This month, I pay tribute to two good friends, one of them sadly no longer with us. For those of you active in the 70s and 80s, the name of Dr V. Ramalingaswami (Dr Rama') (1921-2001), left above, will be familiar. A medical doctor, he was a giant of the nutrition world coming to us from India. We all admired his light manners and balanced judgements. He made great contributions to understanding of the pathophysiology of protein-energy malnutrition. His personal commitment and leadership contributed to the nutritional protection and rehabilitation of millions of refugees at the time of the Bangladesh war in 1970-1971.

For me Jim Levinson, on the right above, is the New England equivalent of Dr Rama. He came to public health nutrition from agricultural economics, and sure made a mark on our profession. This was before he took a vow to help the homeless in Boston and started farming in Massachusetts to provide them with food. He has since come back to the academic world and has been a trusted friend to me ever since – with the friendship now embracing our respective sons.

Just before the beginning of this century the three of us shared a same concern, the topic of this column, and we spoke out about it. (1) But in this day and age of information overload these things get forgotten, they get conveniently swept under the carpet.

I am intrigued to know whether you have come to a similar conclusion as that of this column, as regards the state of international nutrition and specifically the relative balance of attention given to solving the problems of micronutrient deficiencies and those of protein-energy malnutrition. I invite you to read on.

In my early days of work in nutrition, during the late 1970s and early 80s, most attention in impoverished countries focused on protein-energy malnutrition. Its culmination was the era of multisectoral nutrition planning in the 1970s, when we took this form of malnutrition seriously, and understood the importance of working with a range of development sectors. Those of us who pursued multisectoral planning met with disappointment, partly because of the mainly 'nutricentric' lens through which development was viewed, and partly because at least some of us failed to pay adequate attention to the underlying social, economic and political determinants of malnutrition.

A large portion of the nutrition community reacted by pulling in the opposite direction, labelled 'nutrition isolationism'. This is, in effect: 'If we will not be taken seriously by other development sectors, we will ignore them, and pursue nutrition interventions we can carry out and control largely on our own'. And indeed there were attractive candidates, such as new understandings of the consequences of micronutrient deficiencies, particularly iron, vitamin A, iodine, and now zinc. Improved technologies and logistics for delivering micronutrients in the form of massive dose supplements and fortification, made possible significant and attractive achievements within relatively short periods of time.

Hence, many in our profession have pursued such micronutrient interventions --in some cases with evident remarkable success-- and can take some pride in their accomplishments. Nothing in this column should suggest a reduction in efforts directed toward micronutrient malnutrition. But, at the same time, it is clear that we have neglected the overriding problems of inadequate caloric intake, inadequate care and inadequate health care and their determinants, which are continuing to take such an enormous toll on vulnerable populations.

Today, we know considerably more about addressing protein-energy malnutrition through the combined efforts of improving food sovereignty, food security, the nutritional care of women and children, and other public health interventions, than we did years ago. But the attention of the nutrition community and the resources of donors nowadays are still often more attracted by the glamour of micronutrients, a largely technical and often top-down solution (as close to a 'quick fix' magic bullet as we are likely to get in our field). Most of us, and donors, prefer this to the messier and often politically sensitive business of poverty alleviation, people's empowerment, and equity, and the need to be sure that mothers and children have access to care and needed services, and to sufficient and adequate food to eat all year round.

Follow the grants

If one asks nutrition experts to list nutrition research priorities, even those coming from countries with disturbingly high rates of moderate and severe malnutrition, a majority will list micronutrient-related problems. This is not surprising, given the orientation of donor assistance and the appeal of journal articles. But the list hardly reflects the most urgent nutrition needs of, for sure, African and South Asian countries.

Governments and donors have all too often concluded that they can 'check off' their concern and attention to nutrition by launching a micronutrient project, or a pitifully isolated breastfeeding project, and ignore entirely the challenges of protein-energy malnutrition that so seriously affect the ultimate welfare of women and children between birth and 2 years, as well as the longer term development prospects of impoverished countries.

Here then is the challenge we face: We need not only to maintain our momentum in pursuing micronutrient interventions, which reduce suffering and save lives, but also to redress the imbalance, and the relative neglect of the problems of protein-energy malnutrition and household food insecurity, that often require a very different set of interventions.

Our hope in the years to come is that the technical skills and partnerships which have driven salt iodisation and vitamin A, iron and zinc supplementation programmes, can be coupled with the political acumen that has sparked successful social mobilisation movements to bring about the significant structural changes capable of the sustainable reduction in global undernutrition we all desire.

The time has come for the nutrition community to see that micronutrient interventions and protein-energy malnutrition interventions have progressively drifted apart (2). These have become different tracks, responding to what seem different challenges. More, they have grown into two, by now, well differentiated separate domains.

Recognising this fact is important, because it links this discussion to the future of international nutrition and to the evolving debate on public health nutrition and its future role central to our own Association. I invite you to respond to this column in the space provided at the bottom with a consenting or dissenting view on whether this imbalance is not as relevant today as it was in the final years of the last century

More than before, in the last twenty or more years, and following sources of funding, a significant number of nutrition workers have chosen to focus their efforts on the alleviation of micronutrient deficiencies. Does this represent an attempt to avoid the more difficult choices and challenges in the battle against malnutrition? And further – in the name of nutrition – focusing on its more achievable areas of impact, thus choosing the relatively easier path to staying involved in nutrition work and in our profession?

Often, this greater micronutrient focus represents swings from earlier work in protein-energy malnutrition. Examples are manifold, for instance in the work of the US Agency for International Development (USAID), some of that of UNICEF and WHO, as well as that of bilateral donors, and certainly of the Micronutrient Initiative.

