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The Initiative

ARCHIV 107 387 The Micronutrient Initiative

The Micronutrient Initiative (MI) was established in 1992 as an international secretariat within the IDRC in Canada, by its principal sponsors: Canadian International Development Agency (CIDA), International Development Research Centre (IDRC), United Nations Children's Fund (UNICEF), United Nations Development Programme (UNDP), and the World Bank.

The MI's mission is to advance global efforts to eliminate micronutri- ent . The MI provides support in five areas considered critical to national and global efforts in eliminating micronutrient malnutrition: advocacy and alliance building; development and appli- cation of technologies; regional and national initiatives; capacity building; and resolution of key operational issues.

For further information please contact: The Micronutrient Initiative, C/o IDRC, PO Box 8500, 250 Albert Street, Ottawa, Ontario, Canada, K1G 31-19. Tel:(613) 236-6163; Fax:(613) 567-4349; e-mail: [email protected]

This document may be reproduced without prior permission, but please attribute to the Micronutrient Initiative.

Cover photo - IDRC: N. McKee

Publication design - Bob Albery, 3rd Dimension Graphics

Concept for "concentric circles" graphics - PAMM Contents

An amazing reality ...... 1 ...... 5 A deficiency ...... 9 ...... 13 Solutions ...... 17 References and some key resources ...... 25 Some key organizations ...... 28

1

An amazing reality

What would the people of the earth do if faced with a serious problem that affects millions in many areas of their lives and that could be obliterated quickly, painlessly, effectively and economically? Obviously, we would take action to correct the situation, right? Perhaps riot; because such a situation exists with respect to micronutrient malnutrition. One of the greatest evils, one of the most com- pelling challenges confronting humanity today is micronutrient malnutrition. This is A third of people on the earth are something too few are aware of, and even affected by deficiencies of iron, fewer talk about. Yet, over 2 billion people, or iodine. a third of earth's inhabitants, are affected by deficiencies of iron, vitamin A or iodine.

Magnitude of the problem 2 billion people are affected by iron deficiency- 35% of world population 1.6 billion live in iodine deficient areas, 655 million have goitre, 11 million are affected by cretinism 254: million children under 5 years of age have clinical or severe or moderate subclinical vitamin A deficiency

source: World Health Organization (1992, 1994, 1995)

The impact of this form of malnutrition extends beyond considera- tions of only health. Labour productivity, the ability of those affected by micronutrient malnutrition to learn and to function as part of society, and the ability of whole societies to satisfy their economic needs can all be adversely affected.

"The numbers of humans affected by micronutrient malnutrition are truly staggering," said Dr. V. Ramalingaswami of the All India Insti-

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tute of Medical Sciences in New Delhi. Dr. Ramalingaswami was The numbers affected, and the speaking as Chair of the historic conference on "Ending Hidden effects Hunger" held in Montreal in October, 1991. Examples of the stag- themselves, are gering numbers he referred to include the fact that: staggering 13 million people suffer night blindness or total blindness due to vitamin A deficiency.

Iron deficiency reduces work capacity in adults by 30% and learning ability in children by up to 60%. Iodine deficiency is the leading cause of intellectual deficiency on the planet.

Over 43 million people worldwide have mild brain damage result- ing from iodine deficiency.

By themselves, these figures disclose a major human tragedy. What is truly unimaginable is that these deficiencies should rob so many children and adults of their lives and their dreams when the solutions to the deficiencies are: available; feasible; and affordable.

But what is micronutrient malnutrition?

It is a quiet hunger. It is a largely hidden public health problem. Unlike the gnawing hunger that results from going without food, the hunger of micronutrient malnutrition often goes unnoticed, even by those affected. There are usually no visible signs of deficiency, at least to the untrained eye, and even the person affected may not be aware that a problem exists. The term micronutrient refers to and minerals. Most of these cannot be made in the body. They must be part of the diet or taken as supplements. The human body only needs them in tiny

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amounts. For example, a person needs no more than a teaspoon of iodine over an entire lifetime. Hence the prefix "micro." However, failure to ensure an adequate intake of these small quantities could lead to devastating effects. There are dozens of these . Three of them require our most urgent attention. Firstly, because they are the ones most often found to be deficient in people's diets. Secondly, their deficiency leads to grave health, social and economic consequences. Thirdly, there are cost-effective strategies to overcome the deficiencies. These three deficiencies are iron deficiency, vitamin A deficiency, and iodine deficiency. Whatever the cause of them, the problem is a

Effects of Deficiency of Micronutrients

Physical Mental Socio-Cultural Economic

* growth retardation brain damage loss of self esteem lost hours of work

fatigue impared brain isolation work capacity function

lethargy neurologic dysfunctions discrimination 1 family income

apathy l IQ non-participation 1 national economy

llearning skills stigma associated with T health care costs disability

speech and hearing 1 psychomotor skills T no. of unskilled T custodial care disabilities workers

pallor no. of unemployed T educational costs (special education or grade repetition)

ime for caring

1 academic achievement by children

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Micronutrient universal human concern. The struggle to overcome micronutrient malnutrition- malnutrition is one which people in all lands, North and South, it's a social cannot afford to lose, and which demands involvement of all sectors- problem, a industry, nongovernmental organizations, government, consumer universal human associations, and academics. There is every reason to get rid concern of this plague in our midst. And there is no reason not to. Its existence hurts us all-either physically, economically or ethically. Its removal responds to our collective, universal self-interest. Our failure to act is amazing.

