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State of the World's Children 1998

Carol Bellamy, Executive Director, United Nations Children's Fund


CHAPTER II

Statistical tables

1  Basic indicators
2  Nutrition
3  Health
4  Education
5  Demographic indicators 
6  Economic indicators 
7  Women 
8  The rate of progress
   Measuring human development
   Regional summaries country list

Statistics, vital indicators of the care, nurture and
resources that children receive in their communities and
countries, help chart progress towards the goals set at the
1990 World Summit for Children. The eight tables in this
report have been expanded to give the broadest possible
coverage of important basic indicators for nutrition, health,
education, demographics, economic indicators and the
situation of women, plus rates of progress and regional
summaries. They also include complete data, as available, on
less populous countries, covering 193 countries in all,
listed alphabetically. Countries are shown on page 93 in
descending order of their estimated 1996 under-five mortality
rates, which is also the first basic indicator in table 1.

Panels

1  Vitamin A supplements save pregnant women's lives
2  What is malnutrition?
3  Stunting linked to impaired intellectual development
4  Recognizing the right to nutrition
5  Growth and sanitation: What can we learn from chickens?
6  Breastmilk and transmission of HIV
7  High-energy biscuits for mothers boost infant survival by  
   50 per cent
8  UNICEF and the World Food Programme
9  Triple A takes hold in Oman
10 Celebrating gains in children's health in Brazil
11 Rewriting Elias's story in Mbeya
12 Women in Niger take the lead against malnutrition
13 BFHI: Breastfeeding breakthroughs
14 Tackling malnutrition in Bangladesh
15 Kiwanis mobilize to end iodine deficiency's deadly toll
16 Indonesia makes strides against vitamin A deficiency
17 Making food enrichment programmes sustainable
18 Zinc and vitamin A: Taking the sting out of malaria
19 Protecting nutrition in crises
20 Progress against worms for pennies
21 Child nutrition a priority for the new South Africa

Spotlights

World Food Summit
Ten steps to successful breastfeeding
Vitamin A
Zinc
Iron
Iodine
Folate

Text figures

Fig.1  Malnutrition and child mortality
Fig.2  Trends in child malnutrition, by region
Fig.3  From good nutrition to greater productivity and beyond
Fig.4  Poverty and malnutrition in Latin America and the      
       Caribbean
Fig.5  Causes of child malnutrition
Fig.6  Inadequate dietary intake/disease cycle
Fig.7  Intergenerational cycle of growth failure
Fig.8  Better nutrition through triple A
Fig.9  Iodine deficiency disorders and salt iodization
Fig.10 Progress in vitamin A supplementation programmes
Fig.11 Measles deaths and vitamin A supplementation
Fig.12 Zinc supplementation and child growth (Ecuador, 1986)
Fig.13 Maternal height and Caesarean delivery (Guatemala,     
       1984-1986)

References

Glossary

Press Kit
 Summary: Malnutrition: Causes, consequences and solutions
 Fact Sheet: Summing up malnutrition's shame
 Fact Sheet: Malnutrition: Causes
 Fact Sheet: Micronutrients
 Feature: Child malnutrition and women's rights
 Feature: In Burundi camps, the spetre of malnutrition looms
 Feature: Malnutrition in industrialized countries




The state of the world's children 1998 - Chapter II
******

Panel 1

Vitamin A supplements save pregnant women's lives

Each year, nearly 600,000 women die worldwide from
pregnancy-related causes. Prenatal vitamin A supplements will
help reduce this massive toll, according to preliminary
results from a major new study. By measuring the impact of
low weekly doses of the vitamin on the health and survival of
pregnant women in southern Nepal, the study found that deaths
among women receiving  either low-dose vitamin A or
beta-carotene supplements dropped dramatically, by an average
44 per cent.

Like many parts of the developing world, Nepal has a
notoriously high maternal mortality rate - 125 times that of
the United States - and vitamin A deficiency is common,
particularly among pregnant women. Night-blindness, long
ignored by the medical establishment and viewed by women as a
routine consequence of pregnancy, but in reality a worrying
sign of vitamin A deficiency, develops in 10 to 20 per cent
of pregnant women.

Researchers from Johns Hopkins University in the United
States and the National Society for Eye Health and Blindness
Prevention in Nepal, supported by the United States Agency
for International Development (USAID) and Task Force Sight
and Life, based in Switzerland, conducted the study to see
whether  maternal, foetal or infant mortality could be
lowered by providing women of childbearing age one low-dose
vitamin A capsule each week. Night-blindness and anaemia in 
women in the study and birth defects in their infants were
also care fully  investigated.

Approximately 44,000 young married women, nearly half of whom
became pregnant during the study, were given either vitamin A
supplements (a) or placebos. The supplements were in the form
of either pure vitamin A or beta-carotene, the vitamin
A-active ingredient found in fruits and vegetables that the
body converts to vitamin A.

Among the women receiving pure vitamin A there were 38 per
cent fewer deaths and among those receiving beta-carotene
there were 50 per cent fewer deaths, during pregnancy and the
three months following childbirth, than among women receiving
no supplements. (b) Anaemia, which is usually associated with
iron deficiency and which is known to be a contributing cause
of maternal deaths, was a surprising 45 per cent lower in the
women receiving supplements who were not infected with
hookworm.

Women suffering from night-blindness (an inability to see at
dusk or in dim light) were found to be more likely to get
infections, to be anaemic and underweight and to be at
greater risk of death. Night-blindness  was reduced by 38 per
cent and 16 per cent, respectively, in the vitamin A and
beta-carotene groups, leaving questions about the most
appropriate mix of nutrients, and the amounts needed, to
prevent the condition. No reduction in foetal or infant
mortality through six months of age was apparent in children
born to women in the study.

The scientists have not yet completed analysing the effects
of supplements on the different causes of maternal deaths.
However, deaths from infection are one important cause of
high maternal mortality rates, and vitamin A is known to be
essential for the effective functioning of the immune system
that reduces the severity of infection.

The results of this study indicate that where vitamin A
deficiency is common, the regular and adequate intake of
vitamin Ac or beta-carotene by women during their
reproductive years can markedly reduce their risk of
pregnancy-related  mortality. Adequate intake of vitamin A
may also dramatically reduce anaemia in pregnant women if
combined with deworming.

This study helps highlight the urgent need to improve the
nutrition of girls and women as part of a multi-pronged
approach to reduce the tragedy of maternal mortality in the
developing world and opens the way to new prevention
strategies that can be widely implemented in the near future.

************

NOTES

a. The low-dose supplements contained 7,000 microgram of
retinol equivalents (RE) (23,300 IU) of vitamin A, or a
similar amount of beta-carotene, which is  approximately
equivalent to a woman's weekly requirement.

b. Deaths were reduced from 713 per 100,000 pregnancies in
the group of women not receiving supplements to 443 and 354
deaths per 100,000 respectively in women receiving the weekly
vitamin A and beta-carotene supplements.

c. Although found in many foods,  vitamin A has powerful
biological effects and care is essential to prevent the 
misuse of supplements, especially by pregnant women.
High-dose (200,000 IU) vitamin A supplements of the type 
routinely provided at four to six monthly  intervals to young
children in developing countries should never be taken by
women of childbearing age because of the risk of possible
harm to a developing foetus. High-dose supplements may,
however, be safely given to women within eight weeks
following childbirth. Low-dose weekly vitamin A supplements,
like those given in this study, and even lower-dose daily
supplements can be taken by women during their  reproductive
years with little risk to mother or foetus and with
considerable benefit wherever deficiency is likely.

                         * * * *


Panel 2

What is malnutrition?

Malnutrition is usually the result of a combination of
inadequate dietary intake and infection (Fig. 6). In
children, malnutrition is synonymous with growth failure -
malnourished children are shorter and lighter than they
should be for their age. To get a measure of malnutrition in
a population, young children can be weighed and measured and
the results compared to those of a 'reference population'
known to have grown well. Measuring weight and height is the
most common way of assessing malnutrition in populations.

Although many people still refer to growth failure as
'protein-energy malnutrition,' or PEM, it is now recognized
that poor growth in children results not only from a
deficiency of protein and energy but also from an inadequate
intake of vital minerals (such as iron, zinc and iodine) and
vitamins (such as vitamin A), and often essential fatty acids
as well. These minerals are needed in tiny quantities, on the
order of a few thousandths of a gram or less each day. They
are con sequently called micronutrients. Micronutrients are
needed for the production of enzymes, hormones and other
substances that are required to regulate biological processes
leading to growth, activity, development and the functioning
of the immune and reproductive systems.

All of the minerals that the body needs - calcium,
phosphorous, iron, zinc, iodine, sodium, potassium and
magnesium, for example - have to come either from the food we
eat or from supplements. While the body manufactures many of
the complex organic molecules it needs from simpler building
blocks, the vitamins - A, the B complex, C and so on - are
not synthesized. Vitamin D is exceptional in that it can be
made in the skin, providing a person has sufficient exposure
to direct sunlight.

While micronutrients are needed at all ages, the effects of
inadequate intake are particularly serious during periods of
rapid growth, pregnancy, early childhood and lactation. We
are learning more every day about the importance of
micronutrients for the physical and the cognitive development
of children.

While widespread moderate malnutrition may not be obvious
unless children are weighed and measured, some severely
malnourished children develop clinical signs that are easily
observed - severe wasting (or marasmus) and the syndrome
known as kwashiorkor, with skin and hair changes and swelling
of arms and legs. Despite years of research, the reasons why
some children develop kwashiorkor and why others develop
marasmus remains a mystery. What is clear is that left
untreated, children with either condition are at high risk of
dying from severe malnutrition, and that both kwashiorkor and
marasmus can be prevented by ensuring an adequate intake of
nutritious food and freedom from repeated infections. Less
severe forms of malnutrition also cause death, mostly because
they weaken children's resistance to illness (Fig. 1).

