l THE WORLD BANK /IFC I MIGA

OFFICE MEMORANDUM DATE: July 30, 1993

TO: All Human Resources Divisions

FROM: Alan Berg~~ EXTENSION: 33433

SUBJECT: New & Noteworthy in Nutrition (No. 21>

Highlights: Help for nutrition task managers (page 1) ... How the WDR sees nutrition (page 2) ... New annual project volume figures show continued climb (page 3) ... "N" word suddenly becomes politically-correct (page 3) ... Gender disparity in nutrition (page 7). This issue is organized as follows:

New Tools for Task Managers WDR's Fix on Nutrition Operations More on Micronutrients Infant Formula Revisited

New Tools for Task Managers

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1 2 3 5 6

Insights on Breastfeeding Gender Issues Recent Relevant Research

Findings Worth Noting Quotable

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7 7

8 9

12

1. Nutrition Advisory Service. Effective July 1, PHN established a new Nutrition Advisory Service -- an unintentionally timely move given the July 12 pronouncements in the aftermath of the Wappenhans Report. Judy McGuire will have responsibility for this new activity which, in effect, will provide to regional PHR divisions a number of technical services as well as consultancies that will be paid from PHN's budget. Establishment of the new service follows decisions, made in the wake of last January's reorganization, that the main thrust of HRO's nutrition energies in the coming few years should be devoted to support for interested regional PHR divisions in efforts to improve or add nutrition to their lending programs.

2. Consultant Roster. Special technical areas of concentration, languages, countries of experience, and performance on earlier consultancies are all part of a new computerized nutrition consultant roster to assist the PHN's new Nutrition Advisory Service. After extensive screening, the roster includes some 180 names. Access to UNICEF's nutrition consultant roster has also been arranged.

3. "Best Example" Guide. A collection of examples of outstanding nutrition mission reports has now been compiled by PHN to guide work of Bank nutrition consultants on sector, reconnaissance, preparation, and other missions. The reports will provide some guidance on both process and substance and will show consultants the standards being sought. (Contact: Rae Galloway, ext. 33122.)

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4. WOR Follow-up. The different specific emphases on nutrition in WDR '93 (please see paras. 7-9) are being spelled out in more detailed guidance for staff with several new technical papers. An HRO Dissemination Note on "Enhancing Investments in Education through Better Nutrition and Health" and an HRO working paper on "Making Nutrition Improvements at Low Cost through Parasite Control" have been issued, and two pieces on micronutrients -- a Working Paper on iron and a Dissemination Note on vitamin A -- will be out shortly. Also recently published by PHN are "Incorporating Nutrition in Social Funds" and "Global Indicators of Nutritional Risk," both in the HRO Working Paper series.

5. Just Do It. And here is a model for developing nutrition strategy that other regional Human Resources Divisions may want to consider: Birger Fredriksen, AF5PH, recognizes that his Department's work on nutrition has not been commensurate with the considerable nutrition needs of the Sahelian countries. And he also notes that some countries at the same income level do much better on nutrition than others. So he has taken several initiatives. First, through the new Nutrition Advisory Service, he retained Dick Heyward, former Deputy Executive-Director of UNICEF, to prepare a nutrition strategy for the Department. Second, he sent Joyce King, an expert consultant on feeding programs, to three AF5PH countries to look for ways to add nutrition into education projects. Third, divisional task managers have been asked to screen all education and health projects to see what changes might be made to incorporate nutrition. "All should have nutrition in them," he said, "or else a good reason not to have."

6. Lpoking for Co-financing Opportunities? Last issue mentioned that the Asian Development Bank is getting involved for the first time in nutrition. Its initial action may be co-financing with the World Bank a nutrition project in Bangladesh. This prompted Nuria Homedes, LA3HR, to report that the Inter-American Development Bank also will take the plunge in nutrition, following-up on the Bank's Health and Nutrition Project in Guyana. And, as if this were becoming infectious, the African Development Bank is now, for the first time, financing a nutrition intervention -- supporting UNICEF nutrition activities in Morocco.