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Iron deficiency

So, what's the problem?

Iron deficiency is the world's most common nutritional disorder. It affects around 2 billion people. Half of that number suffer iron defi- ciency anemia. In developing countries, 51% Anemia Among Pregnant and Non-Pregnant Women of children under the age of four years, 40% by Region, 1980s loo of all women and 51% of pregnant women 90 are affected. 80 Iron deficiency anemia reduces the ability of the to carry oxygen from the to the brain, muscles and other organs. This phenomenon results in reduced capacity to work and to learn. Fatigue, shortness of breath even after slight exertion, dizziness, 1 South Southeast Sub- Near Middle China South headache, and loss of appetite are also com- Asia Asia Saharan East/ America America Africa North mon with anemia. Africa ACC/SCN (1992). Second Report on the World Nut. Situation: Global & One of the greatest dangers posed by iron regional results Vol 1. ACC/SCN, Geneva deficiency is that it diminishes the ability to fight infection and thus increases vulnerability to transmissible . Anemic expectant mothers face the risk of death resulting either from spontaneous abortion, the stress of labour or other delivery complications. Up to 200,000 of the half million women who die in childbirth each year do so because of the effects of anemia. Even in developed countries, 18% of pregnant women suffer from iron deficiency anemia. Mater- nal anemia almost always leads to infant anemia. The babies of severely anemic mothers suffer from low birth weight and confront a greater than average risk of early death. Mental and motor develop- ment is impaired in anemic infants and children, and apathy, inactiv- ity and significant loss of cognitive abilities can occur. The effects on a child's development can be irreversible.

------Joining Hands to End Hidden Hunger Up to 200,000 There are many women die of childbirth causes of iron defi- complications ciency. The main attributable to anemia one is low levels of iron in the diet, and

350 poor absorption of million the iron that is 2 billion affected by preschool iron deficiency and consumed. These school age children factors may be suffer impeded accentuated by learning increased iron needs Source: ACC/SCN, 1992 and Viteri, F. 1991 during , and rapid growth in children and adolescents, or chronic iron loss resulting, for example, from excessive menstrual bleeding or parasitic infection.

What can be done to reduce iron deficiency? There are several concrete and well-defined actions that, if effectively implemented, can achieve a dramatic level of success in the preven- tion and control of iron deficiency with a modest investment. These are , supplementation, dietary improve- ment, and public health measures. These strategies usually work best in combination with each other. The ideal strategy is to improve the diet to include a large variety of iron-rich foods and to increase dietary iron absorption. Many foods contain iron. Foods from animal sources such as , and eggs are good sources of iron in a form that the body can readily use. But too often, people cannot afford these foods, or the foods are cultur- ally unacceptable. Iron is also found in grains, legumes, and vegeta- bles, but in a form less easily absorbed unless taken at the same time with meat or foods rich in vitamin C, or processed in a way to en- hance the absorption of iron. Thus, plant-based diets in developing countries are often deficient in absorbable iron.

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Food fortification is a major instrument in the effort to reduce iron deficiency in both industrialized and developing countries. Food fortification means adding a needed nutrient or nutrients to foods which are centrally produced and commonly eaten within a particular society. A number of foods and condiments have been fortified with iron, and different forms of iron have been used. In a number of Latin American and Caribbean countries, including Venezuela, Ecua- dor, Brazil, and Grenada, wheat and corn flour are already fortified with iron and . Investigators in India have played a leading role in researching salt fortification. And Chile has used biscuits fortified with dried hemoglobin, as well as full-fat milk powder forti- fied with iron and ascorbic acid as part of a school meal program.

Of course, fortified foods can only be effective if they are eaten. The focus is on a range of commonly consumed staple foods. In addition, weaning foods, flat breads, curry powder, fish sauce, and a range of processed noodles lend themselves to iron fortification.

Many industrialized -countries have used food fortification, for example, iron has been added to food in the United States for a long time. A recent evaluation in the United States has used a population-based approach to examine the impact of food fortification during the 1970s on iron and some B vitamins intakes from fortified foods. The main food items fortified in the 1970s were cereal grain based products (flour, bread, ready to eat cereals, etc.). Studying the effects of fortification on the proportion of population with iron intake levels above 2/3 of the recom- mendations, showed that iron intake shifted from moder- ate level to adequate mostly benefiting infants, and young adult females.

Source: Popkin, B. et al, 1995

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Supplementation with iron tablets is useful as a preventive as well as a therapeutic measure. Iron supplementation programs are often aimed at specific high-risk groups, such as pregnant women, infants, and preschoolers. Iron supplementation to enable women to go through pregnancy with adequate iron nutrition has proven to be effective, and routine supplementation may be justified in a number of settings. This provides fundamental benefits to mothers and babies, and can prevent long-lasting, undesirable effects.

According to studies among Colombian, Guatemalan, and Indian agricultural workers, and among Kenyan industrial workers and Sri Lankan tea pickers, work output increased by as much as 20% following iron supplementation of workers with iron deficiency. Increased' take-home pay and an improved sense of well- being have also been noted. In studies conducted in India, Indonesia, and Thailand, iron supplements led to an improvement of 5- 25% in test scores among iron- Photo - IDRC: N. McKee deficient infants and children performing at a subnormal mental level. Similar studies revealed improved mental and motor skills among Chilean children.