The 1990 World Summit for Children singled out deficiencies
of three micronutrients - iron, iodine, and vitamin A - as
being particularly common and of special concern for children
and women in developing countries. Recently, knowledge of the
prevalence and importance of zinc for child growth and
development has placed it in that league as well. Vitamin D
deficiency is now recognized as a major problem of children
in countries such as Mongolia, the northern parts of China
and some of the countries of the Common wealth of Independent
States that have long winters.

Throughout this report, the term malnutrition is used to
refer to the con sequences of the combination of an
inadequate intake of protein  energy, micronutrients and
frequent infections.

                       * * * *


Panel 3

Stunting linked to impaired intellectual development


Malnutrition early in life is linked to deficits in
children's intellectual development that persist in spite of
schooling and impair their learning ability, according to a
recent study in the Philippines. The study analysed stunting
- which is low height for age and a basic indicator of
malnutrition - among more than 2,000 children living in
metropolitan Cebu, the Philippines' second largest city.
Nearly two thirds of the children studied were stunted. Those
stunted earliest in life, before six months of age, were the
most severely stunted by age two, the study found. The same
children scored significantly lower on intelligence tests at
8 and 11 years of age than children who were not stunted.

The study holds profound implications on a global level: 226
million children under age five in developing countries,
nearly 40 per cent of this age group, suffer from moderate or
severe stunting. "High levels of stunting among children
suggest that there will also be long-term deficits in mental
and physical development that can leave children ill-prepared
to take maximum advantage of learning opportunities in
school. This can also have consequences for children's suc
cess later in life," says Linda S. Adair, Ph.D., Associate
Professor of Nu trition at the University of North Carolina,
in Chapel Hill (US), one of the researchers.

"Stunting does not directly cause poor intellectual
development in children," emphasizes Professor Adair.
"Rather, the same underlying factors that cause stunting are
also likely to impair children's intellectual growth." Among
children in Cebu, the causes include low birthweight,
insufficient breastfeeding, nutritionally inadequate food
given to complement or replace breastmilk, and frequent
diarrhoea and respiratory infections. Stunted children tend
to enter school later and miss more days of school than
well-nourished children, the study also found.

The study, part of a collaborative research programme of the
Office of Population Studies at the University of San Carlos
in Cebu and the University of North Carolina, found that 28
per cent of the children surveyed were severely stunted. At
age two, these children were nearly 11 centimeters (5 inches)
shorter than children who were not stunted. The IQ scores of
the severely stunted children at eight years of age were 11
points lower than those of the children who were not stunted.


When the children in the study were tested again at age 11,
those who had been most severely stunted at age 2 still
scored lower on the intelligence test than children who had
not been stunted, although the gap was narrower at about 5 IQ
points. Children who were severely stunted also had
significantly lower scores on language and math achievement
tests.

Most of the children in the study were from poor families,
and their diets, and those of their mothers, were below the
nutritional levels recommended by the Philippine Government.
They came from densely populated, poor urban communities,
from newly settled areas on the outskirts of the city and
from rural communities.

This study underscores the importance and lasting impact of
nutrition in the crucial months of infancy and beginning
before birth with sound maternal nutrition. Infants denied a
strong start in life face problems in making up the lost
ground, and the impact on their own development and that of
their societies can be a lasting one.


The effects of stunting

In a non-verbal intelligence test given to eight-year-olds in
the Philippines, scores strongly correlated with children's
level of stunting at age two. Children severely stunted at
age two had the lowest test scores, while non-stunted
children had scores on average 11 points higher.

                   Level of stunting
                      (IQ score)

                    None       57.9 
                    Mild       53.3
                    Moderate   51.3
                    Severe     46.8


                         * * * *


Panel 4

Recognizing the right to nutrition

Nutrition has been expressed as a right in international
human rights instruments since 1924. Among these are
declarations, which are non-binding, and conventions and
covenants, which are treaties carrying the force of law.

Some of these human rights milestones are noted below.

1924: Declaration of the Rights of the Child (also known as
the Declaration of Geneva). Adopted after World War I by the
League of Nations through the efforts of British child rights
pioneer Eglantyne Jebb, the Declaration marks the beginning
of the international child rights movement and is also the
first international affirmation of the right to nutrition.
The Declaration affirms that "the child must be given the
means needed for its normal development, both materially and
spiritually" and states that "the hungry child should be
fed."

1948: Universal Declaration of Human Rights. This human
rights land mark, adopted by the United Nations General
Assembly, proclaims in article 25 that "everyone has the
right to a standard of living adequate for the health and
well-being of himself and of his family, including food,
clothing, housing and medical care and necessary social
services . . . ." This article also affirms that "mother hood
and childhood are entitled to special care and assistance."

1959: Declaration of the Rights of the Child. Adopted
unanimously by the United Nations General Assembly, the
Declaration states in principle 4 that children "shall be
entitled to grow and develop in health" and that children
"shall have the right to adequate nutrition, housing,
recreation and medical services."

1966: International Covenant on Eco nomic, Social and
Cultural Rights. Adopted by the United Nations and ratified
by 137 States as of mid-September 1997, this Covenant was the
first to spell out States' obligations to respect people's
economic, social and cultural rights. Article 11 affirms the
right of everyone to an adequate standard of living,
including adequate food, and the "fundamental right of
everyone to be free from hunger." The Covenant also mandates
States parties to take steps to realize this right, including
measures "to improve methods of production, conservation and
distribution of food."

1986: Declaration on the Right to Development. Article 1 of
the Declaration, which was adopted by the United Nations
General Assembly, proclaims that the right to development "is
an inalienable human right," with all people entitled to
participate in and enjoy economic, social, cultural and
political development "in which all human rights and
fundamental freedoms can be fully realized." Article 8 calls
for all States to ensure equal opportunity for all in access
to health services and food.

1989: Convention on the Rights of the Child. The most widely
ratified human rights treaty, the Convention establishes as
international law all rights to ensure children's survival,
development and protection. Article 24 mandates States
parties to recognize children's right to the "highest
attainable standard of health" and to take measures to
implement this right. Among key steps, States are mandated to
provide medical assistance and health care to all children,
with an emphasis on primary health care; combat disease and
malnutrition, with in the framework of primary health care,
through the provision of adequate nutritious foods, and safe
drinking water and adequate sanitation; and provide families
with information about the advantages of breastfeeding.

Ratifications: 191 States as of mid-September 1997, with only
two countries - Somalia and the United States - yet to
ratify.

1990: World Declaration and Plan of Action on the Survival,
Protection and Development of Children. The unprecedented
numbers of world leaders attending the World Summit for
Children committed themselves to "give high priority to the
rights of children" in the Summit's World Declaration. The
Summit's Plan of Action set out the steps in 7 major and 20
supporting goals for implementing the Declaration. Reducing
severe and moderate malnutrition by half of 1990 levels among
under-five children by the end of the century is the main
nutrition goal.

The 7 supporting  nutrition goals are: reduction of
low-weight births to less than 10 per cent of all births; 
reduction of iron deficiency anaemia in women by one third of
1990 levels; virtual elimination of iodine deficiency
disorders; virtual elimination of  vitamin A deficiency;
empowerment of all women to exclusively breastfeed their
children for about the first six months; institutionalization
of growth monitoring and promotion; and dissemination of
knowledge and supporting services to increase food production
to ensure household food security.


                          * * * *


Panel 5

Growth and sanitation: What can we learn from chickens?

Poultry farmers have known for some time that a chicken
living in a dirty environment is a chicken that grows poorly.
Even if it is not overtly sick all the time, it gains little
weight.

Is there a message here about the growth of children? Because
growth, like other nutrition outcomes, is deter mined most
immediately by diet and illness status, the answer, at least
in part, may be yes. Infectious illness - which spreads more
easily in unsanitary conditions - leads to poorer dietary
intake and poor use of the nutrients ingested. This, in turn,
leads to lower resistance to infection, and so on, in a
vicious diet-infection cycle (Fig. 6).

Now studies suggest that an unsanitary environment may have
effects beyond those associated with particular bouts of
illness. Researchers believe that children living in such
conditions may suffer from a fairly constant, low-level
challenge to their immune systems that impairs their growth,
as has been shown in domestic fowl. Dr. Noel Solomons of the
Centre for Studies of Sensory Impairment, Aging and
Metabolism and colleagues suggest that along with classifying
children as healthy (having no clinical illness) and acutely
infected (with signs of illness readily detectable), there is
also a category of "inapparently infected." Children who are
inapparently infected have no signs of clinical illness but
do have abnormal levels of some immunological indicators.
Such inapparent infections and the chronic low-level
stimulation of the immune system associated with life in
unsanitary conditions may mean that nutrients go to support
the body's immune response rather than growth.

Poverty occurs in both South Asia and sub-Saharan Africa, but
rates of malnutrition, especially stunting, are much higher
in South Asia. A number of hypotheses have been advanced to
explain this difference, and one is that it is due to poorer
sanitation and hygiene practices, the much greater population
density and degree of overcrowding in South Asia.

Certainly, the dangers posed by poor access to potable water
are well known. A recent review of data collected by the Dem
o graphic and Health Surveys, a USAID-supported project,
indicates that health and nutrition benefits from improved
sanitation, especially improved ex creta disposal, may be
even greater than those associated with better access to safe
water alone.

A group led by Dr. Reynaldo Martorell of Emory University
(US) has designed a study to shed light on the relationship
between sanitation and growth stunting. This study would
follow 800 children in two locations in South Asia and 800
more in two locations in sub-Saharan Africa from the time
their mothers become pregnant to when they are two years old
and would collect a wide range of information on sanitation,
hygiene practices and other aspects of the house hold
environment. The children's growth would be measured
frequently along with indicators of feeding practices, diet
quality, illness and many other factors. UNICEF is helping to
secure funds for this study.