WDR's Fix on Nutrition

7. People who have been saying malnutrition is bad for your health turn out to be right, according to the 1993 World Development Report. "Inadequate diets account for a large share of the world's disease burden" at least 20 to 25 percent among children. Philip Musgrove, PHN, who looked after the nutrition part of the study, calculated that 60 million healthy life years are annually lost because of early childhood malnutrition alone. And this estimate is conservative, given malnutrition's role in one-quarter of the childhood deaths attributed to respiratory and diarrheal diseases and measles -- usually minor ailments, were it not for the malnourished condition of the children.

8. WDR '93 emphasizes the value of micronutrients, especially iodine and vitamin A, as being among the most cost-effective of all health

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interventions. (A year of healthy life can be bought for less than $10; a death can be averted for $50.) It also stresses the importance of "inexpensive and highly efficacious" nutrition interventions to address long­neglected needs of school-age children, especially providing micronutrients and curing worm infections. (A year of healthy life from the latter will cost from $15 to $30.)

9. Also stressed is that "governments need to encourage healthier behaviors on the part of individuals and households by providing information on the benefits of breastfeeding and on how to improve children's diets." "Inducing behavioral change," says the Report, "is often the most cost­effective way to improve nutritional status." ... Too much of what governments spend on health goes to care that provides little gain for the money spent, summarizes Bank President Lewis Preston in the WDR Foreward, and "too little goes to low-cost highly effective programs such as control and treatment of infectious diseases and of malnutrition."

Operations

10. Onward and Upward. Nutrition lending continues its upward climb. Preliminary tabulations for PHN's contribution to the Annual Report on Portfolio Performance show that total project resources for nutrition in FY93 increased four-fold from last year, to approximately $600 million. An estimated $377 million of this is covered by Bank loans and IDA credits. This is well above our projected estimates at this time last year. Additive to the PHN portfolio are nutrition components in education and agriculture projects, which will amount to another $100 million in total project resources. These figures do not capture nutrition portions of structural adjustment projects in which nutrition sometimes looms large. South Asia far outpaces other regions in quantity of resources invested in nutrition. LAC and East Asia & Pacific, with nearly equal amounts of lending for nutrition, are next, followed by ECA. MENA had no projects with nutrition this year. As in FY92, 60 percent of all PHN projects contain nutrition components.

11. A Boomlet of Political Popularity. Nutrition is now being seen as sufficiently significant, or sufficiently important to be politically-correct, for presidents in a number of countries (particularly Latin American countries) to begin making pronouncements on the subject. In Ecuador, at the June launching of the Health and Nutrition Project, President Duran Ballen acknowledged that this project, though prepared by the previous government, represented his "Government's first installment towards paying the country's social debt." The project supports growth monitoring and counselling, other nutrition education and promotion, and the provision of food supplementation and micronutrients. (Task Manager: Patricio Marquez, LA4HR, with Francisco Mardones, LA3HR.)

12. Bolivia's President Jaime Paz Zamora regards the Integrated Child Development Project as "one of the star turns of the Paz Zamora social policy," according to July 19 coverage in Tbe New York Times. The project, approved by the Board on June 29, involves nutrition and early learning for children between six months and six years. It is run by Rosario Paz Zamora,

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the President's sister. "Educational reform is no use if the children have already been damaged before they get to school age," Ms. Paz said in The New York Times. (Task Manager: Xavier Coll, now of LA4HR.)

13. Argentina's President Carlos Menem in late March said the upcoming MCH and Nutrition Project has become the national program for MCH and Nutrition. His presidential decree also says MCH and nutrition issues are now of highest priority for government. Argentina has already requested a second similar Bank-supported project. (Task Manager: Pepe Andreu, LA4HR, with Patricio Marquez and Francisco Mardones.)

14. In the Philippines, President Fidel Ramos in June vowed to end malnutrition in the country by the year 2000, particularly that caused by micronutrient deficiencies. "This is necessary," he said, "to ensure that every Filipino child is globally competitive." He ordered half-a-dozen government agencies to push the program simultaneously: the Food and Drug Administration to develop standards and guidelines on food fortification, the Education Department to make sure that nutrition messages are incorporated into school curricula, the Department of Agriculture to increase the supply of nutrient-rich foods, and so on. The Bank's new operation there, the~ Health and Nutrition Project, described in earlier New & Noteworthy memos and approved by the Board June 15, is one of the more innovative Bank nutrition efforts in recent years. (Task Manager: Stan Scheyer, ASTTP, with Catherine Fogle, EAlPH.)