The response to food fortification and supplementation programs will take longer if iron losses from the body are not minimized. Public health measures can help to reduce iron losses. Measures include birth spacing, the control of parasitic infections, to prevent infections, and improved water supply and sanitation.

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Vitamin A deficiency

So, what's the problem? Every year, vitamin A deficiency (VAD) curtails the lives and hopes of millions of people. This is happening more than 75 years after the development of our knowledge about the deficiency and about its prevention and treatment. Ancient Egyptians knew about night blindness and some other vitamin A-related eye disorders, and treated these conditions by prescribing liver in the diet or through the topical application of juice squeezed from cooked liver.

In the words of Dr. Alfred Sommer of the Johns Hopkins School of Hygiene and Public Health:

Eduard DeMaeyer always complained that vitamin A deficiency was the "Cinderella" of diseases: nutritionists ignored it as a problem for blindness prevention, while those involved with blindness prevention ignored it as a problem of malnutrition. We now recognize it is appropriately central to all those working to prevent childhood deaths and disability. In fact, among children under five, over 250 million suffer from vitamin A deficiency. So do large numbers of school age children and women of child-bearing age. It is estimated that vitamin A deficiency is now a problem of public health significance in over 70 countries. 0.5 million: According to the World Health Organization, severe eye damage/ 2.8 million: blindness: : about 3 million children have some form of vitamin A-related eye . These may vary from night blindness to irreversible partial or total blindness. Of the quarter to half million who go blind each year, about two-thirds die shortly after, often within weeks. 251 million pIVAD: olers moderate tre Eye diseases are only one way in which vita- subchnica min A deficiency strikes its innocent victims. A much larger number of children suffer from

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sub-clinical vitamin A deficiency. Vitamin A helps the immune sys- tem of the body to resist infections. It keeps the cells of the surface of the body healthy so that it is difficult for microorganisms to enter the body. It also helps a child to grow properly. It is these effects of vitamin A that lead to the contracting or prolongation of a range of illnesses, and to an increased number of deaths from common child- hood infections. According to WHO (1994) 3.1 million pre-school children had eye damage, and another 251 million more are severely ormoderately subdinically deficient.

Intervention studies that provided vitamin A to young children in many countries have established that in areas where a deficiency exists, there is a significant effect on mortality-with an average of 23% less likelihood of deaths-among children who receive vitamin A. In Tanzania and South Africa, death rates from dropped by half among children given vitamin A Global estimates are that between 1.3 capsules. The improvement in vitamin A and 2.5 million deaths could be status can also lead to a significant reduc- averted each year by improving vitamin tion in the severity of illnesses and in the A status. Humphrey, J. et al. WHO Bulletin, 1992 length of hospital stays.

What can be done about vitamin A deficiency?

The root cause of vitamin A deficiency is the continued inadequate dietary intake of vitamin A-rich foods. The preferred solution is to add more vitamin A-rich foods to the diet. Important sources of vitamin A are: foods from animal sources, like liver and other organ meats, milk, poultry, and eggs; and plant sources, such as red palm oil, dark green leafy vegetables, and orange or yellow fruits. Vitamin A from plant sources is widely available and generally inexpensive. However, these plants are often not fed to preschool aged children because of cultural influences on food intake. Therefore, programs to encourage dietary change must be coupled with appropriate public education. Agricultural policies that favour small animal husbandry and poultry production and the growing of fruits and vegetables,

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processing techniques to preserve fruits Decrease in % of children with serum level below 10 mcg/dl (1975-77) through consumption of and vegetables, the promotion of home vitamin A-fortified sugar and community gardens, and increasing incomes--all are actions that can help increase the intake of vitamin A. Fortification of foods with vitamin A is cost-effective and appropriate where there is a centrally processed and widely vitamin A consumed food. For example, of F can often easily be added to relief food 1975 1976 1976 1977 1977 Oct/Nov Apr/May Oct/Nov Apr/May Oct/Nov supplies such as flour and vegetable oil. Source: Arroyave, 1979 Vitamin A has been successfully used to fortify sugar in Guatemala, in

Photo -1DRC: N Mcgee

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the Philippines, corn flour in Venezuela, and cooking oil in India and Pakistan. The case of sugar fortification with vitamin A in Guatemala provides a good example of an intervention which actually works. In 1994, addition of vitamin A to sugar became mandatory by law in Guatemala. Impact studies showed significant improved vitamin A status of preschool children. But due to scarcity of foreign exchange, sugar fortification was discontinued. Following this, it was discovered that vitamin A deficiency once more assumes serious proportions in the country. This led to reintroduction of sugar fortification during the 1980s. Often, however, immediate-acting measures may be needed, and supplementation with vitamin A is chosen. Vitamin A can be stored in the body for long periods. This makes it possible to provide a large dose which is then available to the body over a period of time. A single capsule of a vitamin A supplement every 4 to 6 months can not only save a child's sight, but will also prevent him or her from illness and untimely death. Mass capsule distribution pro- grams have been effective in a number of countries, including Bang- ladesh, Indonesia, and the Philippines where the lives of tens of thousands of children have been saved. Vitamin A supplements given to the lactating mother within 6 weeks of delivery reach not only the mother but the breastfed baby as well. Breastmilk can be the main source of this vitamin for the first two years of a child's life.

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Iodine deficiency

So, what's the problem?