Establishing a link between sanitation conditions and child
growth in a cause-and-effect way will go a long way to
clarifying priorities for action in this area. Such a link
will also  reveal just how useful the 'dirty chicken' model
is for understanding stunted growth among children.


                       * * * *


Panel 6

Breastmilk and transmission of HIV

Breastfeeding confers enormous benefits, preventing
malnutrition and illness, saving lives and money. It is also,
however, one way an HIV-positive mother could transmit the
virus to her infant. A child stands the greatest risk -
believed  to be 20 per cent - of vertical or mother-to-child
transmission during the time of late pregnancy and
childbirth. There is an additional 14 per cent risk that an
infant will become infected through breastmilk.

This risk of infection through breastfeeding needs to be
weighed against the great dangers posed by artificial
feeding: In communities where sanitation is inadequate and
families are poor, death from diarrhoea is 14 times higher in
artificially fed infants than in those who are breastfed. If
HIV-positive women and those who fear HIV (without actually
being infected) were to abandon breastfeeding in large
numbers, with out safe and reliable alternatives for feeding
their children, the ensuing  infant deaths from diarrhoea and
respiratory infections could vastly outnumber those from HIV.

The dilemma facing an HIV-positive woman who does not have
easy access to safe water, who does not have enough fuel to
sterilize feeding bottles and prepare alternatives to
breastmilk, or who cannot afford to buy sufficient formula to
ensure her child's nutrition is a wrenching one that no
mother can solve on her own. Support for women facing this
dilemma is imperative, as the Joint United Nations Programme
on HIV/AIDS (UNAIDS) made clear in 1996. The following
measures are important starting points:

*    Pregnant women should have access to voluntary and
confidential counselling and testing to determine their
health status. If they are HIV positive, they should receive
appropriate treatment to  reduce the risk of vertical
transmission. If they are HIV negative, health education is
vital to help them and their partners remain that way.

*    HIV-positive mothers should be informed of the risks of
both vertical transmission through breastfeeding and
infections associated with artificial feeding in their local
environment. Each woman should be assisted by HIV counsellors
or health professionals to understand these risks and then
make her own decision.

*    If an HIV-positive mother has access to adequate
breastmilk substitutes that she can prepare safely, then she
should consider artificial feeding. Other alternatives
include wet-nursing by an HIV-negative woman, which may be
acceptable in some cultures. Heat treatment of expressed
breast milk (62.5°C for 30 minutes) destroys the virus, which
may be a good choice for some women.

*    When mothers who test positive for HIV choose not to
breastfeed but are unable to or cannot afford feeding
alternatives, help will be needed from a range of parties,
including governmental and partner agencies. Attention must
be paid to the needs of the most disadvantaged women, which
include improved water and sanitation and attentive family
health care.

These measures should be part of an integrated strategy to
reduce vertical transmission since breastfeeding is only a
small part of the problem. Access to voluntary, confidential
testing and counselling is key to any strategy to reduce
vertical transmission. Access to a range of prenatal and
obstetric care measures associated with reduced transmission
risk is also essential.

Studies now in progress will soon give a better understanding
of the mechanisms, timing and risks of vertical transmission.
It may be possible in a few years to offer all women
low-cost, easily delivered services that will minimize or
even eliminate the risk of vertical transmission. For now,
access to the testing, counselling, information and other
services noted above should be high priorities.

                        * * * *


Panel 7

High-energy biscuits for mothers boost infant survival by 50
per cent

In the Gambia, well-targeted interventions to improve the
nutrition of pregnant women are making a difference in the
birthweight of their babies, and at the same time sharply
reducing the risk of babies dying during, or shortly after,
birth.

A large, controlled study in the country's rural West Kiang
region has determined that the number of low-birthweight
babies fell by nearly 40 per cent and that stillbirth and
perinatal mortality rates in infants were almost 50 per cent
lower when pregnant women received a daily ration of locally
prepared, energy-rich biscuits. These remarkable results
strengthen the argument for providing food supplements to
pregnant women to reduce low birthweight.

"The study clearly demonstrates that improved maternal
nutrition, deliverable through a primary health care system,
can have highly beneficial effects when efficiently targeted
at women in genuine need," says one of the study's authors,
Dr. Sana Ceesay, of the Dunn Nutrition Centre affiliated with
the University of Cam bridge, which has been working in
partnership with the Gambian Health Department. The findings
were published in the British Medical Journal in September
1997.

UNICEF estimates that each year over 24 million babies are
born below the low-birthweight threshold of 2.5 kg, and that
95 per cent of these births occur in the developing world.
Low birthweight puts infants at a greatly increased risk of
neonatal death and is an important cause of poor growth and
development in later childhood. It can be due to a number of
factors, including a woman's small size, uterine infections,
smoking, low oxygen levels in the blood (due to excessive
work or high altitude) and malarial infection. However, when
all these factors are equal, the incidence of low birthweight
is higher in economically deprived mothers than in affluent
ones.

The most likely explanation for the difference is that
inadequate  maternal nutrition suppresses foetal growth. It
has often been difficult, nevertheless, to show real benefits
to infants from improvements to a mother's diet during
pregnancy. The study in the Gambia provides such evidence.


In this part of West Africa, previous studies had indicated
that pregnant women - challenged as many women are by the
high energy demands of water and fuel collection,
agricultural work and child-care activities but also by the
energy and other nutrient needs of pregnancy - did not eat
enough or well enough to meet all these needs. The growth of
their babies was thus threatened.

The five-year, prenatal supplementation trial covered 28
villages in one region of the Gambia. In the intervention
villages, pregnant mothers received daily high-energy
groundnut-based biscuits, providing 1,000 kcal/day on average
after 20 weeks of pregnancy. The biscuits were made from
local ingredients and were baked by two village bakers in
traditional clay ovens. Women in control villages received
antimalarials, iron/folate supplements and antenatal care as
did women in the intervention villages, but they did not
receive the biscuits during pregnancy. Field workers weighed
all the women in the study at regular intervals, and weighed
and measured all infants at delivery.

The biscuit supplement caused a highly significant increase
in birthweight, reducing the numbers of infants classified as
low birthweight by 39 per cent. Particularly noteworthy was
the reduction in low birthweight occurring in births during
the annual 'hungry season', when birthweights normally are
lower than in the harvest season, as a result of poor
maternal nutrition combined with hard seasonal agricultural
work. (It is unlikely that food supplements would have the
same impact on pregnant women who are not chronically
energy-deficient.)

In addition to these remarkable benefits, this study refutes
the idea prevailing in some circles that improving the diet
of pregnant women will cause them to suffer higher rates of
obstetrical complications because of the larger size of their
newborns. Birthweight was indeed higher in the children of
women who received the biscuits, but head circumference,
which is the factor more closely related to pelvic
disproportion in birth, was only slightly greater. The rate
of obstetric complications of this kind was not higher in the
supplemented women.

                        * * * *


Panel 8

UNICEF and the World Food Programme

The World Food Programme (WFP), the food aid organization of
the United Nations system, began operations in 1963 and is
now the largest such organization in the world. WFP responds
to food needs associated with emergencies and development,
often working with the other two Rome-based agencies, the
Food and Agriculture Organization of the United Nations (FAO)
and the International Fund for Agricultural Development
(IFAD).

WFP provides three broad categories of food aid: emergency
rations for victims of natural and man-made disasters
(Food-For-Life); food aid distributed through health clinics,
schools and other community centres to particularly
vulnerable groups (Food-For-Growth); and food rations
provided in exchange for work on development projects
(Food-For-Work). In all three categories, much of WFP's work
is linked to the priorities and efforts of UNICEF.

The link between the two sister agencies goes beyond
organizational coordination. Their work is complementary, and
they share common goals. Both recognize that children are at
once the most vulnerable group in society - and yet the
future of every community. Together, the two agencies have
the tools to attack malnutrition, helping to ensure access to
adequate nutrition, with food, health and care, and to fight
with a unified voice for the elimination of hunger.

In crisis situations requiring Food-For-Life assistance,
UNICEF and WFP collaborate to provide therapeutic and
supplementary feeding to save the lives of young children
during emergencies, as occurred in the recent past in the
countries of former Yugoslavia. They also share logistics
capacity, for example in Uganda, where WFP stored UNICEF's
health kits and supplementary feeding supplies, subsequently
transporting them to Rwanda during the sudden return of
refugees in late 1996. And they cooperate in making joint
assessments of the problem of inadequate nutrition and
priority needs for addressing it, as in the case of the
Democratic People's Republic of Korea, where a nutrition
assessment was completed in September 1997. In southern
Sudan, the two agencies, together with NGOs and counterparts,
lead an annual needs assessment mission, which not only
examines food security but also 'health security', based on
nutritional status and access to health services.

UNICEF and WFP also work together on post-conflict projects,
such as the demobilization of child soldiers. In Bukavu, in
eastern Democratic Republic of the Congo, WFP provides food
to a centre set up by UNICEF to help children who fought in
the civil conflict reintegrate in society.

Food-For-Growth, the cornerstone of one of WFP's major
priorities, is particularly close to the concerns of UNICEF.
This type of food aid is  designed to provide assistance to
mothers and children and other vulnerable groups at critical
times in their lives. In Zambia, UNICEF worked closely with
WFP in 1994 to ensure that a food supplement, aimed at pre
venting malnutrition in young children during prolonged
drought, was appropriately formulated and fortified. The
high-energy protein supplement was used as part of a
coordinated programme to provide both food and health care to
children judged to be at particularly high risk of
malnutrition.

