical and historic reason. Some of the most valuable information on basic aspects of nutrition and nutrient requirements as well as much useful, practical guidance for nutrition improvement programmes had emerged from the joint expert committee meetings organized by FAO and WHO in the 1950s, 1960s and early 1970s. These meetings not only enriched nutritional science but were also of practical use to nutrition workers in the field. It is hoped that the successful organization of the ICN could help not only in reaffirming the legitimate international leadership role of these two front-line organizations of the UN system in the field of nutrition, but also in reviving the culture of their joint action and collaboration in the area of nutrition, which had proved so rewarding in the past.
The ICN was noteworthy in yet another important respect. Despite the fact that the participants at the conference represented a wide range of countries at varying points in the developmental spectrum, frank discussions at the meeting resulted in the emergence of a broad consensus on several issues (including somewhat sensitive ones) related to nutrition. The larger humane goal of ensuring nutritional uplifting for people as a whole apparently gained precedence over narrow national and sectarian interests. "Inconvenient" issues which are generally diplomatically sidestepped or soft-pedalled at intergovernmental meetings were boldly articulated and debated (sometimes hotly); moreover, the conclusions of such debates were ultimately set out in the World Declaration and the Plan of Action in forms that found general acceptance.
The World Declaration and the Plan of Action unanimously adopted at the end of the conference cover a rather wide ground. It is not the purpose of this communication to discuss individual points contained in these documents in detail, The attempt here is to highlight some salient features.
Nutrition and development
Perhaps, from the point of view of the planner and policy-maker, a statement in the World Declaration that may be considered highly significant is the following, contained in item 11.
We recognize that the nutritional well-being of all people is a pre-condition for the development of societies and that it should be a key objective of progress in human development. It must be at the centre of our socio-economic development plans and strategies.
In most developing countries, plagued with resource constraints, programmes for nutrition improvement have generally been looked upon as welfare relief operations, rather than as aspects of the fulfillment of an essential precondition for social and economic development. Nutrition programmes did not enjoy high priority or adequate resource allocation in the development agenda. Nutrition improvement was, at best, perceived as a derived rather than a direct objective of the development process. As a result, there were no strong attempts either to ensure nutritional orientation of national food policies or to lay adequate focus on nutrition in primary health care. Experience belies the facile assumption that improved nutrition will automatically result as a spin-off effect of improved food production or of extended child-survival promotion operations.
In recent years, however, there has been increasing recognition of the importance of the nutrition factor in development, and several large-scale nutrition intervention programmes have been attempted; but these have not necessarily been part of a coherent, well-conceived national nutrition policy.
Socio-economic inequities, the root of the global nutrition problem
From the global point of view, the statements in the World Declaration that draw pointed attention to the inequities and incongruities in the present-day world that lie at the root of the malnutrition problem are highly significant. It is these statements that elevate the declaration from a narrow political plane to the larger humanistic one.
The World Declaration states in its opening paragraph:Hunger and malnutrition are unacceptable in a world that has both the knowledge and the resources to end this human catastrophe... We recognize that globally there is enough food for all and that inequitable access is the main problem.
Today, we are witness to the cruel paradox of global food surpluses reaching record levels on the one hand, and vast pockets of growing hunger around the world on the other. Because of socio-economic inequities between countries and within countries, millions of poor people around the world do not have adequate access to food. A clear recognition of this truth would call for a humane and equitable economic order at both the global and national levels. Today, because of the debt crisis and the stipulations of international lending agencies, many developing countries are forced to manage their macroeconomic policies in a manner that effectively prevents them from addressing the problems of poverty and hunger among deprived sections of their populations. It is in this context that the following statements (items 16 and 17) in the declaration become highly relevant.
Efforts of low-income countries should be supported by actions of the international community as a whole. Such actions should include an increase in official development assistance in order to reach the accepted United Nations target of 0.7 percent of the GNP of developed countries as reiterated at the 1992 United Nations Conference on Environment and Development. Also, further renegotiation or alleviation of external debt could contribute in a substantive manner to the nutritional well-being in medium-income countries as well as in low-income ones. We acknowledge the importance of further liberalization and expansion of world trade, which would increase foreign exchange earnings and employment in developing countries. Compensatory measures will continue to be needed to protect adversely affected developing countries and vulnerable groups in medium- and low-income countries from negative effects of structural adjustment programmes.
In consonance with the above statements, the World Declaration also pleads (item 10) for a rational redeployment and redirection of available resources "towards productive and socially useful purposes to ensure the nutritional well-being of all people, especially the poor, deprived and vulnerable", seizing the opportunity now created by "changing world conditions and the reduction of international tensions".
The wide expectation implicit in the above statement that, with the cessation of the cold war and consequent ending of the need for an armaments race, the resources of wealthy countries will become increasingly available for socially constructive purposes has not, as yet, materialized. Protective trade barriers which have served to perpetuate (and indeed to aggravate) existing inequities have not been dismantled But perhaps it is too soon to give up all hope in this regard.
