Thank you Richard, Thank all of you for this opportunity. One which I was looking forward to because Urban Jonsson was to have given this talk but this morning he realized that he couldn't be here and in Tokyo at the same time so I am standing in for him. They are big shoes to fill but even a lower and tougher voice to follow so I will do my very best to reflect and I promised to set my stop watch as well..to reflect on the challenge of malnutrition and particularly to identify the actionable doables that Jim Grant reminded us were so important for us to have in mind.
When the machine gets warmed up I'll start with some slides to review what Dr. Nyi Nyi just showed us, the present situation with respect to nutrition and nutrient deficiencies. I'll say at the outset that I think it is highly appropriate that in this meeting that the first technical subject we should deal with is indeed malnutrition. So very often we have focused on some of the other problems which are more medical in nature. Malnutrition is the end result of the entire environment of the child. The health, the caring, the total upbringing. It is indeed in that context that it seems highly appropriate to start our talk.
I won't spend much time because there are session during the week on micronutrient deficiencies but I want to remind you all that the problem of iodine deficiency disorders which affect something like 1.6 billion people living throughout the world, not longer confined as it once was thought to be to mountainous areas. This is the largest preventable cause of mental retardation today and as Dr. Nyi Nyi pointed out it is not just the 200 million people with goiter, not even the 6 to 10 million with mental deficiency of severe forms, but in fact it is probably the lowered metabolic activity of a large proportion of that 1.6 billion people living in these countries shown in the dark colors that has brought this to public attention.
It is also appropriate to point out that while this was thought to be a rare disease, relatively rare, confined to mountains that when it was brought to public attention, only really five years ago, in any large and substantial way that today as Dr. Nyi Nyi pointed out 80 to 85% of the salt in these countries is now already iodized and this problem is being solved. It's a wonderful example of the marriage of good epidemiology of proper communications that as Juan Flavier talked about social mobilization and concern that people get access to iodized salt and the political will, the kind that Mr. Grant always got up. When he was at his last state dinner in India, he pulled out his iodine testing kit at the Prime Minister's table, he pulled up the salt, put it in a bowl and tested it to see if it was blue. Indeed we held our breath and indeed it was blue so India passed. That was the kind of man who could think at that level and was not embarrassed at the Prime Minister's table to pull up and say is your salt iodized, because I would really feel badly if it weren't.
We have the next transparency. The second micronutrient deficiency that I will mention again in passing is really a miracle of recent marriage of technology and what we hope is the application of readily affordable solutions. Vitamin A deficiency afflicts the countries shown darkly on the slide and probably many others as well in which the deficiency is not yet well characterized. There are something in the order of 200 million children living in these Vitamin A deficient areas. I'm not sure whether those children are Vitamin A deficient themselves, but there is something between 60 and 120 thousand blindness episodes a year and that used to be thought that was the only significant effective Vitamin A deficiency. You are all aware of the remarkable studies, that even Al Summer when he did them, I remember he and I were living in Indonesia together, 15 years ago when his studies first came out. He called me and asked me if I could meet him in Jackarta. He said I've gathered this data because I'm an epidemiologist to look at the incidents of disease in mortality but I was - he's an optomologist and he was looking at the eyes - but he found a dramatic fall in mortality in his study group in Bondon and as a good epidemiologist went on to plan studies and with many of you in this audience and colleagues around the world, now there have been studies conducted in a score of places which have shown the remarkable effects on Vitamin A, not only on saving eyes from blindness but more importantly on its effectiveness of reducing mortality from the most common of infectious diseases. The same countries appear in every slide and will in every slide I have to show you and yet the deficiency we are talking about here costs only pennies a year to treat. Dr. Nyi Nyi talked about how that is done and we in India are pleased to have had one of the first Vitamin A nation wide programs although we are still lacking in the depth of its implementation. There's remarkably even battle amongst the profession as to whether you should give it at this month or that month and whether or not the fontanelle bulges that that's really a bad enough sign that no one should get it even though all of these countries have shown a mortality reduction as much as twenty-five to thirty percent in certain age groups in Vitamin A deficient communities. I think we are over that hump right now. At least I hope so.
The next slide shows the third and last micronutrient deficiency that I shall allude to which again is not as well characterized as the others but again you notice India, South Asia being most prominent for iron deficiency anemia. The last large study in India showed 84% of women had significant anemia and that wasn't pregnant women, it nears almost 100% in pregnancy. Indeed throughout the world it's about 40% of children have iron deficiency anemia, and more than half of pregnant women. Not much has been designed to deal with this although we have a goal for the year 2000 of reduction by one third and India has taken this on as one example and has already achieved about 70% of women who are now that level or getting antenatal care and iron tablets are given throughout pregnancy. That does give some benefit though it doesn't eliminate the problem.
The next slide begins the subject that I would like to conclude my time with and that is protein energy malnutrition. Here is the distribution of underweight children throughout the world and you will notice once again that my country where I live and work India and neighboring Bangladesh are by far the highest levels of protein energy malnutrition. The report progress of nations shows that we have 69% of our children under five years of age are under nourished by international standards and Bangladesh is similarly so. We have in that country 50% of the world's under nourished children. We have malnutrition levels which are about twice those of Subsahara in Africa and so you can see that while we have many concerns about many of the problems there are better coping strategies in some of the poorest countries than there are in some of those which should have a better situation.