In Madagascar, UNICEF and WFP work together to rehabilitate
schools in the poorer regions of the south. UNICEF provides
school kits and equipment, and WFP contributes school meals.

The two agencies also work together on Food-For-Work projects
when such aid dovetails with UNICEF mandates. In Malawi, for
example, following the introduction of free primary education
in 1994, WFP and UNICEF later designed a school feeding
programme with the aim of 'Keeping kids in school'. Mothers
of schoolchildren are 'paid' a food allocation in exchange
for the preparation of school meals.


                         * * * *


Panel 9

Triple A takes hold in Oman

Over the last 27 years, Oman has made great strides in child
survival and development. Child mortality dropped from 215
per 1,000 live births in 1970 to 25 in 1995. School
enrolment, particularly among girls, has increased
dramatically. Revenues from oil have pro vided an economic
foundation-Oman's GNP per capita in 1995 was $4,820 - but
these gains would not have been possible without the
Government's commitment to improving people's lives.

Progress has been slower, however, in terms of child
nutrition. The Ministry of Health, with support from UNICEF,
has been working to address this challenge since 1993. To
improve children's nutritional status, a community-based
programme of growth monitoring, counselling and nutrition
education was devised. A particular focus is 105 villages of
Al Dakhiliya, an arid, rocky region in upper-central Oman
where a 1995 survey found that nearly one third of the
children under the age of five were underweight.

The results to date are impressive. Since the project's
inception, there has been a significant drop in the number of
underweight children, according to an appraisal in 1996.
Later the same year another appraisal described the project
as well focused, effectively managed and clearly building a
momentum towards nationwide nutritional improvement.
Motivation, commitment and participation were high among
mothers and community volunteers. And women enjoy the
opportunity the programme offers to meet together and find
common ground in helping their children grow better.

The driving force of the programme is called 'triple A':
three consecutive steps in a problem-solving cycle of
Assessing the problem, Analysing its causes and initiating
Actions to improve children's nutrition. Triple A is an
iterative process that repeats the cycle of reassessment,
re-analysis and re-action, leading to regular modifications
and improvements in the approaches taken.

True to this model, the people of the small villages and
nomadic or semi-nomadic settlements of Al Dakhiliya were
involved from the very start, attending meetings to identify
the problems, discuss solutions and select from among
themselves the volunteers who would be central to the effort.

Every month throughout the region, at public meetings or
during visits to homes, these volunteers weigh children and
chart their growth, referring severely underweight children
to health care centres. They advise families on how to feed
children and to improve caring practices, on how to keep
children healthy and manage illness when it occurs and on how
to space births. They also reinforce other public health
activities, encouraging pregnant women to register early for 
antenatal care, for example, and helping in community
immunization campaigns and national health days.

Regional trainers were brought in to teach the volunteers
about the incidence and causes of malnutrition, and how to
improve and support appropriate feeding and caring practices,
using the triple A methodology to solve problems. A programme
coordinator at the regional level links the communities with
programme support structures at the national level and
supervises, monitors and trains trainers. There are programme
coordinators at the district level as well. Finally, back-up
support for the volunteers is provided by teams of health
staff from nearby health centres.

A nutritional monitoring system has also been created: At the
monthly weighing sessions, the volunteers fill out forms for
all children, recording their age and weight. The information
on the nutritional status of all the children in a village
goes on the form volunteers send every month to the district
health supervisor, who then reports the status of the
district's children to the regional coordinator.

The tangible change for families and children in Al Dakhiliya
has been so positive that the programme is being expanded to
additional villages in the region and has been introduced in
another five regions of the country.

                        * * * *

Panel 10

Celebrating gains in children's health in Brazil

Residents of the Morro de Ceu slum in Rio de Janeiro normally
have little time for celebrations. But on a recent Saturday
afternoon, 40 mothers, their children and community leaders
affiliated with the Brazilian Child Pastorate gathered under
the trees outside a parish hall. The community leaders set
the children one by one on a scale, re cording their weight
in notebooks and consulting with the mothers on any nutrition
or health problems. The weighing over, the occasion turned
festive. Community leaders brought out trays of home-baked
cakes and cookies; the yard filled with conversation and
laughter and the happy shrieks of children at play.

The Child Pastorate's success in protecting the health and
development of poor children in Brazil is definitely cause
for celebration. The Pastorate estimates that in the
communities where the programme is in place, the malnutrition
rate among children under five does not exceed 8 per cent,
compared to 16.3 per cent nationally as found in a 1996
Demographic and Health Survey applying the same criteria*.
Additionally, the Child Pastorate estimates that the
incidence of low birthweight babies is 6 per cent in
communities it assists, while the incidence is 9.2 per cent 
nationally.

The Child Pastorate is one of the largest NGOs in the world
devoted to child health, nutrition and development. Its aim
is to empower the poor both to improve their children's lives
and to participate in transforming their communities and
their country.

The National Conference of Brazilian Bishops founded the NGO
in 1983, with efforts beginning in one community in Parana
state. Now the Child Pastorate operates in 22,000
communities, in cities large and small, as well as in rural
areas, and serves 2.1 million families, including over 3.1
million children under the age of six and nearly 144,000
pregnant women.

The Pastorate's nearly 83,000 community volunteers, mainly
women, are the backbone of the programme, working directly
with 10 to 20 families in their neighbourhoods. "They are
like shepherds, looking after their communities," says Dr.
Zilda Arns Neumann, a paediatrician and the national
coordinator of the NGO since its inception. Community leaders
are trained in basic child and maternal nutrition and health
skills, including monitoring growth, tracking immunizations,
supporting breastfeeding, treating diarrhoea with oral
rehydration therapy (ORT) and preventing and detecting
pneumonia.

The Pastorate makes nutrition a community issue: Families get
help, encouragement and support from neighbours in improving
their children's well-being. Community leaders visit the
homes of children who are malnourished, monitoring their
weight frequently and referring families to local health
facilities if necessary. They screen pregnant women for
indications of malnutrition and refer them to medical
facilities for pre natal care and delivery, and after birth,
support for breastfeeding is a main priority. Families also
learn how to prepare nutritious meals with low-cost
ingredients that are available locally. The Pastorate
promotes child development through play and activities to
improve speech and motor skills; its basic education
programme serves 46,000 teenagers and adults.

The Child Pastorate's work is guided by a four-part
methodology. The first three - 'see' (observe the situation),
'judge' (define the causes) and 'act' (take action based on
the causes) - are similar to UNICEF's triple A approach. The
fourth is 'celebrate' (rejoice in the gains made in
children's nutrition and health).

The Child Pastorate uses its partnerships - with the
Government at all levels, with other NGOs and with the media
- to maximum effect, planning budget and activities to
complement those of the Ministry of Health. It works through
municipal councils to help maintain public services in
communities, from the quality of tap water to health services
to education.

The broadcast media are strong allies. Nutrition and health
messages developed by the Child Pastorate are aired on a
15-minute radio programme, Viva a Vida (Enjoy Life), once or
twice a week by 910 radio stations. Since 1995, the Child
Pastorate has received about one quar ter of the proceeds of
the annual fund-raising television campaign 'Crianca
Esperanca' (Child Hope), sponsored by UNICEF and Globo TV, to
assist municipalities with high infant mortality rates
through out the country. The  Pas tor ate estimates that in
the campaign's first year, malnutrition declined by 14 per
cent in the municipalities featured on the programme.

The Child Pastorate is able to operate at low cost, in part
because of the considerable efforts of its volunteers and the
logistical net provided by the Catholic Church. Training,
transportation and other support for the programme's
community leaders are among the main expenses. The Child
Pastorate received assistance from UNICEF in its early years.
Since 1987, the Brazilian Ministry of Health has provided
support, with additional funds raised from the private
sector.

                      * * * *


Panel 11

Rewriting Elias's story in Mbeya

My name is Elias. I am two-and-a-half years old and I live on
the outskirts of Mbeya with my mother, father, two older
brothers and an older sister.

We are poor and our house has no toilet. My mother gets up
early to fetch water from the river since our house has no
tap. Then she goes to her farm plot, leaving me with my
sister, Sophia, who is seven. Sophia collects firewood and
does other chores for my mother, so she doesn't have much
time to spend with me.

When my mother returns from her plot, she cooks a meal,
usually maize porridge. Last year my mother grew enough
maize, but this year she had to sell some to get money to buy
other things. Now she says she doesn't know what we will eat
when our maize stock runs out.

When I was younger, my mother breastfed me. Since she
stopped, I have often been ill with fevers and diarrhoea.
When I last had a fever, the nurse at the dispensary said it
was probably malaria. My mother bought medicine but I didn't
get better. Now I feel very ill and I don't have much energy.
 
    - From a drama staged by HANDS' community organizers

Elias's story is a cautionary tale of how poor sanitation,
the cessation of breastfeeding, disease and poverty converge
all too often in malnutrition or even death for young
children. The Health and Nutrition District Support (HANDS)
project is helping people in Mbeya, a large urban centre in
south-west Tanzania, rewrite this tale with a healthier, 
happier ending for their children. Launched by the Tanzanian
Government in 1992 with support from the United Kingdom
Overseas Development Administration, HANDS' success has been
impressive.

Moderate malnutrition in children fell to 22 per cent in 1995
from 33 per cent in 1992, and severe malnutrition dropped to
0.4 per cent from 3.3 per cent in areas where HANDS operates.
In contrast, malnutrition increased by 7 percentage points
among children under five in Mbeya as a whole.

In the same period, in HANDS' areas, the percentage of
pregnant women with anaemia declined from 37 per cent to 33
per cent, and the incidence of low birthweight was also
reduced. Ninety-nine per cent of children between the ages of
one and five were fully vaccinated, up from 86 per cent. The
proportion of households with access to safe water increased
from 60 to 96 per cent, and those with pit latrines from 75
to 92 per cent. In all, about 125,000 people benefited
directly and indirectly.