15. And when Brazilian President Fernando Collor was unceremoniously ushered out of office earlier this year, who would have thought that this change would provide a long-awaited opening for nutrition in that country? An unsolicited request for Bank help came in the form of a Brazilian delegation to the Bank on July 15, which brought the government's $1 billion proposal for a nutrition program. New President !tamar Franco is obviously interested in doing something about malnutrition. Tbe Economist writes of his launching an "ambitious plan to attack hunger." And The New York Times says his recently established National Food Security Council "may prove the most important initiative of his government." "Brazil has a population of insomniacs," the President said recently, "those who can't sleep because they are hungry, and those who stay awake out of fear of those who don't have anything to eat." 16. Recently Approved. Other operations of nutrition interest approved by the Board in the three months since the last issue include China Grain Distribution and Marketing Project (Task Manager: Alan Piazza, EA2AG), the Columbia Municipal Health Project (Task Manager: Eleanor Schreiber, LA3HR), and the Mozambique Food Security Project (Task Manager: Neeta Sirur, AF6PH). Nutrition also appears, more modestly, in the recently approved Burundi Social Action Project (Task Managers: Benoit Millot and Lynne Sherburne-Benz, AF3PH).

17. To the Board. Argentina MCH and Nutrition is scheduled for the Board on August 3, Peru Health and Nutrition on September 16, and Guinea Health and Nutrition on October 12. The two newest nutrition projects on the horizon since the last issue are Kenya and Nepal. Progress on the Nigeria Nutrition Project is held up because of the political situation there.

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More on Micronutrients

18. Turning Crime on Its Head. A common problem regarding fortification of staple foods with needed nutrients is that, in a number of countries, adding any external ingredients is tantamount to adulterating food -- and often there are penalties for this. Urban Jonsson, UNICEF's Senior Nutrition Adviser, is now turning this "crime" on its head, exploring with legal authorities in some countries whether it can be made a crime DQt to fortify foods with critically needed ingredients. He is now speaking in terms, for instance, of "the criminalization of non-iodized salt." Interesting concept.

19. New Vehicle for Fortification. Scientists from the Institute of Nutrition and Food Hygiene of China's Academy of Preventive Medicine have successfully tested a micronutrient-fortified rusk or hard-crisp bread (usually known here as a teething biscuit). It promises to be an effective vehicle for fortification, with improvements in iron status clearly noted in the children who ate it. The advantages of rusk are its exceptionally long shelf-life and, of course, the opportunity for effective targeting for a high­risk age group. "The cost of production and hence the selling price of the rusk," says the Chinese report in the April issue of Tbe American Journal of Clinical Nutrition, "are apparently compatible with the purchasing ability of rural Chinese populations, and it is intended it will be distributed through state nurseries."

20. Mother First. Vitamin-A supplementation of the mother safely delivers vitamin A through breastfeeding to the infant in well-absorbed form for at least eight months, according to a new study of Indonesian mothers by Rebecca Stoltzfus and others, published in the Journal of Nutrition. This requires only one mass-dose contact with the vitamin-A delivery system (whereas direct supplementation to the infant requires at least two contacts), and two people -- the mother and infant -- both benefit from the maternal supplementation ... Relatedly, non-breastfed infants can become blind as early as two-to-three months of age when breastmilk, a rich source of vitamin A, is replaced with foods containing no vitamin A, according to Barbara Underwood of WHO at the last Interagency Meeting on Breastfeeding, in Geneva.

21. Zapping Vitamin A. Little is known about what happens to vitamin A in foods that have been irradiated. In a recent issue of Food Policy, Leah Bloomfield of Australia argues that a better understanding should be a precondition of widespread irradiation, particularly for foods -- including food aid and other food imports -- to be eaten in countries with vitamin-A deficiency.

22. Catch-up With Iron. Prior to treatment with ferrous sulphate, a group of iron-deficient anemic Indonesian infants, aged 12-18 months, had poorer performance on tests of mental and motor development than did non­anemic children. After four months of treatment, however, the performance of children in all categories was essentially the same, demonstrating that among 12-18 month olds (one can't extrapolate beyond this age group), development delays due to iron-deficiency anemia can be reversed. These findings,

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published in Tbe Lancet by PonPon Idjradinata and Ernesto Pollitt, are particularly important due to Pollitt's research discussed earlier in New & Noteworthy showing that in malnourished populations the level of motor maturation at 15 months is associated with cognitive test performance at 18 years of age.

