In a rural village in Bolivia, a young woman nurses her baby. The most noticeable thing about her is a large lump deforming her neck. She has had a goiter, or enlarged thyroid gland, for several years now. But because so many others in her village have one too, it is not considered abnormal. Nor is it seen as unusual that she had difficulties learning as a child or that now she frequently is very tired. As the woman looks down at her child, she silently wonders why the baby is so small, and why it seems he does not do all the things other children do at age 1.

The woman and her baby suffer from micronutrient malnutrition. They do not get enough of the essential nutrients their bodies need in very small quantities--particularly iodine, vitamin A, and iron. As a result, their functional capacity and overall health are dramatically and sadly compromised.

They are not alone. Iodine deficiency disorders, the world's greatest single cause of preventable brain damage and mental retardation, are estimated to affect 30% of the world's population. Approximately 15 million children under 5 have some degree of vitamin A deficiency. A large number of these children will become blind because of it, and many will die. Others will be unable to fight infection and will therefore be at higher risk for complications of diarrheal disease or measles. And an estimated 94 million people worldwide suffer from iron-deficiency anemia, the most prevalent micronutrient deficiency, with women of reproductive age and children under 5 most affected. (Twenty percent of maternal mortality worldwide is attributed to severe anemia during pregnancy.) The World Bank estimates that in a hypothetical country of 50 million people, micronutrient deficiency alone would translate into 20,000 deaths a year and account for 1.3 million person-years of lost work and the loss of 360,000 student years.

Micronutrient malnutrition occurs for many reasons. There may be insufficient food available both in terms of quality and quantity. Inequitable access to food may be the problem, or food taboos may prevail. Access to information sources may be limited. Unemployment or underemployment could mean that people cannot afford to buy the right foods for a healthy diet. But the three major strategies to solve the problem--food fortification, supplementation, and dietary diversification--are neither complex nor expensive to implement, and they have drawn increasing attention over the last 10 years.

Food fortification has generally been recognized as the most effective way to eliminate dietary micronutrient deficiencies. It is socially acceptable, requires no change in food habits, and it can be legally enforced and easily monitored. It is also very affordable. Fortification efforts can restore nutrients lost during food processing by enriching a food with the depleted nutrient, or they can increase the level of specific nutrients in a food. In most industrialized countries, foods have been fortified for years, including salt with iodine, and flour and milk with vitamins.

The challenge of food fortification, especially in developing countries, is to find suitable foods and appropriate micronutrient compounds. Processing and storage are also considerations. A number of foods have been fortified with vitamin A in various countries, including sugar, rice, flour, grains, and tea. Fortified salt is prevalent in many countries as well. In Chile, El Salvador, Guatemala, and other countries, wheat flour has been fortified with iron.

Supplementation efforts in the developing world to date have tended to focus on providing iron to pregnant women. Iron supplementation is a challenge because scientists still don't know definitively how much iron people actually need, and food sources of iron are limited. Supplementation programs also depend on an effective health care delivery system and sometimes result in pharmaceutical programs rather than in primary health care interventions.

Cultural Awareness

Dietary diversification must take into account what foods are available and affordable, and what food taboos or culturally related food practices prevail. For example, some foods that are actually high in micronutrient content may be seen as detrimental during pregnancy. Fruits and vegetables, good sources of vitamin A, may be unavailable altogether, or they may be difficult to obtain in some environments. Likewise, many processed foods are often beyond the reach of the poor. Nevertheless, educational campaigns aimed at diversifying diet wherever feasible are an important part of strategies designed to overcome micronutrient malnutrition.

The Pan American Health Organization (PAHO), along with partners such as the United States Agency for International Development (USAID) and UNICEF, have been working hard to overcome the health problems associated with micronutrient deficiency. PAHO's Food and Nutrition Program has adopted the goals set out in the 1990 Declaration of the World Summit for Children and the 1992 International Conference on Nutrition, and has used them as the foundation for its Regional Plan of Action on Food and Nutrition. The plan, which emphasizes micronutrient malnutrition, outlines two specific work areas: food and nutrition security, and the prevention and management of problems and disorders linked with malnutrition. In the area of food security, the plan seeks to enable people to make better use of their limited resources in terms of food consumption, a goal that often means helping people to change their behavior with respect to their food practices. In terms of preventing and managing malnutrition problems, PAHO focuses on undernutrition throughout the life cycle and on micronutrient deficiencies. Its Plan of Action calls for a one-third reduction in iron deficiency anemia in pregnant women by the year 2000, as well as the virtual elimination of iodine deficiency disorders and vitamin A deficiency by that time.

Are these goals realistic? Dr. Abraham Horwitz, Director Emeritus of PAHO and the former chair of the United Nations Subcommittee on Nutrition, is cautious. "There is progress," he says, "but I have my doubts that the goals for all three micronutrient deficiences will be met by 2000. There needs to be a large investment if we are going to succeed, and people need to be motivated to change their behavior."