An important strategy of HANDS lies in careful targeting: The
project focuses on areas with the highest levels of child
malnutrition and infectious diseases, lowest levels of
domestic sanitation and most limited access to health
facilities. Equally important, the community has been
intimately involved, from planning through implementation and
management, with evaluation. The poor identified their
priorities and became partners with government staff in 
implementing a range of health-enhancing  development
activities.

Donor support has been critical in providing training,
essential equipment and transport. An investment was also
made in council and community development funds, enabling the
council to improve health services and access to safe water,
upgrade sanitation and promote household hygiene in targeted
areas.

Revitalized maternal and child health services in the
community now are responsible for child vaccination,
antenatal and post-natal care, family planning, diarrhoeal
disease control, treatments for common childhood illnesses
and growth promotion activities. Health and nutrition
education activities are stronger and focus on children's
vulnerability during the period when complementary foods are
being introduced, on the nutritional needs of pregnant women
and on home-based oral rehydration therapy. Outreach services
now support households with malnourished children, and
community-based day-care centres have improved the well-being
of young children.

Four new water schemes serve over 50,000 people, and three
health centres were upgraded, now reaching 80,000 people.
Affordable latrines and basic hygiene are promoted, and
innovative work is being done on low-cost public  toilets.

Thanks to seminars, formal training and drama sessions run by
Tanzanian women lawyers, the rights of women and children are
higher on the public agenda. A subsequent survey found that
fathers are making greater contributions to child welfare.

The HANDS project is now in a second phase: Tanzanians have
replaced international staff, and project management lies
with local council committees. The commitment and
participation of local government staff and community members
indicate that the project is sustainable.


                        * * * *


Panel 12

Women in Niger take the lead against malnutrition

Better seeds and fertilizer, a diesel-powered mill and two
donkey carts: With these modest improvements, women in Kwaren
Tsabre, a village in central Niger, are lessening their
workloads and beginning to overcome the widespread
malnutrition threatening their children.

The problems seemed intractable just a few years ago. Over
half the young children in the village of 680 inhabitants
were underweight, and many showed signs of serious vitamin A
deficiency-which can lead to blindness and death.

Progress is being made thanks to a close partnership between
the community and district-based government agents, founded
on the people's own assessment and analysis of their
situation. The problems were acute: As in many villages in
the heart of the Sahel region in West Africa, Kwaren Tsabre
experienced chronic shortages of staple foods; diets lacked
richness and diversity; women were grossly overworked and had
little access to education and information; and health
services were remote and often of poor quality.

Because women were most seriously and directly affected, it
was necessary to put them at the centre of decision-making
and have them benefit from the new initiatives. A women's
group - the Village Women's Committee - was formed, with
members trained by government agents in the district. The
first step, as Zouera, the first President of the Committee,
explained, was to identify actions that could bring about
measurable improvements in nutrition.

"We realized that because our workdays were so long - between
14 and 17 hours - we couldn't care for our children as well
as we wanted to," she said. Getting a loan for a diesel mill
to relieve the women of the  arduous task of hand-pounding
sorghum and millet was one response. Another was to purchase
two donkey carts to reduce the hours spent carrying wood and
water. Both mill and carts save time and generate income: The
villagers of Kwaren Tsabre and their neighbours from miles
around agreed to pay modest fees to grind grain and use the
carts.

With technical help, better irrigation and improved seeds and
fertilizer, staple crop yields have nearly tripled and new
vitamin A-rich foods are also being produced, including
amaranth and baobab leaves. The women incorporated these
vitamin A sources and small amounts of oil into their usual
meals and soon began noticing a decrease in night-blindness
(a symptom of vitamin A deficiency) among their children.
Women in neighbouring villages have reported that
night-blindness has also been  reduced among pregnant women.

Zouera and her colleagues in the Committee also decided, in
consultation with government technical staff, to set up a
cooperative cereal bank. This bank purchases and stores grain
safely after the harvest and gives poor families a place to
buy grain at reasonable prices during pre-harvest seasons,
when they cannot afford the market price.

In a short time, the cereal bank paid for itself and even
turned a profit. "With this money we're subsidizing other
activities, such as the distribution of peanut butter as a
complementary food for very young children who are still
breastfeeding," Zouera said. The Committee also gives a small
cash bonus to the women who supervise the regular growth
monitoring of children. The monitoring enables women to see
for themselves what is happening with their children, and
they can use the information to analyse and act on problems
in their own homes and community.

Children's malnutrition rates in Kwaren Tsabre have fallen by
10 percentage points in a short time between 1995 and 1996.
And this is only the beginning. Poor-quality and inaccessible
health services are still a problem and an impediment to
further gains against malnutrition.

But the women of Kwaren Tsabre now know that they have the
tools and a process for addressing even that difficult
problem with the help of their partners. Multiply the
achievements of Kwaren Tsabre by the 326 villages across the
Maradi Province of Niger into which this programme has
spread, and one begins to see victory emerging in the age-old
battle against child malnutrition.

                     * * * *


Panel 13

BFHI: Breastfeeding breakthroughs

Smiling at her infant in her arms, Elba Diaz awaits Juanito's 
six-month check-up at a primary health care centre in
southern Santiago. Her third child draws nothing but
compliments from health workers, unlike Ms. Diaz's first two
children, who were not so healthy. The difference is that
Juanito - born at the Barros Luco Hospital, one of 19
baby-friendly hospitals in Chile - is the only child she has
been able to breastfeed exclusively.

"Immediately after Juanito was born," recalls Ms. Diaz, "he
was laid on my body. Words can't describe how blissful I was,
feeling his warmth and looking at his flushed face so close
to me. I began nursing him at the breast while we were still
in the delivery room, and he was beside me always, receiving
only my breastmilk."

In Chile, breastfeeding support and counselling for mothers
have led to enormous health benefits for tens of thousands of
children like Juanito in little more than a decade. In 1985,
only 4 per cent of infants were exclusively breastfed for the
first six months of their lives. Remarkably, only a year
after the Baby-Friendly Hospital Initiative (BFHI) was
launched in 1991, a study of 9,200 infants nationwide showed
that the rate had risen to 25 per cent. And preliminary
results of a national survey in 1996 suggest that the
exclusive breastfeeding rate for the first six months is now
about 40 per cent.

What lies behind this transformation? Training is an
important part of the answer. With support from the NGO
Wellstart International and UNICEF, training materials were
adapted, and in just four years over 7,500 health workers
learned to help women breastfeed effectively. Strong support
from the Ministry of Health was another factor, and UNICEF
provided sustained advocacy. The National Breastfeeding
Commission, organized in 1992, has also kept breastfeeding
high on Chile's child health agenda.

Another effective measure was expanding 'baby-friendly'
practices into primary health care centres, where trained
staff offer breastfeeding education and support. "The staff
acquainted me with breastfeeding during my pregnancy," said
one mother. "The first week after delivery, I joined a group
session at the clinic to share my concerns with other
breastfeeding mothers. I feel very secure, having easy access
to professional advice on any breastfeeding questions."

These achievements in Chile have been replicated across the
world through BFHI and related efforts. In Cuba, only about
63 per cent of newborns were breastfed exclusively at the
time they left the hospital in 1990. Now, six years after
BFHI was introduced, an estimated 98 per cent of newborns are
exclusively breastfed when they leave the maternity ward. And
more strikingly, about 72 per cent of those infants are
exclusively breastfed through four months of age, up from 25
per cent in 1990. All 44 hospitals handling over 1,000
deliveries a year and 42 per cent of smaller hospitals in the
country are baby-friendly. In 1996, Cuba extended the
baby-friendly programme to the community level by putting it
into practice at small community health centres attended by
family doctors.

On the other side of the globe, China had over 6,300
baby-friendly hospitals at the end of 1996. Thanks to BFHI
and some regulation of the marketing of breastmilk
substitutes, 48 per cent of infants in urban areas and 68 per
cent in rural areas are now exclusively breastfed for four
months, a 1994 survey found. Just two years earlier, the
rates were 10 and 29 per cent respectively. Considering that
about 20 million infants are born each year in China, this
represents a remarkable accomplishment.

Iran, which began promoting breastfeeding in the 1980s, has
held training workshops for over 30,000 health professionals
each year between 1991 and 1996 after BFHI was introduced.
The national support has led to a leap in the exclusive
breastfeeding rate from 10 to 53 per cent in that period. An
added windfall is the more than $50 million that the country
saves annually, as infant formula imports dropped by 75 per
cent from 48 million tins in 1991 to 12 million in 1996.

Because of the many benefits of breastfeeding since BFHI
started, it is impossible to calculate the lives saved and
those made better - though they certainly number in the
millions. It is difficult to imagine any other way in which
these results could have been achieved so effectively and in
such a short time. Baby-friendly hospitals have surely made
the world a friendlier place for babies and their families.


                       * * * *


Panel 14

Tackling malnutrition in Bangladesh

A new project in Bangladesh is helping to reduce malnutrition
among children and mothers by improving caring practices,
supporting breastfeeding and empowering women and their
communities.

Some 56 per cent of Bangladeshi children under five suffer
from moderate and severe malnutrition, 21 per cent of whom
are severely underweight, and studies show that more than 70
per cent of pregnant and breastfeeding women are also
malnourished. Protein-energy malnutrition is the main problem
but, as often happens, it occurs together with such
conditions as iron deficiency anaemia and vitamin A
deficiency. In Bangladesh, lack of food is not the main cause
of malnutrition; the lack of proper caring practices for
children and pregnant women is an important contributing
factor.