The bold and enlightened plea on food aid contained in items 14 and 15 of the World Declaration, and in particular the affirmation (item 15) that "in the context of international humanitarian law, food must not be used as a tool for political pressure" and that "food aid must not be denied because of political affiliation, geographic location, gender, age, ethnic, tribal or religious identity" is noteworthy, especially considering that the signatories to this statement included both the providers and receivers of food aid.
The World Declaration ends (item 19) with a statement of specific goals - the elimination of acute malnutrition in its many forms such as famine and acute starvation, and the substantial reduction of the chronic, less severe forms of undernutrition. These specific goals are no doubt laudable. Perhaps some of them are unlikely to be attained even "substantially" within the decade, even so, to the extent that the statement of these goals reflects the earnest commitment of the official participants to the cause of the nutritional improvement of their peoples, it must be welcome.
The Plan of Action adopted at the conference lists overall objectives, sets out policy guidelines designed to achieve these objectives, discusses strategies and actions and the organizational and administrative arrangements that may be needed for this purpose, and ends with recommendations for follow-up action. The Plan of Action is a fairly comprehensive statement, though some issues that deserve special focus in the light of emerging developments may not have received adequate emphasis. The following are some salient aspects of the Plan of Action.
Nutritional orientation to agricultural and food-production policies
The Plan of Action refers to the need for "strengthening agricultural policies" (item 10) and more specifically to the need for investment in agricultural research (item 27), "to promote environmentally sound and economically viable farming systems to increase crop production and maintain soil quality, to encourage resource management and resource recycling" and "to encourage the development of safe biotechnology in animal and plant breeding and facilitate the exchange of new advances in biotechnology related to nutrition".
While these recommendations are good as far as they go, in the form in which they have been stated they have not succeeded adequately in alerting the world to the major dangers that currently threaten food production systems, especially in some developing countries. Salinization and alkalinization of soils and depletion of soil micronutrients brought on by ill-monitored farming technologies are posing serious threats to soil fertility in parts of Asia. The conference could have given a clear warning in this regard, and appropriate remedial measures should be a distinct part of overall ICN follow-up actions.
Another important aspect of food production that has not received adequate focus in the ICN's recommendation is the growing threat to reverie and marine food sources. Because of uncontrolled discharge of industrial effluents and untreated sewage into ponds, rivers, seas and coastal systems, there has been not only a progressive depletion of marine food sources but also disturbing evidence of poisoning of marine foods with toxic metals. With increasing industrialization, not always regulated by adequate environmental safeguards, this problem could acquire larger dimensions in the years to come. The ICN could have drawn forceful attention to this emerging threat. Again, strong action in controlling these problems is clearly integral to implementation of both the ICN recommendations and those of the 1992 UN Conference on Environment and Development (UNCED).
Furthermore, unlike research in the era of the green revolution, which was freely shared and disseminated, biotechnology research at present is largely privatized and commercialized. The results of such research are often shrouded in secrecy and are not being freely shared If this trend is not discouraged, the inequities that lie at the root of the nutritional problems of the world could grow. An international code of conduct with respect to the sharing of information arising from research in plant breeding using genetic engineering biotechnology is necessary. The raw materials needed for much of this research come from poor developing countries with rich biodiversity. Legal and humanitarian considerations would argue in favour of free exchange and dissemination of information generated from research on this material. Techniques related to combating undernutrition around the world should not be allowed to become instruments for commercial exploitation. A forthright stand on this important issue could have greatly added to the credibility and stature of the ICN.
Household food security
The section on improving household food security (items 29, 30 and 31) constitutes, as it were, the central part of the Plan of Action and has been dealt with comprehensively and ably. This section should prove especially valuable to policy-makers in developing countries. This is as it should be, considering that poor access to food on the part of millions of poor households is currently the major cause of undernutrition in the world.
However, since the section covers a very wide ground, the recommendations in it may appear to be of an omnibus character. Because of severe resource constraints, many developing countries will find themselves unable to attempt several of the laudable recommendations contained in this section, Public food distribution systems in several developing countries are subject to severe strain. The economic implications of prevailing food subsidies are being debated, as is the sustainability of ongoing large-scale food supplementation programmes. Employment generation programmes which could help to raise income levels of poor households suffer from limitations. Also, several well-conceived programmes for improving household food security are often disrupted by the periodic supervention of large-scale disasters - floods, droughts and cyclones -to which some unfortunate countries are prone. Under the circumstances, the necessity to tide over the population from one crisis to another hardly leaves adequate time and resources for an orderly attack on the problems of poverty and poor access to food which lie at the heart of the nutrition problem of poor countries. Despite these limitations, the recommendations in the section on household food security should provide valuable guidance.
Food quality and safety
The need for ensuring food quality and safety (item 32) has also received the attention it legitimately deserves.
This aspect will gain increasing importance in the years to come. In many developing countries today, rapid urbanization is resulting in the proliferation of overcrowded and unsanitary urban slums. This is greatly adding to the urgency and importance of the need for institutional arrangements to ensure minimum standards of food quality.