Iodine is a mineral essential to human life. Some of the basic func- tions of the human body depend on a steady supply of iodine. Iodine is present in its natural state in the soil and water. In many regions, however, the iodine has been leached from the surface soil through repeated floods or glacial erosions. When the soil is iodine-deficient, the crops grown on it are iodine-deficient, and people and animals-- who depend on these foods to meet their needs for iodine--will be iodine-deficient, unless they eat iodine-containing imported foods. Yet the question remains why IDD continues to be a plague on humanity, three quarters of a century after the technology to prevent iodine deficiency disorders (IDD)--i.e., adding iodine to commonly eaten foods, like salt--was developed and made available at decidedly feasible costs.

Goitre is the most visible sign of iodine deficiency. It is a swelling in the neck caused by an enlarged thyroid gland. The thyroid increases in size when there is not enough iodine available to it. Without enough iodine, a person can become dull, easily tired and less active. Photo - IDRC: N. McKee Iodine deficiency also results in stillbirths and high rates of infant mortality. In pregnancy, this defi- "We ought to agree that it is a ciency leads to mental and physical defects in the crime that one more child be baby ranging from mild mental retardation to allowed to be born a cretin.... cretinism. Must we end the century with hundreds of millions still at risk The mental effects of iodine deficiency have been when we know the answer and illustrated in terms of an iceberg. At the tip is the can afford the price?" Former senior figure of 1%-10% representing the number of UNICEF official David P. Haxton persons succumbing to cretinism. Concealed under this figure are up to 30% of victims suffering some brain damage. Further down the iceberg are as many as 70% who suffer loss of energy due to hypothyroidism.

Iodine deficiency regarded as an environmental problem because of its link to environmental degradation, remains a public health prob-

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lem in over 100 countries. More than 1.6 billion people--30% of the world's population-are at risk of iodine deficiency, because they live in areas where iodine deficiency is widespread. Of these, 655 million have goitre. About 43 million suffer some form of brain damage including over 11 million who are affected by Iodine deficiency, is the single cretinism. Spontaneous abortions, still births, greatest cause of preventable mental impaired fetal brain development, speech and retardation in the world today. hearing defects, impaired school perform- ance, apathy, gait disorders--these are some of the ways in which iodine deficiency strikes. Studies from many countries around the world show that children in iodine-deficient areas suffer from poor hand-eye coordination and have 10 to 15 IQ points less than children who get enough iodine in the diet. The effects upon a child born to a severely iodine-deficient mother are rarely reversed. It is, therefore, best to intervene before or during preg- nancy if the child is not to suffer a lifetime of compro- mised growth and development and of mental and other disabilities. Sometimes, whole villages are known to be at risk of IDD. The potential impact, in terms of arrested personal and community development and high levels of physical and mental disabilities, is enormous. No wonder iodine The estimated 1.6 billion people at deficiency has been called one of the greatest, and most risk represent approximately 30% of the world's population unnecessary, human tragedies of our time.

Source adapted from WHO, UNICEF and ICCIDD 1993 Mixed with the overpowering reality of this sad story is the evidence that victory is attainable, if we would only reach out, collectively, and grasp it. Success in reaching the goal of virtual elimination of iodine deficiency disorders by the year 2000 is

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within reach. Eighteen countries have already achieved the goal. Another 46 have programs which show evidence of success. Governments worldwide, working in collaboration with private com- panies, and with development agencies such as the World Health Organization, UNICEF, and the Canadian International Development Agency, as well as nongovernmental organizations (NGOs) such as Kiwanis International, have all been engaged in the struggle against IDD.

How can IDD be eliminated?

The strategy of choice is salt iodization. Wherever iodized salt is eaten as part of the daily diet, IDD has become a thing of the past. This is seen most clearly in North America where iodized salt was introduced in the 1920s, and in many west European countries. Still though, IDD continues to be a concern in some parts of Europe. And great progress is now rapidly being made in many developing coun- tries. The Andean nations of Ecuador and Bolivia were once among the world's most IDD-afflicted countries. Today, Ecuador has declared itself free from the problem. In Bolivia, a 60.5% prevalence rate of goitre was found in populations not using iodized salt. This figure dropped to about Effect of salt iodization on goitre prevalence in Bolivia 20% after a number of private companies and cooperatives established iodized salt after iodized salt - 20.6% production plants, and iodized salt was widely made available. before iodized salt - 60.5%

In West Africa, over 65% of edible salt is iodized. In East Africa, the proportion of edible salt that is iodized jumped from under 10% to about 40% in less than two 7 0 10 20 30 40 50 60 70 years. Over 50% of the edible salt pro- Goitre prevalence (%)

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duced in is iodized. China, home of the largest number of IDD sufferers, expects three-quarters of all edible salt to be iodized by the end of 1995. About 50 countries have already approved legisla- tion requiring salt iodization. Laws are being drafted or debated in at least another 38.

Photo -UNICEF: DELHI Joining Hands to End Hidden Hunger 17

Solutions

The solutions are available Enough has been said to indicate that the solutions are available. Experiment after experiment and program after program have re- vealed that overcoming the problem is within our grasp. In Europe and North America, food fortification, increased access to micronutri- ent-rich foods, supplementation, and public health measures have all helped lead to the low incidence of . Today, similar actions are producing positive results from Bangladesh to Brazil, and from Barbados to Burkino Faso.

The solutions are feasible The solutions are One of the reasons why actions are effective in such a range of available social, physical and economic environments is that the solutions are feasible eminently feasible. There are three simple options from which to affordable choose.