Recognizing that malnutrition is hindering national
development, the Government has formulated a National
Nutrition Policy and launched a nationwide nutrition
intervention programme, the Bangladesh Integrated Nutrition
Project. The initiative aims to address malnutrition directly
and help promote faster socio-economic development.

Community nutrition promoters are the backbone of the
project. Earning about $12 a month, they are trained for two
months, including one month on the job. They learn how to
understand the causes and signs of malnutrition and
techniques for its treatment and prevention. They canvass
their communities, persuading mothers to bring their children
to the Community Nutrition Centres for monthly weighing and
growth monitoring, and explaining the importance of child
care, including children's needs for exclusive breastfeeding
in the first six months; the need for smaller, more frequent
and nutritious meals up to age three; and for extra feeding
during and after illnesses to prevent malnutrition.

Marium Begum, one of the nutrition promoters, has already
started to achieve results in her village. During growth
monitoring sessions at her Community Nutrition Centre,
situated in one of the homes in her village, Ms. Begum could
see that Shewli, a one-year-old girl, was suffering from
severe malnutrition. Ms. Begum explained to Shewli's mother,
Shamsun, how to give her daughter a special locally made diet
supplement. She also helped Shamsun to understand that she
had been unable to breastfeed because she had not been eating
enough herself. Following local tradition, Shamsun was
accustomed to eating last, after serving food to her family,
and there was often little food left. Ms. Begum  explained
how to re-lactate - that is, to resume lactation after it has
stopped for some time - and arranged for intensive
counselling at the Community Nutrition Centre.

Improving the nutrition of adolescent girls and pregnant and
lactating women is another priority of the project. The
nutrition promoters urge women to use iodized salt in their
households to prevent iodine deficiency disorders, and to use
oral rehydration therapy when a child has diarrhoea to
prevent dehydration. They discuss the use of vitamin A and
iron supplementation.

Special diet supplements are provided to malnourished women
and children. Village Women's Groups, comprising up to 11
volunteers in each community, buy ingredients for the
supplement - a carefully weighed mixture of rice, lentils,
molasses and oil - at local markets to prepare and package
them. Each member of the group earns about $10 per month
through the sale of packets to the nutrition centres.

The Ministry of Health and Family Welfare, with the
assistance of the Bangladesh Rural Advancement Committee
(BRAC), has established nearly 1,000 Com munity Nutrition
Centres in people's homes, each operating six days a week.
The centres cover 65,000 children and 16,000 pregnant and
lactating women. By the year 2001, the goal is to have 8,000
community nutrition promoters reaching 100,000 pregnant or
lactating women and 500,000 children under the age of two.

In the case of Shamsun, her diet has improved with the
guidance and encouragement of Marium Begum. She was able to
breastfeed her daughter, complementing the breastmilk with
normal family food and the special dietary supplement. And
instead of selling the eggs her six hens lay, she feeds them
to her family. Shewli, although still small and thin, has
resumed healthy growth.


                        * * * *


Panel 15

Kiwanis mobilize to end iodine deficiency's deadly toll

Hundreds of times during the past several years, the Reverend
Bob Wildman, a retired Protestant pastor, has ambled into
Kiwanis International Club meetings all over Illinois and
eastern Iowa in the Mid western United States. Usually, he is
granted only a few minutes to win over some very tough
audiences.

Many of the men and women who make up these Kiwanis clubs are
business executives and professionals who have supported the
organization's service projects helping children and others
in need in their own communities. The 73-year-old Rev.
Wildman, a veteran Kiwanis leader, is determined to expand
their notion of neighbourhood to include the global village.

He has added his preacher's voice to the Kiwanians' first
international service project: the campaign to wipe out one
of the world's most devastating nutritional problems - iodine 
deficiency disorders (IDD). Kiwanis leaders have brought to
this global effort the fund-raising muscle of their 600,000
members in 83 countries.

An estimated 28 million babies are born each year at risk of
mental impairment due to insufficient iodine in their
mothers' diets. Hundreds of thousands of children and adults
suffer the most debilitating effect of iodine deficiency: a
condition known as cretinism.

Rev. Wildman's challenge has been to make club members in his
area care about villagers in remote regions of Africa, Asia
and Latin America. In many developing countries, lack of
iodine has taken a horrendous toll on children - from
physical deformities to mental retardation. Iodization of
table salt - a method of fortification now taken for granted
in industrialized nations and costing less than 5 cents per
person per year - can rid the world of this tragedy.

Before he speaks, Rev. Wildman places on the podium a
poster-sized copy of a cherished photo of a tiny boy named
Abdul Alim - whom he met in a 1994 visit to a village in
Bangladesh. Abdul is an eight-year-old in a four-year-old's
deformed and malfunctioning body. He is profoundly mentally
retarded and deaf and is held by a young man from the village
because he cannot walk.

Rev. Wildman describes Abdul's disabilities and the severe
hardships his care places on a village economy. The picture
of this small child bridges geographical and cultural
divides, and soon his audiences are ready to climb on the IDD
campaign bandwagon.

When Kiwanis International joined the campaign against IDD in
1994, they pledged to raise $75 million by July 1998. Since
then, they have become a key part of the campaign, with over
$20 million raised or pledged so far for programmes in over
50 countries through Kiwanians' efforts. UNICEF estimates
that this contribution has saved around 3 million children
from irreversible mental retardation.

Kiwanis leaders like Rev. Wildman have been shrinking the
distance between their home towns and places like Abdul
Alim's tiny village in Bangladesh, and the concept of
thinking globally while acting locally is taking hold in
creative ways around the world.

The Kiwanis Club of Red im Encrust in Austria staged a
performance of the Chinese Dance and Acrobats Ensemble, for
example, raising $9,000 for the DID campaign. Canines in
Atikokan in Ontario (Canada) brought in the Jolly Ukranians,
a folk group, netting the campaign $2,000. Kiwanis Clubs in
the Philippines are supporting the campaign in their own
country, where  iodine deficiency is still a threat, through
community education projects and the distribution of iodized
salt.

Kiwanians in the Netherlands have pledged to raise $600,000
through the sale of salt pots and a photo essay book. Hong
Kong Kiwanians took in $10,000 for the campaign by obtaining
sponsorships for completing a rugged 60-mile hike. The
Kiwanis Club of Bergerac (France) donated proceeds from a
masked ball, while Kiwanians in Christchurch (New Zealand)
raised $1,300 with a bowling tournament. The Kiwanis Club of
Spanish Town (Jamaica) convinced a local salt factory to
iodize salt, sponsored IDD education events and set up an IDD
prevention billboard on a major highway.

The 95-member Kiwanis chapter in Rockford, Illinois, Rev.
Wildman's home town, has managed to more than double its
original goal of $30,000 through fund-raising efforts large
and small. When Kathleen Sullivan was recently installed as
the chapter's new president at a dinner banquet, instead of
buying expensive flower arrangements for each table, Ms.
Sullivan decided on home-made centrepieces anchored with
boxes of salt. "The money saved went to the IDD campaign,"
says Ms. Sullivan, "and when I was making these centrepieces
with my daughters, I explained what IDD was doing to children
just like them. I like to believe they have a better view of
the world because of the campaign."

                       * * * *


Panel 16

Indonesia makes strides against vitamin A deficiency

One of the great - and still evolving - nutritional success
stories is the progress made by Indonesia towards eliminating
vitamin A deficiency. Two decades ago, in this nation of
islands with a population of 200 million - the fourth highest
in the world - the problem was serious. High levels of
vitamin A deficiency, which can cause blindness and damage
the immune system, greatly increasing the risk of illness and
death, affected more than 2 million Indonesians.

The Government, in cooperation with UNICEF and other
international partners, tackled the problem through the
distribution of high-dose vitamin A capsules to children ages
one to five, reducing deficiency levels dramatically. The
rate of severe vitamin A deficiency has declined by more than
75 per cent, according to a national survey in 1993, sparing
the eyes, health and lives of millions of children. Blindness
among children due to vitamin A deficiency was eliminated in
1994.

Indonesia has not fully solved the vitamin A problem,
however. Severe deficiency remains a problem in three
provinces, and the survey also found that approximately half
of all children under five had inadequate levels of vitamin
A. Studies among schoolchildren and breastfeeding women in
West Java have shown mild and moderate deficiency to be
prevalent.

In response, the Indonesian Government has set the goal of
eliminating vitamin A deficiency by the year 2000, using four
strategies. The first is continued distribution of vitamin A
capsules to children ages one to five through posyandu
(community health posts), an effort which reached 60-70 per
cent of children in this age group in 1993-1994. The second
strategy is distribution of high-potency vitamin A capsules
to mothers after they give birth, which will require special
efforts, as only 35 per cent of births occur under medical
supervision. The other strategies are food fortification with
vitamins and minerals, including vitamin A (which is already
under way by noodle manufacturers), and promotion of
increased consumption of foods rich in the vitamin.

In support of this effort, the Government, with assistance
from Helen Keller International, the Micro nutrient
Initiative and UNICEF, has launched the Central Java Project
to improve vitamin A intake among children in this region in
the first two years of life.

The project undertook three major efforts beginning in 1996,
with the Indonesian system of posyandu and its cadre of
midwives and birth attendants at the centre. First, a
supplementation programme was launched to give one
high-potency vitamin A capsule to all new mothers during the
first month after delivery, along with two doses of deworming
pills, to improve their health and nutrition. Ensuring
mothers' adequate intake of vitamin A also ensures that 
babies receive the amount they need through breastfeeding.

In the first six months of the project, nearly 20 per cent of
new mothers in Central Java received vitamin A capsules,
almost double the rate in the previous two years. The goal of
the project is to reach at least 80 per cent coverage.

