Nutrition mission to Iraq for UNICEF.

At the request of UNICEF, the authors conducted a rapid nutritional assessment of children from birth to five years of age in southern Iraq during the second half of June 1991. With support from local UNICEF staff, the nutrition team examined 680 children, measuring weight, height, and mid-upper arm circumference and observing clinical signs of anemia, vitamin A deficiency, and dehydration. These measurements and observations were performed in 14 rural, urban, and periurban settings in Basrah and Amarah governorates. Evidence of both acute and chronic malnutrition was found in large numbers of the children examined. However, the acute nutritional signs of impending famine were not evident at the time of the survey. This is true notwithstanding epidemic levels of infectious disease, market prices for basic food items three to 20 times prewar levels, and a reported crisis in mothers' ability to breastfeed. Other signs of impending famine (distress sales of family assets, disintegration of social structures, etc.) may have existed, but were not evident to the team.

Famine: a perspective for the nutrition community.

Famine is a nasty turn of events that intrudes on the world's consciousness from time to time. Pictures of starving people and acutely malnourished children, rampant disease, a rising death toll, and massive suffering in some far-off land move many among us to contribute to famine relief, shocked by the paradox of famine in a world "awash in grain". Those who think about it appreciate that famine is related to poverty, that it is often triggered by climatic instability, and that it is both an instrument and tragic by-product of political conflict. But few know very much about famine beyond such fleeting insights. Even fewer are aware that the collective response to famine is woefully deficient. Just as we in the nutrition community had to fight long and hard to get malnutrition onto the development agenda as an explicit concern of public policy, so we and others like us are going to have to labor hard again to do the same for famine. This paper is an attempt to crystallize the issues involved.

Multisectoral nutrition planning: a post-mortem.

PIP: Multisectoral nutrition planning emerged in the early 1970's as a bold new approach to combating malnutrition in low-income countries. Conceptually elegant and operationally ambitious, it blossomed on paper but collapsed in practice notwithstanding vigorous promotion by international assistance agencies. This essay reviews the meteoric rise and fall of the multisectoral approach and then proceeds to examine its theoretical underpinnings. The essay concludes by identifying 12 lessons learned that, if heeded, can help the current generation of intersectoral initiatives against malnutrition to realize their potential. In retrospect, it was a mistake to assign responsibility for nutrition to economic planners and scientists who possessed little political influence or operational authority. Nutrition requires high-level political sponsorship if it is to command resources, be integrated with established ministerial responsibilities and have staying power. Nutrition planning bcame attractive to basically conservative governments anxious to accommodate international benefactors without having to accept more fundamental reforms; the analysis of malnutrition causality focused primarily on attributes of the malnourished and their families, not on the social, economic, and political order around them.^ieng

Supplementary feeding in rural Egypt--the health system in action.

PIP: Of the several direct interventions against malnutrition, supplementary feeding is the most frequently employed in poor countries. If properly designed, implemented, and integrated with other services, the allocation of supplementary foods can contribute significantly to the alleviation of malnutrition. The authors survey the ambitious efforts of Egypt's Ministry of Health to make food available to chidlren at risk. These efforts are likely to have disappointing results unless the process of distribution is accompanied by improved program design and management, and greater sensitivity to the culture of health care delivery at the grassroots level.^ieng

Infant mortality, the birth rate, and development in Egypt.

PIP: This paper is a product of the Massachusetts Institute of Technology-Cairo University Health Care Delivery Systems Project which has examined the delivery of health services in Egypt in relation to malnutrition, early childhood mortality, and fertility. Egypt's economic progress since the 1952 Revolution has had only limited effect on high mortality among preschool children, infants and a high rate of population growth. This paper uses governorate data and simple analytical methods. 10% of Egyptian children die in the 1st year of life; subsequent mortality is also extensive in the preschool age children. The crude birthrate remains in the high 30s and overall population growth continues unabated. Early childhood mortality reflects the interplay of malnutrition and infection and population growth is caused by the fact that children, especially males, are considered economic assets. High fertility is a reflection of high mortality to a significant degree. 4 dimensions of development in Egypt are: 1) an urban cluster, 2) poverty, 3) the incidence of women in the paid labor force, 4) development in the rural sector, and 5) population density. Agricultural income increases as women enter the paid labor force and agricultural productivity is weakly related to the practice of women working for pay. Infant mortality in Egypt varies with and is most influenced by population pressures on the land, including urban crowdedness and by the proportion of households living below the poverty line. Female employment adds to family income and affects infant mortality indirectly. Policy implications are: 1) the government must deal with the density factor, 2) it must pursue a development strategy that stimulates productivity and raises the resource base of society, and 3) the government must address infant mortality along with malnutrition and morbidity. The author concludes that: 1) variation in the birth rate is less than variation in the infant mortality rate, 2) mortality and fertility are responsive to different social and environmental influences, 3) the birth rate is unaffected by much that qualifies as development, and 4) the effects of socioeconomic change on fertility appear to be conditioned by residential context.^ieng

Family planning in rural Egypt: a view from the health system.

PIP: The objectives of this discussion are to present in summary form data from the M.I.T.-Cairo University Health System Questionnaire that are directly relevant to family planning in rural Egypt and then to analyze the patterns observed using other relevant data from the questionnaire. Popular receptivity to family planning is the primary issue addressed. Other issues include the types of contraceptives offered by the rural health system, their utilization by the public, and the significance of the doctors' own disposition toward family planning. This view from the health system is concerned with how the doctors in charge of rural health facilities perceive the situation and how they cope with it. The data examined provide only a partial indication of the prospects for successfully delivering family planning services in rural Egypt. The most common birth control method offered by rural health facilities is oral contraception (OC). 98% of the centers and units responding to the questionnaire offered OC. Following in popularity are IUDs (33%) and condoms (24%). A very small percentage provide foam and creams and none offer sterilization. Utilization reflects these patterns in large measure. The big difference between availability and utilization has to do with the prevalence of prolonged lactation. Although not offered by the health service, prolonged lactation is cited first as the most commonly used method of birth control by a plurality of doctors (47%). The apparent popularity of prolonged lactation as a birth control technique may reveal the extent to which the rural families make their family planning decisions independently of the health system. The gap between the system and society implied by the continued popularity of prolonged lactation is not because of lack of effort on the system's part. Education on family planning is widespread in rural Egypt. A 2nd problem revealed by the data is that although doctors may favor family planning, they also perceive the public as hostile to it. A promising route to lessened fertility lies in reducing the incidence of early childhood mortality.^ieng