The first and the best is dietary improvement. This aims to increase the availability and consumption of vitamin- and mineral-rich foods. Not only availability, but also accessibility--i.,e., having the means to buy these foods--is equally important. Dietary improvement means improving the way we cultivate, select, prepare and choose the foods we eat ourselves or feed our children. For example, growing vegetables and legumes, and raising livestock or poultry for use or sale can be encouraged. Cooking methods that maximize nutritional benefits, and strategies that enhance absorption, should be promoted. Programs to promote and support breastfeeding need to be encouraged, since breastmilk is an important source of nutrients, even into the second year of life. Often, though, attention needs to be paid to economic and practical obstacles that hinder the adoption of good food and nutrition habits.

The second option is fortification. The technology is available to fortify a variety of foods with one or more nutrients. Food fortifica- tion has, to a large extent, been responsible for the disappearance of

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vitamin and mineral deficiencies in Canada, Switzerland, the United States, and the United Kingdom. Fortification of margarine with vitamin D helped eliminate from Britain, Canada, and North- ern Europe decades ago. In Sweden and the United States, fortifica- tion of refined flour with iron is credited with the dramatic reduction of iron deficiency anemia. Salt iodization, which began in 1922 in the United States, showed immediate and spectacular results in overcoming iodine deficiency.

Commercial food fortification is particularly appealing because, if the right food is selected, high coverage is assured without requiring a The strategies change in the eating habits of the consumer. The keys to a successful are: fortification program that can be sustained are political support, the dietary involvement of the food industry, the creation of consumer demand improvement for nutritious foods, and consumer acceptance of such products. food fortification The third measure is supplementation. Supplementation is the supplementation provision of nutrients in capsule, tablet, injectable or liquid form. It public health can be beneficial in preventing deficiencies, or even necessary as an measures immediate and effective measure to treat those affected. For exam- pie, in areas where people are at risk of vitamin A deficiency, giving vitamin A supplements to infants over 6 months of age and to moth- ers within 6 weeks of delivery is widely supported. Iron supplementa- tion is often recommended for all high-risk groups (e.g., breast - feeding women, children under two years) in areas with a high preva- lence of anemia. Iron supplementation of pregnant women is often needed as a routine measure to prevent anemia. Where goitre and cretinism are still evident, supplementation with iodized oil is an effective solution while salt iodization programs are being put into place. These three strategies--dietary improvement, food fortification and supplementation--are relevant for the prevention and control of all three micronutrient deficiencies discussed. Although one strategy may be more important than the others, depending on the nutrient

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and the situation, more often, however, the most effective solution Benefits would involve all three actions. Where needed, there can also be benefit in improving public health measures, in addition to taking in inl' up these specific strategies.

The solutions are affordable These solutions are economical in two senses: the costs are low, and the benefits are high. Fortifying salt with iodine for a year costs about 10 cents per person; iodine supplementation costs around 50 cents. Fortification of foods with iron can cost up to 20 cents per person per year. Vitamin A capsules costing as little as 5 cents each can provide the protection needed by large numbers of children at risk. The parasitic infection, hookworm, can be controlled for as little as 22 cents per person per year. And, in Bangladesh, people were about vitamin A and motivated to produce vitamin A- rich educated Costs foods at a cost of 11 cents per person for one year. The corresponding benefits, the other side of

; t h e co i,n are a 1 mos t imm easur a bl e F o r ex a m- According to the World Bank, the ple, how does one measure the ten-cent cost economic and social payoffs of of two vitamin A capsules needed to protect a micronutrient intervention programs child for a year against the fact that 2 children are as high as 84 times the program are probably dying this very minute because of costs. the lack of protection which those two cap- sules could provide? The World Bank estimates that problems of micronutrient malnutrition cost national economies up to 5% of their gross domestic product (GDP) through death and disability, but that the solutions would cost as little as 0.3% of GDP!

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Action is needed at all levels In this booklet, we have given some examples of real people taking real actions to respond to what is a real problem. People from all walks of life have already joined the effort. Heads of states and gov- ernment officials. Researchers and medical professionals. Agricultural workers, teachers, and communication specialists. Business people and community leaders. All have joined hands in this endeavour to which all are summoned to play a part.

The world has promised to end this hidden hunger Governments everywhere have made a political obligation to take action against micronutrient malnutrition. At three major international conferences--the World Summit for Children in 1990, the Ending Hidden Hunger Conference in 1991, and the International Conference on Nutrition in 1992--most governments made a commitment to achieve these goals by the year 2000: reduction of iron deficiency anemia in women by one- third of the 1990 levels; virtual elimination of vitamin A deficiency and its conse- quences, including blindness; and virtual elimination of iodine deficiency disorders.

If the story yet remains unfinished, there are two reasons. The first is that there is still need for more hands, especially from some sectors. The second is that the partnerships which have already been forged need to be extended and strengthened.

Action is needed at every level. Individuals, both those in "at risk" environments and groups and those less likely to be troubled, directly, by this scourge, need to be informed about the seriousness and the hope regarding micronutrient malnutrition. Families need to be

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educated about healthy food choices and available preventive and therapeutic options. At the community level, there is the need to assess, to plan and to act. At the district and provincial levels, training, the provision of essential community services, the allocation of governmental resources and the monitoring of action and results must be undertaken. At the national level, strategic support must be given, linkages with national plans must be ensured and bridges with the international community must be built and maintained. Finally, the regional and international levels must continue to expand and refine the al- ready growing global movement aimed at overcoming micronutrient malnutrition.