A second element of the project is a large-scale social
marketing campaign to promote consumption of foods rich in
vitamin A, focusing on eggs and dark green leafy vegetables.
Research found, for example, that while a number of vitamin
A-rich foods - such as eggs, liver, spinach, cassava leaves
and papaya - are available year-round, few mothers or
community leaders recognized these as good sources of vitamin
A. Therefore a series of radio and television spots, posters,
banners, advertising and one-on-one counselling methods were
developed to publicize the benefits - for pregnant and
breastfeeding women and for children between the ages of 6
and 24 months in particular - of eating eggs and vitamin
A-rich foods.

Third, a nutritional surveillance system was instituted to
provide information on nutritional status, food consumption
patterns and updates on the effectiveness of the project.

Thus far, the project clearly has improved the understanding
of nutrition and diet patterns in Central Java. Within three
months of the start of the social marketing campaign, egg
consumption by both children and mothers had  increased,
correlated with higher vitamin A levels.

Vitamin A capsules will continue to be an important measure
because people's diets are still not sufficiently high in the
vitamin. But the project has demonstrated that enriching
diets through eggs, an available and rich source of vitamin
A, is an important and sustainable step towards ensuring that
mothers and children receive the vitamin A that they need to
help them live and grow.

                         * * * *


Panel 17

Making food enrichment programmes sustainable

Fortification of food staples with iron, vitamin A, iodine
and other micronutrients is the most cost-effective,
sustainable option for eliminating micronutrient
deficiencies. Salt iodization, reaching an additional 1.5
billion consumers worldwide since 1990 and sparing millions
of babies from mental retardation each year, is testimony to
how successful fortification programmes can be.

But as positive as the end results are, fortification is a
complex undertaking that requires government and industry to
commit to working  together as partners. Recent experience
shows that fortification succeeds when producers are involved
from the start in formulating regulations and in  resolving
the marketing and technical issues that can make or break a 
programme.

It's the law: Effective legislation is a basic requirement,
helping to set goals and define roles of food producers, the
health and nutrition authorities and scientific institutions.
Without such a framework, a programme is more vulnerable to
weak implementation, uneven results and possible failure.
That was the experience of South Africa, where a
maize-enrichment programme launched in 1983 without
compulsory legislation was pronounced a failure after 10
years. Efforts are now being made to review the programme,
with a focus on legislation and the role of the food
industry.

Even then, legislation must be enforced and supported by
policies. Guatemala passed a law in 1975 mandating that sugar
be fortified with vitamin A. Not only was the law unenforced
but the programme also quickly fell apart for lack of the
foreign exchange needed to purchase the vitamin and because
producers were not convinced of the programme's
effectiveness. A decade passed before fortification was
resumed, after the Institute of Nutrition of Central America
and Panama (INCAP) and UNICEF worked with producers to
explain the importance of fortification, provided technical 
assistance and helped them obtain vitamin A at below-market
prices or through donation. Guatemala's Ministry of Health
now enforces the law: Producers whose sugar shows low levels
of vitamin A in random tests are first warned and then are
either fined or shut down.

Pricing and marketing: Start-up costs of equipment and
training can be high, but these are primarily one-off. Costs
of the fortificant, labour and equipment maintenance are
recurrent. Fortifiers' competitive position in the market
place can be further eroded by price controls or taxation,
and governments can play a helpful role in these areas. When
Brazil's Government removed price controls and reduced a
value-added tax on milk, for example, dairy production
received a boost and fortification of milk became more
attractive to producers.

Laws can eliminate the price advantage enjoyed by
non-fortified products. In 1997, Oman banned local production
and importation of white wheat flour not fortified with iron
and folate, and Bolivia mandated that all wheat - local,
imported or donated - be fortified with iron, folic acid and
vitamin B complex.

Yet government intervention does not always succeed in
lowering costs to workable levels. In Indonesia, efforts to
fortify monosodium glutamate (MSG) with vitamin A were
unsuccessful because technical problems of maintaining
vitamin stability and colour consistency were too costly to
solve. In the Philippines, it was so expensive to develop
fortified margarine that only one multinational corporation
carried through with it.

Questions of quality: Fortification can have commercial
consequences, since any change in the way a product tastes,
looks or smells can hurt sales and market share. For example,
when Venezuela in the late 1980s decided to fortify maize
flour with ferrous fumarate (iron), in product tests the
flour turned from its familiar white to grey. Sensing that
consumers would not buy the product, producers baulked. The
situation was resolved in 1992, when the National Institute
of Nutrition allowed producers to fortify with a blend of
iron components that did not change the colour of the flour.

Follow-up: It is vital to keep tabs on the process to ensure
that fortified products maintain potency standards and reach
consumers. Chile began fortifying wheat flour with iron in
the early 1950s, but it was not until 1967 that a system for
monitoring and quality control was established, and only in
1975, when a national survey revealed the iron status of the
population, that the programme's efficacy from that point on
could begin to be evaluated.

Commitment and coordination: "Authorities must be convinced
of the need to make fortification compulsory. And to
eliminate any possible resistance, producers must be
convinced of fortification's benefits," says Jorge David,
head of the Latin American Millers Association (ALIM).

In 1996, Bolivia became the first country certified to have
virtually eliminated iodine deficiency as a public health
problem. The phenomenal success stems from legislation that
expressed a public policy decision to iodize and 13 years of
coordinated work by salt producers, the Government and
international cooperation agencies.


                       * * * *


Panel 18

Zinc and vitamin A: Taking the sting out of malaria

Early evidence from a study in Papua New Guinea suggests that
zinc and vitamin A supplements may boost children's
resistance to one of the world's most insidious infectious
diseases: malaria.

Two fifths of the world's population, in 90 countries across
sub-Saharan Africa, Asia and Central and South America, is at
risk of contracting malaria. At least 300 million people
worldwide endure its recurrent fevers, malaise, anaemia and
risk of seizures or coma. Malaria kills from 1.5 million to
2.7 million people annually. It is the sixth leading cause of
disability among children under four years of age in the
developing world. Some 600,000 young children die of malaria
alone each year; over 1 million die of malaria in conjunction
with other illnesses - a rate of one child every 30 seconds.

Many approaches have already been tried to combat the
disease. However, the parasite that causes malaria is no
longer vulnerable to some of the most powerful antimalarial
compounds available. For a time, the widespread use of
pesticides in the 1950s managed to suppress the Anopheles
mosquito that transmits the parasite, but it, too, has
developed  resistance.

Arming the body to defend itself through immunization is one
approach to preventing the disease. But vaccines are
difficult to develop since the parasite moves between 
organs, changing its appearance from stage to stage and
hiding from the immune system in a place that the immune
system doesn't check: inside red blood cells. Consequently,
the best vaccines to date have managed to protect only around
30 per cent of test populations from  infection.

However, naturally acquired resistance does develop over time
as people are repeatedly exposed to the parasite. A recent
study by the Johns Hopkins School of Public Health and the
Papua New Guinea Institute of Medical Research investigated
the ability of vitamin A and zinc to help boost such natural
resistance.

Nearly 800 children under the age of five were enrolled in
the study. All of the children lived in an area of
north-western Papua New Guinea where malarial infection is
common. The parasite that is responsible for the disease can
be found in the blood of over 40 per cent of under-fives in
the region, and it is the major cause of death among children
from the age of six months to four years.

In controlled trials, regular vitamin A and zinc
supplementation appeared to be complementary in decreasing
the burden of malaria in children. According to Dr. Anuraj
Shankar of Johns Hopkins University, chief researcher of the
study,  vitamin A reduced by more than a third the febrile
illnesses due to mild to moderately high levels of malaria
parasites in children and significantly reduced spleen
swelling, an indicator of chronic malaria. However, it had
little influence on the worst cases, where children had a
very high number of parasites in their blood.

Zinc, on the other hand, helped blunt the severity of the
worst cases. As a  result, there were over a third fewer
malaria cases seen at health centres among those given zinc
than among those given a placebo. In addition, overall clinic
visits by those children who had received zinc decreased by a
third, and signs of other infections (cough and diarrhoea,
for example) were reduced by 20-50 per cent.

The Papua New Guinea experience shows that vitamin A and zinc
status in children may be as important in reducing malaria as
other commonly used malaria-control techniques, such as
insecticide spraying and the use of insecticide-treated bed
nets. And the cost is minimal: A year's supply of zinc
supplements costs $1 per child, with an additional 10 cents
for vitamin A capsules.

A second study is under way in the Peruvian Amazon to measure
the effectiveness of vitamin A and zinc in boosting the
efficacy of anti malarial drugs. Peruvian scientists at the
Loreto Department of Health and colleagues from Johns Hopkins
are studying more than 1,000 children who are suffering from
malaria to see if a short, five-day course of zinc or 
vitamin A in conjunction with anti malarial drugs improves
their health. Some children are receiving both the 
micronutrients, in the hope that the zinc-vitamin  A
combination will be more effective, as zinc is known to 
promote vitamin A metabolism in the body.

Despite the surge of international interest in malaria from
both the public sector and private industry and the promise
that vitamin A and zinc may hold, funding for research into
disease prevention and treatment unfortunately remains
meagre. Currently, funding levels run at roughly $42 per
malaria death, compared with $3,274 for each AIDS fatality.

                         * * * *


Panel 19

Protecting nutrition in crises

When refugees stream into a country, when families lose their
homes, fields and crops in war or disaster, when children cry
from hunger, it is not surprising that food can seem like the
only priority and the only answer to averting widespread
malnutrition.

But in emergencies as well as in other situations, food,
health and care are all crucial to saving lives. Access to
basic health services and water and sanitation facilities is
essential in emergencies not only to keep children alive, but
also to protect their growth and development. To prevent
outbreaks of measles, mass immunization usually along with
the distribution of vitamin A supplements has become standard
practice in emergencies. In Haiti, for example, a measles
vaccination campaign in 1994-1995 reached almost 3 million
children, helping end an epidemic that began when the country
was in the midst of civil unrest.