23. Decreeing Enrichment. From supervising the Social Development Project in Venezuela, Bruce Carlson, LAlHR, reports a major micronutrient effort underway there. A National Commission on the Nutritional Enrichment of Foods was established under a recent presidential decree. Agreement already has been reached with the private sector to enrich, at no extra cost to the consumer, all corn used to prepare the basic staple arepa. A similar agreement is being worked out between government and the private sector to enrich flour for baking bread, and a third initiative involves the enrichment of a low-income pasta. Prime-mover in this is not the Ministry of Health, but the Ministry of the Family.

Infant Formula Revisited

24. Beware of Imitations. The June 12 British Medical Journal calculates that in Uganda "the cost of bottle feeding a baby for a year is nine times a manual worker's annual income." HQR '93 reports that breastmilk substitutes would cost an estimated $15 billion a year for the 120 million infants now relying on mother's milk ... The HQR also notes that infants who are not breastfed are 18 times more likely to die of diarrhea and three times more likely to die of respiratory illness, "both because they got less to eat and because of increased risk of infection."

25. India Clamps Down. After a six year tug-of-war between nutrition advocates and baby food manufacturers, India's Parliament has passed into law one of the strictest "Infant Milk Substitutes, Feeding Bottles and Infant Foods" bills anywhere. It will severely restrict the advertising and promotion of baby products by stringent conditions for the labelling of baby foods and categorical bans on the use of pictures of infants or women. All information on the product must promote breastfeeding and stress the "financial and social implications" of using infant formula and baby bottles. (Further, manufacturers are "forbidden from offering inducements to, or fixing salaries of, employees on the basis of volume of sales.") Offenses under this act may be punishable by imprisonment for up to three years. The baby food manufacturers had stalled the legislation for a considerable time. And no wonder, with some US$400 million in sales a year. The question now is whether the law can be enforced successfully. The problems of inspection are many.

26. Broadening the Ban. UNICEF reports that 70 countries have now banned free promotional supplies of infant formula in hospitals and maternity centers and, in the majority of these countries, in all health-care facilities.

27. Much Ado. Nestle, the largest marketer of infant formula in developing countries, has quietly disbanded its highly-publicized audit

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committee that was set up to investigate publicly the allegations against improper Nestle marketing practices among the poor. This happened shortly after its seven-year study in Mexico confirmed that Nestle had indeed violated the WHO International Code of Marketing of Breastmilk Substitutes.

Insights on Breastfeeding

28. Breast Shields. Evidence has been growing (and discussed in earlier New and Noteworthy memos) that women who breastfeed have lower risk of breast cancer, ovarian cancer and osteoporosis. Now a paper by Ted Greiner, SIDA's Nutrition Adviser, points out for the first time that breastfeeding protects from iron deficiency anemia those women most at risk. The reason: the average amount of iron saved during lactation amenorrhea due to reduced loss of menstrual blood is more than twice the iron secreted into breastmilk. And the more undernourished the mother, the longer the period of lactation­induced amenorrhea.

29. Sex. Lies and Breastfeeding. What is the proper time for nursing women to begin using contraceptives so as to keep the cost of double protection as low as possible? At the 1989 Bellagio Conference on the "Use of Breastfeeding as a Family Planning Method," breastfeeding was recommended as an effective and reliable method of contraception during the first six months after birth. Now a study of 4,580 Bangladeshi women, reported by Peter Weis in the April/May issue of Studies in Family Planning, shows that in Bangladesh at least the recommendation could have been safely extended to 12 months.

30. Now Hear This. A study in the May issue of Pediatrics concludes that children exclusively breastfed for four months or more had half the acute ear infections as those who did not breastfeed and 40 percent less than infants whose diets were supplemented with other foods before four months.