I will come to that in a moment but let us look at the next slide at some of the data broken down by region. Here are the numbers and by the way this is 184 million and this is the latest estimates of WHO and FAO and the number of underweight children that's less than two standard deviations of NCHS standard. You can see that Subsahara in Africa has 28 million in this category while South Asia which includes Bangladesh, India, Pakistan about 1.1 billion people we have over 100 million children under nourished and of those a substantial number under three standard deviations as well.
Let's look at the next slide. The trends in many things are hopeful as Peter Adamson said but they are not as hopeful as we would like them to be. You see that somehow we in South Asia still about 60% are very malnourished even though it seems to be coming down. Except in Subsahara Africa the entire world seems to have some slight declining trend in malnutrition, hardly an acceptable one.
Next slide please. It's very, very slow and although in some countries you see remarkable declines which coincide with things that are happening in those countries which I will come back to and may have more to do than what we normally think of in the nutrition programs. Thailand is a remarkable afall in south east Asia has shown what really can happen with concerted programs. On the other hand I don't know if Juan Flavier is still here, there are some countries that have done well in organizing some things but the Philippines has remained remarkably cure calcitant in spite of many years of activities. I think we know the reason why. I'll come back to that.
Could I go next please. Looking at South Asia again, you notice Sri Lanka which is South Asia's way of saying but we can do it if we want to because the state of 30 million in the southern tip of India with 85-90% female to literacy with a fertility rate of women of 1.7 has also been able to reduce malnutrition in spite of being one of India's poorest states. Meanwhile India and Bangladesh are vying for first place in the number of malnourished.
Next please. The picture in Africa is also similarly confusing but I would like to point out that Tanzania is the one country that has a remarkable fall. Again coming around to a question of what are they doing right when things are difficult in the other studies and I will address that in a moment.
Next please. Could it be food? Well almost everyone thinks that's what malnutrition is all about. It's not enough food to eat. Right? Wrong. There is more food today with a possible exception of Subsahara in Africa on a per capita basis than there has been for the last twenty years. World wide on every graph it goes up even in India and Bangladesh where we have so much. We have 30 million tons of food in storage in Indian food depots. It's not a question of food availability in the aggregate although it may well be food availability or the entitlement at the household level. Most investigators find and most studies have found that in spite of all of our attentions to food that in fact food is not a good answer to why there is this malnutrition and so it is in the Philippines where you have had outstanding nutrition programs focused on food and food supplements for the past 25 to 30 years. You saw that flat curve and so it is in many of the other nutrition programs such as India's ICDS, the largest child survival program in the world which provides food to every child but it hasn't had any impact as near as we can measure.
Next slide. Well if it's not food could it possibly be health. Well surely we are learning that there is much more of an association due to infectious diseases and repeated causes of infections and this graph and I had to ask someone for the acronyms of the attributable risk, the partial attributal risk of malnutrition to the overall death of children shows that world wide about 55% of childhood deaths could be attributed to the underlying malnutrition. That is if the children were normally nourished the death rates would be 55% less. You notice in India that figure is 65% and a falling off from these other countries but malnutrition plays a role in virtually every country shown there.
Next slide. So it is food but not in most cases is food the limiting factor and it is very often the heavy burden of infectious diseases combined with malnutrition. This is a graph of malnutrition rates in India broken down by age groups and I would like you to notice that for those who are less than six months of age and these are real data collected from UP you will see that our malnutrition rates are respectively low and you notice that our programs for malnutrition intervention usually start at about two to three years of age. That's where the ICDS comes in, that's where most of your feeding programs come in. The food supplement programs. They come in when people are malnourished rather than when they are becoming malnourished. The programs attempt to treat malnutrition rather than prevent it. They are dealing with children at a time when they are eating for themselves rather than when they are being fed. This graph I believe and Urban Jonsson believes is perhaps one of the important answers to the problem of childhood malnutrition. As Urban says, usually at this point, putting on his glasses, it depends on what glasses you wear. If you are looking for it you are going to find what you are looking for and for many years we have lumped children under five into the same age group but this is probably the underlying factor of why Tanzania in spite of having more poverty than almost any other country in Africa, not having excessive food grains and having a heavy burden of infectious disease but Tanzania has embarked on a major program of helping mothers to cope and to cope at the community level and this important age group from birth up to eleven, twelve or twenty-four months of age and that the attention for caring for the child at this age seems to be the key missing factor in most of our nutrition programs.
Let me close by again reminding you of what Urban would have said and on behalf of Mr. Grant that this analysis of malnutrition talked about the science. The science tells us what we can do, but really at the same time, malnutrition is an issue of ethics and ethics tells us what we should do. We know that we can deal with malnutrition, we know that we should deal with malnutrition. Those two, the science and the ethics, the can and the should is what Jim Grant called the doables. So as he used to say to us. Let's get out and do it.
Thank you very much Jon. We now turn to breast feeding and the baby-friendly hospital initiative and Micheline Beaudry will be making the presentation. Micheline Beaudry has been with UNICEF just under a year as chief of nutrition. Before that she was professor of international nutrition and community nutrition in the University of Laval in Quebec City. Thus she is one of Canada's gifts or at least one of Canada's loans to UNICEF. Micheline Beaudry.