Technical and political issues

The difference between these two areas of concentration is between one that is primarily technical with only few political overtones, and one that is the opposite: primarily political with some added important technical challenges. The micronutrients endeavour does have a potential for silver bullet solutions to work, while working to alleviate protein-energy malnutrition does not. Professionals who seek tangible results to report in the literature, like to have silver bullets in their armamentarium.

Myself, I made my choice over 30 years ago. Having lost faith in silver bullets, I have steered my professional life in the direction of a primarily political focus with technical overtones. I have no regrets. Silver bullets have not worked beyond pilot stages, and are not replicable even close to the scale needed. Protein-energy malnutrition has always claimed my attention. It is a sore reminder of the social injustices that underlie it. If anything, my conviction has been strengthened since I adopted the human rights-based framework as my paradigm of action.

This is not an academic nuance. As you my readers will know, I am clear that solutions to protein-energy malnutrition are largely outside the field of nutrition itself, and solutions for micronutrient deficiencies are importantly, though not altogether, inside the realm of what we can do technically. It follows that these two components of nutrition work have to adopt different strategies and require different skills, approaches and tactics.

Colleagues who get involved in micronutrients work get absorbed in resolving mostly immediate causes, and only some of the underlying causes, of malnutrition. They rarely touch its basic causes. They also address more top-down programmatic challenges, such as management, distribution logistics, and food technology issues. Not all this type of work is strictly nutrition engineering though. Work on food fortification, in Brazil for example, tries to push the issues into the socioeconomic and cultural arena and tries to involve consumers and to promote community participation.

People involved in micronutrients work typically lobby for policy changes that are relatively uncontroversial and apolitical, and tend to get support more readily from national decision-makers. Examples of such policies are starting nutrient fortification schemes, or getting salt iodisation legislation and regulations passed.

When applying information, education and communication techniques in micronutrient work, such as seeking to change the dietary habits of a population, or changing the behaviour of pregnant and lactating mothers, colleagues face many more problems. Then, socioeconomic issues come to the fore. They feel they are less well equipped, or less in control, or less inclined, to handle those issues. Too often, nutritionists end up teaching mothers to feed themselves and their families foods that they cannot afford, or, when using social marketing techniques, seeking to impose changes in behaviour without seeking people's understanding of why these changes are needed and beneficial. Social marketing fails to put people more in control of their own lives (3).

To combat protein-energy malnutrition means dealing with issues of equity, popular participation, wealth redistribution, physical and economic access to health, and to education. It is about the appropriate care for women and children. All these have been adversely affected by the many structural adjustment programmes imposed on impoverished countries worldwide, as a condition of receiving foreign loans (3) Protein-energy malnutrition does not respond unless its immediate, and also its underlying and basic causes are tackled simultaneously and all together. Interventions at individual level are necessary, but not sufficient.

Because micronutrient strategies so heavily depend on government-based and donor-based service delivery and logistic interventions, as well as on ongoing capacity building at lower levels, they very often create dependency on a given technology and on the continuation of centrally funded and controlled services. For these and other reasons, sustainability remains elusive.

In contrast, resolving protein-energy malnutrition requires empowering people and communities to get involved in actions that they themselves select and demand as legitimate claim holders. Although often not yet achieved, this has the potential of creating less dependence and more self-reliance and sustainability (4).

Micronutrient interventions can reach coverages in the 90 per cent range almost universally, where there is massive funding and support by the donor community. Then what? Will we see a switch back to protein-energy malnutrition work, which by then may well have become worse? Protein-energy malnutrition will not go away in the next generation. The donor community pays mostly only lip-service to needed structural changes. Governments are not tackling these basic problems on their own either. Moreover, macroeconomic policies imposed by the World Bank and other Bretton Woods institutions more often than not have the effect of making protein-energy malnutrition worse(3).

Nutritionists tend to choose tracks in their careers according to their preference, plus the level of tolerance of frustration they can stand. Do political ideology and ethical commitments also shape their choices, especially when faced with only snail pace progress? Are ultimate goals of social transformation part of the equation in their choice? If the answer to this question is 'no', I see a bleak future for the role we can play in the battle against malnutrition in the world. Changes will come about without and despite us, and history will bypass us.

Engineering and activism

Challenges like these are not being clearly spelled out to young and aspiring professionals during their undergraduate and graduate training. Some say we are trained less than engineers (5). I would say we need more than engineers: we need nutrition activist engineers.

Any work in nutrition is not only engineering or activism. It involves both. But if we are to overcome the great challenges facing us, the balance must shift towards activism. We need more commitment to facing the basic determinants of disease and health. We need to train young nutritionists accordingly, preparing them better for their role as activists, clearly understanding and capable of intervening in the political dimensions and determinants of malnutrition. Dr Rama would agree. So will Jim Levinson. They both are examples of people who live their beliefs.

References

1. Schuftan. C. Ramalingaswami. V, Levinson. J. Micronutrient deficiencies and protein-energy malnutrition. Lancet 351, 1812, June 13 1998.
2. Schuftan. C. Point counterpoint: The gap between nutrition engineers and nutrition activists. Ecology of Food and Nutrition 38, 6, 1999.
3. Schuftan. C. Questioning the Solution: The Politics of Primary Health Care and Child Survival. [Book review] Health Policy and Planning 13,1, March 1998.
4. Schuftan. C.: The community development dilemma: When are service delivery, capacity building, advocacy and social mobilization really empowering? Community Development Journal 3, 3, 260-264, July 1996.
5. Berg. A. Sliding Toward Nutrition Malpractice – Time to Reconsider and Redeploy. Martin Forman Memorial Lecture, 24 June 1991.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: : Schuftan C. Micronutrient deficiencies and protein-energy malnutrition [Column] Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Geoffrey Cannon.