Gender Issues

31. More is Less for Girls. Several earlier studies have surprisingly indicated that gender-biased food allocation within a family is most pronounced in better off households. Now a new study published about Bangladesh by Helen Keller International, discussed by Martin Bloem of HKI/Bangladesh at a July 9 presentation at the Bank, confirms this. "In landless households," he said, "there is little difference in rates of undernutrition between boys and girls. With increase in house value, the prevalence of undernutrition in boys decreases sharply. For girls the decline is far less pronounced, resulting in an increasing gender gap." Bloem concludes that general poverty alleviation might actually be of little benefit for girls without explicit efforts at behavioral change.

32. Defying the Odds. longer than men, populations women. "Nutritional neglect Development Report as a main

Defying the biological norm that women live in South and East Asia include more men than of the girl child" is cited by UNDP's new Human reason.

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33. Share and Share Unlike. One might expect an absence of gender differences in a strongly socialist society, but the first multivariate analysis in recent history of nutrition status of Vietnamese children gives low Marx in this regard. Although the Vietnamese government officially espouses equality between the sexes, apparently "remnants of the Confucian ethos (which values men above women) remain," says the report. (Main message of the excellent Vietnamese study -- reported by Suzanne Shoff, Joanne Csete, the latter newly with UNICEF, and others in the Ecology of Food and Nutrition-- is the "alarming prevalence of undernutrition." Four-fifths of the children under six years of age in the non-clinic-based study were moderately or severely malnourished.)

34. Eating for Future Roles. More ammunition for giving special attention to improving nutrition status of girls prior to childbearing is presented by Vivien Tsu of the University of Washington in the International Journal of Epidemiology. She reports a two-fold increased risk of cephalopelvic disproportion in Zimbabwean women under 160 em. in height, and the prolonged labor and other high risks associated with it.

Other Recent Relevant Research Findings

35. Unusual Drought Effects. In 1987, India suffered one of its most serious droughts of the century, but according to survey findings by a group from the University of Baroda, published in the most recent issue of Ecolo&Y of Food and Nutrition, the prevalence of malnutrition (low weight-for-height and weight-for-age and of vitamin-A deficiency and iron-deficiency anemia) was lower during the drought period than during the non-drought period. The differences are attributed to effective nutrition intervention programs ... Similarly, weight-for-age figures were substantially better during a recent period of drought in Zimbabwe -- this item contributed by Bill Kinsey, who has had a drought and household resilience survey underway there for some years. The reason, he says, "is universality of drought relief and a better functioning food distribution program."

36. Can Mothers Identify Malnutrition in Their Children? The question is commonly posed whether, in a community in which nearly all children are malnourished, a mother can recognize a nutrition problem. This has important implications for the nature of nutrition education. To assess mothers' perceptions about malnutrition and their ability to identify malnutrition in their own children, a study was conducted in Bangladesh by Swapan Kumar Roy and others from the International Center for Diarrhoeal Disease Research. They found that a full third of the mothers could not correctly identify malnutrition in their children. The study, published recently in Health Policy and Planning, also notes little difference in this regard among mothers with more or less than five years of formal education.

37. More to Worry About. Fetal undernutrition can now be linked with cardiovascular disease in adult life. One UK study shows how later cardiovascular disease fell progressively with increasing weight, head circumference and weight-for-length at birth. In another, death rates from coronary heart disease were almost three times higher among those who weighed

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18 pounds or less at one year of age than among those who weighed more than 27 pounds. Tellingly, the associations are seen in babies who are born small for their gestational age and not in those born prematurely. A new study in the April 10 Lancet (by Barker and others) shows how fetal undernutrition at different states of gestation can be linked to different patterns of early growth and subsequent cardiovascular problems.

38. All in the Family. Two patterns may be used to explain how food is distributed to various family members: a Contributions Rule, by which individuals considered to have higher economic value receive a higher percentage of the family's food, and a Needs Rule, by which those considered to have greater need receive a higher percentage of food. A study in Guatemala by Patrice Engle and Isabel Nieves, published in the most recent issue of Social Science and Medicine, shows that the Contribution Rule is by far a much better predictor of food distribution patterns. For example, children targeted as undernourished by the health center received significantly fewer adequate calories, given their requirements, than other family members and received no more food than other similar-aged children. As expected, the man of the family received a significantly higher proportion of protein than other family members. But, unexpectedly, female heads of households received a relatively higher proportion of calories, given their nutrition requirements, than other family members.