We must work together

Action is needed not only at every level but within many sectors. People everywhere need to educate (themselves and others), advo- cate and participate. Government leaders must incorporate the goals of ending hidden hunger into their national policies, and they must ensure the needed resources are allocated and that programs benefit from proper management and accountability. International organizations must help with advocacy, general guidelines, technical assistance and program support. Voluntary agencies can help with program implementation, innovation and, of course, advocacy. Private industry has an important role in prod- uct research and development, the manufacture of food and pharma- ceuticals and their delivery, quality assurance and consumer educa- tion. Media and communication specialists have a role to market the idea and the means of ending hidden hunger to make them acceptable to all relevant groups. And health, nutritional, educa- tional and agricultural personnel are, of course, at the centre of it all--providing the information, the products and the services and keeping our collective conscience awake to the problems and the possibilities.

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As important as getting these various sectors involved is the need to get them working together. A micronutrient program would be a non-starter if the research work was not relevant to the problems of actions in the field. Or if government policy on fortification did not take account of the willingness or capability of industry and the constraints that might be faced. Or if families or community opinion leaders were not persuaded of the value of eliminating hidden hun- ger.

Partnership to end "Hidden Hunger"

Government NGO's

Policy Education Resources Innovations Program management Advocacy Accountability Service delivery Consumer protection & Funds education /.

Consumers

Awareness Participation Social organizations Demand for food quality

Product development Quality control Delivery Consumer education

Food & Pharmaceutical Bilateral & Multilateral Industries Organizations

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The time for action is now The message is clear: the costs are low, the benefits are enormous, and the needs are urgent. The solutions are available, feasible, and affordable. Many governments are already committed. We now need action. You know there is a place for you in this unfinished task. Join the partnership to end hidden hunger.

If you or your organization do not know where to begin, there are many resources, and organizations available to help. See the lists of resources and organizations in this booklet. Many things that be done. Here are some steps that you might wish to take: Act now! If not us, help inform and educate others, even people in other countries, who? about the gravity and the hope regarding micronutrient If not now, malnutrition; when? work to fortify commonly eaten foods; design food aid programs that add micronutrients to basic commodities, including flour and oil; work with the media-radio, television, newspapers, artists, etc.-to communicate information about micronutrient malnutrition; provide training about micronutrients for agricultural and indus- trial workers, teachers, health care workers, and others; start educational programs, for example take steps to include the topic in your organization's educational activities or in the school curriculum; foster workplace support of micronutrient activities; support programs that assist women in their efforts to produce and preserve micronutrient-rich foods; introduce or support arrangements to deliver nutrient supplements;

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have a workplace or classroom project to test salt for the pres- ence of iodine; promote knowledge about the benefits of breastmilk; use bilateral and multilateral aid and the resources of NGOs to support social programs and actions to eliminate micronutrient malnutrition; help to orient food and agricultural policies to take account of the nutritional quality of the food supply, and support programs to promote the production, marketing and consumption of micronu- trient-rich foods; talk to people to benefit from the experiences of other commit- ted individuals and groups, and to create strong national and inter- national networks.

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References and some key resources:

ACC/SCN. 1994. Maternal and Child Nutrition. SCN News, Number 11, mid-1994. Geneva, Switzerland. 71 pp. ACC/SCN. 1990. Women and nutrition. Papers from ACC/SCN Sessions. ACC/SCN symposium report. Nutrition Policy Discussion Paper No. 6. Geneva, Switzerland. 179 pp. All We Expect: Nutrition, a basic human right. This 24 minute video illustrates the significance and adverse consequences of micronutrient malnutrition in women, and provides information on the three most common deficiencies: iron, iodine, and vitamin A. Examples of the solutions being used around the world are given. The video is aimed at policy advisors, and program managers and planners. It will also be of interest to trainers and the general public. Available in English, French or Spanish, with an accompanying Facilitator's Guide, for PAL, NTSC, or SECAM systems from World Wide TV Associates, 411 Echo Drive, #3, Ottawa K1S 1N5, Canada. Tel: (613) 238- 2410; Fax: (613) 238-7977; e-mail: [email protected]

AHRTAG. Breastfeeding Information Resources. An international listing of sources of resource materials and organisations. Avalailable from: AHRTAG, Farringdon Point, 29-35 Farringdon Road, London EC1M 3JB, UK. Arroyave, G. 1979. Evaluation of sugar fortification with vitamin A at the national level. Pan American Health Organization, Scientific Publication No. 384. Washington, DC, USA. This document describes in detail the original country program for fortifying sugar with vitamin A in Guatemala ant the evaluation of its impact on vitamin A status and health.

Bauernfeind, J.C. 1994. Nutrification of foods. In: Modern nutrition in health and disease. Shils, M.E., Olson, J.A. and Shike, M. eds. 8th edition. Volume 2, Chapter 91. Lea & Febiger, Baltimore. pp. 1579-1592. Bauernfeind, J.C. and Lachance, P.A. 1991. eds. Nutrient additions to foods, nutritional, technological and regulatory aspects. Food and Nutrition Press, Inc. Trumbull. This book provides the first comprehensive overview of the science and technology of food and delivery of nutrients through formulated and fabricated food systems. It covers all aspects of fortifi- cation of staple and processed foods to make them more nutritious and of higher quality. Information is provided in 21 chapters on bioavailability consid- erations, engineering, labelling and regulations aspects of food fortification, with references given at the end of each chapter.