Dr. Wilma Freire, who heads PAHO's Food and Nutrition Program, agrees: "Even though we know about specific interventions that work, the community must be empowered to identify people at risk, and to demand services. Then well-established health services must respond."

Information and Education

A number of nutrition communication and education projects have been designed with cultural needs, preferences, and behaviors in mind. In Niger, for example, a Vitamin A Promotion Project was developed to increase the consumption of vitamin A-rich foods by promoting seasonally available local products. Funded by USAID and carried out by the Ministry of Health with technical support from the Academy for Educational Development and Helen Keller Interna-tional, the project first conducted a pilot study to identify year-round vitamin A-rich food sources and to test village drama as an approach for reaching target groups. Then it mounted a multimedia campaign that reached 80 villages with messages about what local foods were rich in vitamin A.

Four target audiences were identified: men, who purchase most of their family's food; women, who prepare and serve the food; commercial gardeners, who produce vitamin A-rich foods; and health and extension program managers, who often introduce new ideas. Project messages shifted cultural norms about men's role, depicting men as providing their families with a variety of nutrition foods instead of just millet, the traditional staple food, and they promoted liver as a nutritious snack food for women and children, not just men. The key behaviors the project addressed were an increased consumption of liver, increased consumption of greens by children, and increased production of traditional greens in dry season by commercial gardeners.

Telling a Tale

Village drama is a long-standing traditional medium in West Africa used to reinforce social and ethnic values through the use of storytelling and song and dance performances. The project managers successfully adapted this vehicle to serve as an energizing force for community involvement and a powerful way to build interest in nutritional issues. Through realistic scenarios using amateur actors, popular imagination, and local humor, villagers were encouraged to develop their own health and nutrition education programs. Such dramas were later reinforced by radio spots and community workshops. The project demonstrated that promoting locally available and affordable foods can improve the vitamin A status of rural women and children, and it showed that multiple approaches are needed to reach rural audiences because of their limited access to information.

Another project in Indonesia focused on iron supplementation, and a fictional radio personality, Mrs. Nutrition, was created to persuade pregnant women to incorporate iron supplements into their diet. This information, education, and communication strategy was developed on the basis of sound research that explored the preferences and priorities of the target audience and examined barriers to their behavior or attitude change.

PAHO has been an active partner in the USAID-funded Opportunities for Micro-nutrient Interventions (OMNI) Project, which provides technical assistance to selected developing countries to overcome micronutrient malnutrition. OMNI helps countries assess the magnitude of their problem and assists in the development of national strategies and action plans for reducing micronutrient deficiencies. One of its subcontractors, the Program Against Micronutrient Malnutrition (PAMM), based in Atlanta at Emory University's School of Public Health, trains people involved in micronutrient projects in communication and education techniques and in building networks and partnerships at the community level. PAMM has designed a strategic mobilization strategy for changing behavior related to nutrition, and it developed generic school kits for use at the primary level as a way of reaching not only children, but indirectly, their parents as well.

Testing Theories

Besides the work being done by international agencies, national governments, and community groups in the areas of direct interventions, a considerable amount of research is ongoing, much of it centering on vitamin A. In Peru, trial studies are underway to explore the feasibility of administering low-dose vitamin A supplements in conjunction with routine childhood immunizations. Mothers there are also receiving high-dose vitamin A supplements during a two-month post-partum period in order to help improve the amount of vitamin A infants receive through breastfeeding. In Africa, researchers are working on the possibility of vitamin A supplements as a way of reducing the transmission of HIV from mother to fetus. With financial assistance from UNICEF, the Caribbean Food and Nutrition Institute (CFNI), a PAHO technical center based in Kingston, Jamaica, is conducting a survey of pregnant women, preschoolers, and school-age children to assess their vitamin A, beta-carotene, and iron status in order to explore the possible link between deficiencies in these micronutrients to diseases such as heart attack, stroke, and some types of cancer.

Additional areas of research for future study include food technology, farming systems, micronutrient enrichment of crops, and micronutrient bioavailability. Dr. Keith West, Associate Professor of International Health at the Johns Hopkins School of Public Health, and one of its key nutrition researchers, says that nutrition is finally getting the attention it deserves because a new constituency has been identified.

"Part of the challenge," he says, "is to move beyond the moral mandate to a clear demonstration of the health outcomes with affordable food and nutrition strategies. We showed that survival and productivity can be improved, and we rang new bells in policymakers."

Now those policymakers, in partnership with ministries of health, nongovernmental organizations, and private sector businesses and organizations, must lend their support to a comprehensive effort to rid the world of one of its most pressing public health problems. Through regulation and legislation; sound monitoring of ongoing efforts; well-conceived information and education campaigns; the support of such sectors as industry, trade, and transportation; technical and financial donor assistance; and regional cooperation, adequate micronutrient nutrition can be achieved, providing the opportunity for a better life for people such as the woman in Bolivia and her child and others like them everywhere.

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Elayne Clift is a Washington, D.C.-based independent writer and health communications consultant. She teaches International Health Promotion and Communication at Yale University and Emerson College.