39. Cutting Room Floor. A useful example of how nutrition increases worker productivity was dropped from ~ '93 because of space limitation. The penultimate draft (but not the final publication) of the WDR noted that, in rural south India, farm output was nearly 20 percent greater in households whose members averaged 10 percent above the norm of weight-for-height. And, in the same population, casual agricultural laborers who were 10 percent above average in weight-for-height were paid between 3 and 7 percent more than average. (Given these effects, if all cultivating households below the sample mean for malnutrition were brought up to the mean level, aggregate agricultural output would rise by 38 percent; and if all casual laborers were brought up to the mean, their wage rate would rise by an average of 17 percent.)

Worth Noting

40. Conference Call. The World Bank's Conference on Hunger has been announced for immediately after Thanksgiving, November 30 and December 1 -­with a smaller preparatory meeting on November 29. Vice-President Ismail Serageldin, ESDVP, is responsible for the meeting and his side-kick Pierre Landell-Mills is helping manage it. Starting point for the planning will be the World Declaration and Plan of Action for Nutrition, approved by 160 countries at the International Conference on Nutrition last December in Rome, and more specifically the commitment of each country to prepare a nutrition strategy and action plan. What sets the upcoming meeting apart from others on the topic is t~at NGOs are having a sizable role in shaping the agenda. Former U.S. President Jimmy Carter has agreed to keynote the Conference. Some 200 people are expected to attend.

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41. The Tightest Belts. Brazil has the largest occurrence of malnourished children in Latin America, both in terms of percent and absolute number. The percent appears low in Mexico, but in absolute numbers it has the second largest malnourished population. Together Brazil and Mexico contain two-thirds of all malnourished children in the region. This from Human Resources in Latin America and the Caribbean, published by LAC and one of the best and most detailed assessments of a region's nutrition problems and what the Bank is trying to do to help. It reports that "the prevalence of malnutrition in Latin America is disappointingly high, given the average per capita income level of the region as a whole." But "the resources to eradicate malnutrition are available in Latin America," the report says. A modest reallocation of government expenditures (less than one percent of GOP) towards effectively targeted nutrition interventions could substantially reduce malnutrition levels ... (For a more detailed description of Bank nutrition operations in LAC, also see the new HRO Working Paper "Poverty, Social Sector Development and the Role of the World Bank.")

42. Counting Calories. Although per capita figures in food consumption mean little, it nonetheless is interesting to note a buried statistic in UNDP's 1993 Human pevelopment Report: between 1965 and 1990 the number of countries that met the daily per capita calorie requirements doubled -- from 25 to 50.

43. Rich Data. Last December the ACC Sub-Committee on Nutrition came out with another remarkably good Report on the World Nutrition Situation. Now the supplemental volume is out, concentrating on country-specific conditions and trends. Authors Marito Garcia and John Mason also aggregate those country-specific conditions and offer important overall conclusions. Based on 100 sets of nationally-representative data from 66 developing countries, the report shows that household size is a greater predictor of nutrition status than household availability of calories. Also, although nutrition improves as income increases at low levels (between $300 and $600 per capita), over $1000 per capita there is little improvement as income increases. This demonstrates the need, the SCN authors say, for social policy as well as economic policy. (Copies of both the December report and the new supplemental volume are being sent to all human resource divisions; others may call Doreen Jones, ext. 31452.)

44. Mobilizing the Private Sector. Richard Manoff, the social marketing pioneer, proposed in his 1993 Martin J. Forman Memorial Lecture last month a way to mobilize the private commercial sector to support micronutrient initiatives. He proposes a Pro Vita Plan that would create a brand name (or seal of approval) that a government would license to selected manufacturers who agreed to produce fortified food in accordance with prescribed standards. In exchange, the government would undertake to promote the brand name on both radio and TV at no charge to the producers. This was but one of several imaginative proposals put forth in the lecture to mobilize the mass media and the private sector on behalf of nutrition. Copies of the lecture will be available from Helen Keller International in New York.