Preventing death and malnutrition from cholera and other
diarrhoeal diseases - through adequate sanitation, access to
safe water and oral rehydration therapy - saved thousands of
children's lives in the recent emergencies in Rwanda and
Somalia. This is standard practice in the current emergency
in Burundi, for example.

Breastfeeding is an important element of nutrition-related
'care' in emergencies. There has been marked progress in this
area as governments and agencies become increasingly
sensitive to supporting women's ability to breastfeed.
Workers with some NGOs that specialize in preventing
malnutrition in times of crisis have had success in recent
years in promoting relactation - helping women who may have
been separated from their children to begin breastfeeding
again after having stopped.

Sometimes infant formula must be used in emergencies - for
instance, when young children have been separated from their
mothers. In these cases, all UN agencies working in
emergencies and many NGOs have committed to supplying only
generically labelled (no brand name) formula, to prevent
commercial exploitation of emergency situations. During the
conflict in Bosnia and Herzegovina, UNICEF and other UN
agencies jointly urged that infant formula distribution be
severely limited, and relief organizations subsequently ended
mass distribution programmes in January 1995. UNICEF and WHO
strongly promoted breastfeeding, targeting health workers and
joining with local health professionals during and after the
war to develop a national policy on infant feeding.

Children ages 6 to 18 months, pregnant women and women who
are breastfeeding all need energy-dense, nutrient-dense
foods. In emergencies, the approach to meeting these special
needs varies. Agencies that are part of the International
Federation of Red Cross and Red Cres cent Societies, for
example, try to provide a family ration to meet every one's
requirements, including those of children and pregnant and
breastfeeding women. The World Food Programme and some other
agencies generally distribute a ration that meets minimum
needs and, in addition, they cover vulnerable groups with
supplementary feeding programmes. The comparative benefits of
the two approaches need to be evaluated.

Triple A - assessment, analysis and action - is an essential
approach in emergencies as well as in other situations.
Monitoring children's nutritional status, with
weight-for-height a commonly used indicator, is crucial
during emergencies to help target resources and reach the
most affected.

Early warning systems and emergency preparedness are cost-
effective means to prevent mal nutrition in emergencies. The
United Nations Department of Humanitarian Affairs' early
warning system draws on the work of similar systems within
and outside the United Nations in preparing comprehensive
assessments of potential emergency situations, and UNHCR and
other agencies have set up rapid deployment mechanisms for
emergencies. Nonetheless, early warning systems and emergency
planning and preparedness remain sadly underfinanced, a
shortfall that endangers children in particular when crises
loom.


                        * * * *


Panel 20

Progress against worms for pennies

Asked to name the most widespread diseases, few people would
think of including worms. Yet, helminth (worm) infections are
indeed one of the most common - and neglected - of diseases,
affecting more than 30 per cent of the world's people.
Health, productivity and physical and mental capacity may all
suffer.

Children in developing countries are the most severely
affected, particularly those between the ages of 5 and 14, in
whom intestinal worms account for up to 12 per cent of total
disease burden - the largest single contributor. While the
impact of worms on health and growth is commonly believed to
be most significant in children after they reach the age of
five, a new study in India links worm infection with growth
faltering in children between one and four years old.

As many as 150,000 children die each year from intestinal
obstruction and other abdominal complications caused by large
adult worms. In millions more, worms are a significant cause
of malnutrition, stunting growth and causing severe anaemia,
dysentery, delayed puberty and problems with learning and
memory. In 1990, an estimated 44 million pregnant women were
infected with hookworm; their foetuses, therefore, were at
risk of retarded intrauterine growth, prematurity and low
birth weight.

Transmission is insidiously easy, especially where hygiene
and sanitation are inadequate. A child walking barefoot can
pick up hookworm; by putting a dirty finger in her mouth, she
may ingest roundworm eggs. It is not uncommon for a child to
carry up to 1,000 hookworms, roundworms and whipworm that
deplete blood and nutrients.

Overall, about 1.5 billion people have roundworms, making it
the third most common human infection in the world. Whipworm
infects 1 billion people, including nearly one third of all
children in Africa. More than 1.3 billion people carry
hookworm in their gut, and 265 million people are infected
with schistosome, the parasites that cause the debilitating
disease of schistosomiasis.

Worms affect nutrition in several ways, ingesting blood and
leading to the loss of iron and other nutrients. Worms also
cause the lining of the intestines to change, which reduces
the surface membrane available for digestion and absorption.
As a result, fat, certain carbohydrates, proteins and several
vitamins (including vitamin A) are not absorbed properly.
Lactose intolerance and poor use of available iron can also
result.

Treatment is simple and relatively inexpensive. A single dose
of antiworm medicine such as Mebendazole costs as little as 3
cents and can eliminate or significantly reduce intestinal
worm infections. The total cost of treatment programmes is
typically $1 to $2 per year per person. Controlled
experiments in India, Indonesia, Malaysia, Myanmar and
Tanzania have proved that the therapy works for months at a
time. UNICEF, WHO and the World Bank have identified
pre-school and school-age children, women of childbearing age
and adolescent girls as those who would benefit most from
worm control programmes.

The benefits are impressive. An innovative study in Kenya in
1994, which used motion detectors on the thighs of school
children, found that ridding the youngsters of high levels of
hookworm improved physical activity. Dewormed children
reported better appetites and an end to  abdominal pains and
headaches. Within nine weeks, the treated group showed better
growth, weight gain (both in terms of fat deposits and muscle
mass), physical activity and appetite than the untreated
group. Numerous studies have also noted the mental and
cognitive effects of anaemia in children infected with worms,
with intellectual performance improving after treatment.

In a large-scale study done in India in 1996, two groups of
children ages one to four years received twice-yearly vitamin
A supplements; one group was also given deworming tablets. At
the end of the trial, the children in the group given worm
treatment were on average 1 kg heavier than the children who
were not treated. The study shows not only that mass de
worming can improve the weights of young children in areas
where worms are common, but it also opens up the practical
possibility of combining worm treatment with vitamin A
supplementation in areas at risk.

Some believe that deworming is not a satisfactory solution
because it must be repeated in the absence of improved
sanitation, hygiene and health education, and reinfection
occurs frequently. Nevertheless, periodic deworming reduces
helminths' drain on children's development at critical times
in their lives, at least until the causes and conditions of
environmental contamination and infection are successfully
addressed.

                      * * * *


Panel 21

Child nutrition a priority for the new South Africa

Under apartheid, South Africa had a highly sophisticated
medical research infrastructure that served the white
minority, pioneering heart transplants, for example. Yet the
majority of the people were left with poor health and
nutrition care. The advent of democratic rule in 1994,
however, changed all that. The Government is now reorienting
the health system to the needs of the majority, and child
nutrition is a priority.

Establishing a community-level nutrition monitoring system is
an important part of this effort, and one area where this
approach is taking shape is the Bergville district of
KwaZulu-Natal Province. Child health and nutrition problems
in the province are among the most challenging in the
country. Over half the children live in poverty, nearly 40
per cent have vitamin A deficiency, up to one quarter of the
children in rural areas are stunted, and iodine deficiency is
a problem in mountainous areas. Ten per cent of children ages
six months to five years suffer from anaemia, which is also
prevalant among pregnant women, and low birthweight is
common.

In the Bergville district, with a population of 120,000, a
network of community health workers and health assistants is
being trained as part of the new Child Survival Programme.
The approach, based on regular weighing of young children in
their homes to monitor growth, is similar to that used
successfully in other developing countries during the past
decade. Health workers will use the weighing sessions to
discuss children's growth with their families, reinforcing
positive trends and exploring reasons behind faltering growth
to devise solutions. To carry out the programme, the number
of community health workers in the district will be expanded
significantly. The main objective is to cover all families,
including the poorest and most marginalized.

Community participation in planning and operating health
services is at the core of the programme. Community members
formed a health forum in 1994, which serves as the steering
committee of the Child Survival Programme. The group has
helped establish a district hospital board and local
committees to supervise health workers and has organized
workshops on the new programme.

Since 1996, resources for health care have been channelled
more equitably to disadvantaged provinces such as
KwaZulu-Natal, and this will help finance the improved health
services. The University of Natal in Pietermaritzburg is
taking a leading role in supporting child growth monitoring
in the Bergville district. In addition, World Vision of South
Africa, an NGO which has been active in the district since
1980, has helped lay the groundwork for the programme through
various community development projects. These include local
leadership training, skills training for women's groups,
support for a pre-school and creche programme and cooperation
with the health service in addressing malnutrition.

The new system for monitoring growth is sorely needed,
according to a recent survey, which found that while most
mothers had a health  services card for monitoring child
growth, many of the cards were  either left blank or were
incomplete. The survey also found that very little
nutritional counselling had accompanied growth monitoring.

The new programme faces many difficulties: Resources are
stretched, personnel must be trained and there must be
outreach into communities. None the less, the new
partnerships being forged between government, the university,
NGOs and communities represent an approach that holds promise
for the future.

A major effort to tackle vitamin A deficiency is also under
way. Within months after the new Government took office, the
South African Vitamin A Consultative Group launched the
country's largest-ever nutrition survey, covering nearly
20,000 households. The survey found that one third of
children ages six months to five years are vitamin A
deficient or on the borderline. The Government and
non-governmental partners are gearing up to address the
problem. Steps planned include giving vitamin A supplements
to young children and to mothers shortly after giving birth,
fortifying staple foods with vitamin A and encouraging the
production and consumption of vitamin A-rich foods.

                         * * * *

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