Urbanization also poses serious threats to breast-feeding, which has always been depended upon as the last resort for infant nutrition in many poor developing countries. With changing occupational patterns, with mothers having to work outside their homes in unorganized labour sectors with no facility for breast-feeding their infants at work sites and with no maternity leave benefits, breast-feeding in urban areas could come under increasing strain. Commercial baby foods, street foods and ready-to-eat foods will be more widely used. With the poor sanitary facilities and the lack of effective machinery for the formulation and enforcement of food standards in many developing countries, serious hazards to health and nutrition, especially of children, may be expected. This must be considered as one of the major emerging threats to nutritional well-being as we approach the turn of this century. The importance of this problem should be forcefully highlighted in the implementation of the Plan of Action at all levels,.
The need for enforcement of food standards gains added urgency because of the mounting evidence of toxic contamination of foods through industrial effluents. Countries in developmental transition will be subject to increasing hazards of food contamination because of their problems of urbanization and industrialization. Effective food control not only is important for protecting domestic consumers but also increases opportunities for international trade. Furthermore, harmonization of food standards would remove some types of trade barriers that can inhibit agricultural development.
Controlling specific micronutrient deficiencies
The ICN needs to be especially congratulated on its balanced recommendations on the subject of control of micronutrient deficiencies. In recent years, there has been an orchestrated campaign to promote the use of massive doses of synthetic vitamin A to answer the problem of vitamin A deficiency in children, while ritualistic lip-service has been paid to a food-based approach, In contrast to this trend, the ICN in its Plan of Action (item 43) pleads forcefully for a policy of "promoting the dissemination of nutrition information and giving priority to breast-feeding and other sustainable food-based approaches that encourage dietary diversification through the production and consumption of micronutrient-rich foods, including appropriate traditional foods". The drug-based approach (periodic massive doses of synthetic vitamin A) that had been widely promoted earlier has wisely been relegated by the ICN to its rightful place in the far background:
Supplementation of intakes with vitamin A, iodine and iron may be required on a short-term basis to reinforce dietary approaches in severely deficient populations, utilizing primary health care services when possible Supplementation should be directed at the appropriate vulnerable groups, especially women of reproductive age (iodine and iron), infants and young children, the elderly, refugees and displaced persons. Supplementation should be progressively phased out as soon as micronutrient-rich food-based strategies enable adequate consumption of micronutrients.
This is a truly commendable stand which wisely refuses to endorse the exaggerated claims of life-saving properties of synthetic vitamin A and the misconceived attempts at enlarging the use of massive doses of synthetic vitamin A in public health programmes. It is to be hoped that this clear enunciation of the policy for containing micronutrient deficiency by the ICN will serve to correct the aberrations and distortions that have crept into the management of this problem in quite a few developing countries in recent years, much to their detriment.
Focus on women and adolescent girls
Though there is a reference to women and adolescent girls as deserving of focus in nutrition-improvement programmes, the emphasis on this aspect is perhaps not as strong as it could have been Adolescent girls (the mothers-to-be) are currently the segment of the population most neglected by health/nutrition/welfare programmes. Today, millions of teenage girls in Asia are entering motherhood long before they have completed their own growth and development and at an age when they are physiologically and psychologically unprepared for motherhood. Low birth weights of offspring, high maternal mortality rates, poor child-rearing practices and large family sizes are the unfortunate results.
There is convincing epidemiological evidence from many parts of the world of the major role that women can have in ensuring the health and nutritional status of families and households. Improvement of the health, educational level, status and overall competence of women can yield rich dividends to a nation and society as a whole. There is a demonstrable direct correlation between a society's female literacy level and its status with respect to health, nutrition and overall socio-economic development. Though this message does not come out as forcefully as one would have desired from the ICN, the reference to the need for adequate focus on women and adolescent girls is welcome.
The Plan of Action adopted at the conference concludes with the following statement with which few would disagree:
The ICN should be viewed as a milestone in the continuing process to eliminate hunger and malnutrition, especially in the developing countries. The ICN preparatory process began at the national and regional levels and, to be effective its follow-up must now be firmly anchored in national and regional commitment and efforts to protect and promote the nutritional well-being of all.
In the ultimate analysis, the true test of the success of the conference will lie in the follow-up action, especially at the country level, that the conference is able to generate. Action at both the country and international levels is important. The impetus provided by the ICN must be wisely used to initiate sustained action. The logical expectation is that FAO and WHO would help countries to undertake the implementation of the useful suggestions that have emerged at the conference in a phased manner. This will be facilitated if the UN favourably considers the conference recommendation for a declaration of an "International Decade of Food and Nutrition". However, without waiting for a formal declaration of such an international decade, what is immediately important is to ensure that the momentum generated by the conference is not dissipated It is hoped that the Food Policy and Nutrition Division of FAO and the Nutrition Division of WHO will be adequately equipped and strengthened to provide meaningful sustained support and stimulus to national follow-up efforts. The ICN will be viewed as a milestone only if meaningful sustained follow-up actions at the country level are thus stimulated A tremendous responsibility rests on the organizers and participants of the conference to ensure that this in fact does happen.