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Behrman, J.R. 1992. The economic rationale for investing in nutri- tion in developing countries. USAID and VITAL. Washington, D.C., USA. 32pp. Ending Hidden Hunger. A 20-minute video produced by Bedford Produc- tions for UNICEF/WHO. Available in English, French and Spanish, on PAL, NTSC, SECAM formats. For a copy (US $10 plus postage and handling) contact: Bedford Productions Ltd., 6th Floor, 6 Vigo Street, London, W1X 1AH, UK. Tel: (71) 287-9928; Fax: (71) 287-9870

Gillespie, S., Kevany, J. and Mason, J. February 1991. Controlling iron deficiency. A workshop report. ACC/SCN State-of-the-Art Series. Nutrition Policy Discussion Paper No. 9. Geneva, Switzerland. 93 pp.

Hetzel, B. and Pandav, C.S. 1994. S.O.S. for a billion: the conquest of iodine deficiency disorders. Oxford University Press, Delhi. Available from the ICCIDD. 285 pp. ICCIDD. March 1995. ICCIDD Notes. An excellent compilation of a wide range of resources (books, brochures, reports, audiovisuals). Available from: ICCIDD Focal Point, Tulane University School of Public Health and Tropical Medicine, 1501 Canal Street, Ste. 1300, New Orleans, Louisiana 70112 USA. Fax: (504) 585-4090; e-mail: [email protected]

Lotfi, M., Venkatesh Mannar, M.G., Merx, R.J.H.M. and Naber-van den Heuvel, P. 1995. Micronutrient fortification of foods: Current practices, research and opportunities. Micronutrient Initiative and the International Agricultural Centre, Ottawa. 190 pp. Merchant, K.M. and Kurtz, K. Women's nutrition through the life cycle: social and biological vulnerabilities. In: The health of women: a global perspective. Koblinsky, M., Timyan, J. and Gay, J., eds. Westview Press, San Francisco. Micronutrient Initiative. 1995. Food fortification in Canada: Experi- ences and issues. MI, Ottawa. 50 pp. Micronutrient Initiative. 1995. Vitamin A deficiency: key resources in its prevention and control. MI, Ottawa. 47 pp. Popkin, B.M., Siega-Riz, A.M., and Haines, P.S. 1995. The nutritional impact of fortification in the United States during the 1970s. Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27514. In press.

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Sommer, A. 1994. Vitamin A deficiency and its consequences: a field guide to their detection and control, third edition. WHO, Ge- neva. A must-have reference. Available in English, French and Spanish. Order from WHO, Distribution and Sales, 1211 Geneva 27, Switzerland. UNICEF. November 1994. The Prescriber. Special issue on anemia. No. 11. UNICEF, New York. 16 pp. Contains concise information about the causes of anemia and its prevention and treatment, including tables on recom- mended schedule of supplementation for preventive and therapeutic dosage. Available in English, French, Spanish, Portuguese and Arabic from UNICEF, Health Systems Development Unit, H-10F-UNICEF, Three United Nations Plaza, New York, NY 10017 USA. Fax: (212) 326-7059. World Bank. 1994. Enriching lives: overcoming vitamin and mineral malnutrition in developing countries. Development in Practice Series. Stock No. 12987. Washington, D.C., USA. Available from: World Bank Publications, P.O. Box 7247-8619, Philadelphia, Pennsylvania 19170-8619 USA. Tel: (202) 473-1155; Fax: (202) 676-0581. World Bank. 1994. A new agenda for women's health and nutrition. Development in Practice Series. Washington, D.C., USA. 96 pp. Available from: World Bank Publications, P.O. Box 7247-8619, Philadelphia, Pennsyl- vania 19170-8619 USA. Tel: (202) 473-1155; Fax: (202) 676-0581. WHO (World Health Organization) and UNICEF. 1995. Global prevalence of vitamin A deficiency. MDIS Working Paper #2. WHO/NUT/95.3. WHO, Geneva. This is the latest WHO report on the global prevalence of vitamin A deficiency as part of the Micronutrient Deficiency Information System (MDIS) Working Papers. This 118 page report contains tables summa- rizing prevalence by country, plus regional maps showing the severity of vitamin A deficiency in each country. WHO, UNICEF and ICCIDD. 1994. Indicators for assessing iodine deficiency disorders and their control through salt iodization. WHO/NUT/94.6. WHO, Geneva. 55 pp. WHO, UNICEF and ICCIDD. 1993. Global prevalence of iodine defi- ciency disorders. MDIS Working Paper #1. WHO, Geneva. 80 pp.

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Some key organizations:

Administrative Committee on Coordination/Sub-Committee on Nutrition of the United Nations (ACC/SCN). A focal point for harmo- nizing the United Nations system's policies and activities in nutrition. The SCN compiles and distributes nutrition information (including an excellent newslet- ter, SCN News, and has produced a number of publications that focus on women and nutrition) and sponsors technical meetings. Contact: ACC/SCN, c/o WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: (41 22) 7910456; Fax: (4122) 798 8891. Food and Agriculture Organization (FAO). Established October 1945 as a major United Nations Agency to deal with global food and agricultural issues. FAO activities are aimed at raising the levels of nutrition and standards of living of the people in the member countries and to secure improvements in the efficiency of the production and distribution of all food and agricultural products. In 1984, FAO contributed to the United Nations 10-Year Plan to Control and Prevent Vitamin A Deficiency, Xerophthalmia and Nutritional Blindness to increase production of vitamin A and carotene-rich foods and ensure their increased consumption. Safeguarding Sight is a 4-page pamphlet summarizing FAO actions against vitamin A deficiency. Contact Address: Vitamin A Program, Food Policy and Nutrition Division, Viale Terme di Caracalla, Rome, 00100. Tel: (396) 5797 3330; Fax: (396) 5797 3152. Helen Keller International (HKI). A US-based NGO that provides technical assistance to strengthen and expand existing vitamin A programmes. HKI has produced numerous training materials and publications on vitamin A. Contact: HKI, 90 Washington Street, New York, NY, USA, 10006. Tel: (212) 943-0890; Fax: (212) 943-1220. International Council for the Control of Iodine Deficiency Disor- ders (ICCIDD). An international network of experts dedicated to the control of IDD. Assists with the development of national programmes, provides tech- nical counsel and produces numerous technical reports and a newsletter. Contact: ICCIDD, Avenue de la Fauconnerie 153, B-1170 Brussels, Belgium. Tel: 32 (2) 675-8543; Fax: 32 (2) 675-1898. International Nutritional Anemia Consultative Group (INACG). Provides consultative services and advice to operational and donor agencies seeking to reduce nutritional anemia. Publications and guidelines for anemia control programmes are available. Contact: INACG Secretariat, c/o The Nutrition Foundation, Inc., 1126 16th St. N.W., Washington, DC 20036 USA. Tel: (202) 659-9024; Fax: (202) 659-3617.

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International Vitamin A Consultative Group (IVACG). Provides consultation and guidance to agencies seeking to reduce vitamin A deficiency. Publications, resource materials and programme guidelines available. Contact: IVACG Secretariat, c/o The Nutrition Foundation Incorporated, 1126 Six- teenth Street N.W., Suite 200, Washington, DC 20036 USA. Tel: (202) 659- 9024; Fax: (202) 659-3617. Micronutrient Initiative (MI). See inside front cover. Mothercare. Produces numerous publications and guides on maternal health, including training manuals. Contact: Mothercare, c/o John Snow, Inc., 1616 N. Fort Myer Dr., 11th floor, Arlington, VA 22209 USA. Tel: (703) 528- 7474; Fax: (703) 528-7480. Opportunities for Micronutrient Interventions (OMNI). Developed and funded by the Office of Health and Nutrition of the U.S. Agency for International Development (USAID) in Washington, D.C., the Opportunities for Micronutrient Interventions Project (OMNI) is a comprehensive five year effort to control and prevent micronutrient deficiencies in developing countries. OMNI's mission will be accomplished by developing integrated and all-encom- passing programs and strategies to reduce and eliminate major micronutrient deficiencies throughout the developing world. Participating countries will be selected based on their micronutrient malnutrition problems, their commitment by local officials (public and private) to micronutrient activities, and their capac- ity to achieve and sustain a demonstrable impact. For information contact the OMNI Project, c/o John Snow Inc., 1616 North Fort Myer Drive, Suite 1100, Arlington, Virginia, 22209, USA. Tel: (703)528-7474, Fax: (703)528-7480. Programme Against Micronutrient Malnutrition (PAMM). PAMM offers short-term courses to assist national teams working on micronutrient programmes acquire required skills in advocacy, laboratory management, information management, communications and interventions. Also offers technical advice. Contact: PAMM, c/o Centre for International Health, Emory University, School of Public Health, 1518 Clifton Road, N.E., Atlanta, Georgia 30322 USA. Tel:(404) 727-5417/16; Fax:(404) 727-4590. Teaching Aids at Low Cost (TALC). An NGO dedicated to increasing access to educational materials on health and nutrition, TALC offers an exten- sive listing of books and slide materials. Contact: TALC, PO Box 49, St. Albans, Herts, UK, AL1 5TX; Tel: (44 1 727) 853869; Fax: (44 1 727) 846852.

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United Nations Children's Fund (UNICEF). A specialized UN agency that aids governments to undertake programmes benefitting women and children. UNICEF produces various publications and documents, and maintains a UNICEF Video, Film and Radio Catalogue. Contact: your national UNICEF office, or UNICEF House, Nutrition Section, Three United Nations Plaza, New York, NY, USA, 10017. Tel: (212) 326-7000; Fax: (212) 326-7336. World Alliance for Nutrition and Human Rights. The Alliance works in areas such as research, monitoring, education and training, and curriculum on nutrition, ethics and human rights. It has a Steering Committee and a small secretariat. Produces a newsletter. Contact: the WANHR Secretariat, c/o The Norwegian Institute of Human Rights, Grensen 18, N-0159 Oslo, Norway. Tel: (47 2) 411360; Fax: (47 2) 422542. World Health Organization (WHO) A UN agency that acts as the world's directing and coordinating authority on questions of human health. WHO maintains offices in most regions of the world. Numerous publications on nutrition are available. Contact: Nutrition Unit, Division of Food and Nutri- tion, WHO, 20 Avenue Appia, 1211 Geneva 27, Switzerland. Tel: (4122) 7914146; Fax: (4122) 791-4156.

Joining Hands to End Hidden Hunger For every day of delay, another 50,000 infants are born with reduced mental capacity from iodine deficiency; another 300 mothers die in childbirth due to severe anemia; and another 4,000 children die from the effects of vitamin A deficiency.

These are unnecessary tragedies. Proper nutrition is a basic human right.