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45. Policy Shift on Pesticides. With implications for policies in most countries, the U.S. Government has decided to reduce substantially the use of chemicals in the production of the nation's food, citing the need to protect the health of children. The change of policy, announced last month, could alter everything about the way food is grown and what people eat. Infants and children are more vulnerable because they differ both quantitatively and qualitatively from adults in their exposure to pesticide residues in foods; they consume more calories per unit of body weight and eat fewer types of food than adults. The government announced it will create incentives for the development of safe pesticides and remove those pesticides from the market that pose the greatest risk.

46. Aid Without Knowledge. We have been arguing for some time that nutrition education and other efforts at behavioral change are unexploited and under-funded. A case in point: the U.S. Government spends more than $25 billion on food stamps, but less than $2 million on nutrition education to encourage consumers to use those foods in nutritionally-beneficial ways. (More people in the United States now require food stamps, 27.4 million of them, than the total populations of 99 countries.) According to a Hunger Forum put on by the U.S. Secretary of Agriculture on June 17 in Washington, the lowest 40 percent of the population is worse off with respect to food than in 1980.

47. Signs of the Times. The International fund for Agricultural Development's Executive Board currently is considering greater focus on nutrition, appreciating this will mean (according to a paper before it that will be acted on in mid-September) "the potential that project development costs could increase, and the project cycle time-frame become extended due to additional field work." If approved, IFAD will not only give more attention to household food security, but also ensure that other nutrition security conditions do not deteriorate as a result of the project ... The World Health Assembly at its annual May meeting in Geneva adopted a resolution that the World Health Organization give increased emphasis to nutrition. Relatedly, nutrition at WHO has been upgraded to the level of Division -- comparable to the Division of Family Health.

48. Need for Continuity and Memory. The main problems in implementing Bank-assisted nutrition projects, according to Sonya Rahardjo, ASTHR (who has been reflecting now that she is leaving the Bank to return to Asia), are frequent turnover and the lack of institutional memory in governments about nutrition operations. She points to the value of local-hire staff in the Bank resident missions to provide the kind of day-to-day continuity needed and to brief new government staff after turnovers.

49. Urban Confines. Former World Bank nutrition staff member Samir Basta (currently Director of UNICEF in Europe) offers in the April 10 issue of The Lancet reasons why urban malnutrition is increasing: Overcrowding limits opportunities for household production of fruit and vegetables. Limited cooking facilities ("with less room for the proverbial cooking pot") encourage consumption of sweets and quickly prepared foodstuffs (in the former Communist bloc, he says, a trend to ever-smaller kitchens has caused families to steer

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clear of foods that are "messy" or require long cooking), and lack of privacy leads to more bottle-fed babies.

50. Gloom With a View. Another former staff member, David Beckmann, now President of Bread for the World, is the initiator of a legislative initiative called "Every Fifth Child," named for the fact that every fifth child in the United States faces hunger.

51. Food Outlook. FAO's latest forecast shows the 1993 world cereal crop one percent below last year -- rice is slightly up, wheat and coarse grains are down. In Angola and Rwanda, civil strife has sharply increased the need for emergency assistance, which is also required in parts of Somalia, Sudan, and several southern African countries, despite improved harvests there. The food situation, FAO says, remains critical in Bosnia-Herzegovina, Iraq, Afghanistan and in several central Asian republics.

Quotable

52. At a recent brainstorming session called by AF2 Director Francis Colaco to discuss opportunities for increasing nutrition operations, an AF2 staff member asked "how many governments have asked us for nutrition projects?" To which Mr. Colaco responded: "How many governments have asked us for privatization projects?"

53. Joan Gussow, Professor of Nutrition at Columbia University, at the June 17 Hunger Forum in Washington: "We need a nutrition policy that leads to a food policy that leads to an agriculture policy. Now agriculture policies surely are not driven by nutrition considerations."

54. "A child born in Africa today is more likely to be malnourished than to go to school at all," this from former Bank V.P. and Chief Economist (now Under-Secretary of U.S. Department of Treasury) Larry Summers in the July issue of Tbe World Bank Research Observer.

55. From the government of Indonesia's response to the Bank's Project Completion Report on Nutrition and Community Health II: "Difficult to find old project documents due to a poor filing system and mutation of project personnel."

56. Going too far with political correctness: a WHO report referring to "pregnant and lactating persons."

And, as always, thank you to those staff who contributed many of the items to this issue.

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