"Ending Hidden Hunger," Public Health, Spring 1995

End
ing Hidden Hunger Faculty and alumni bring their expertise in public health and law to assault micronutrient malnutrition in the Philippines and around
the world.

After practicing law for 12 years, Rose Nathan returned to the classroom to earn a master's degree in public health. Nathan's unusual combination of skills has made her an expert so ught by developing countries, which need assistance in creating legislation to address deficiencies in iodine, vitamin A, and iron. So far, Nathan's consultant work in micronutrient malnutrition has taken her to China, Pakistan, Malaysia, and the Philippi nes.

uring a trip through Malaysia in early fall, as a consultant for UNICEF, lawyer and alumna Rose Nathan had set aside two da ys to meet with Dr. Glen Maberly in the Philippines. Dr. Maberly, Nathan's adviser at the School of Public Health, had traveled to the Philippines also as a consultant from UNICEF to examine food fortification policies there. Nathan was to join him in ana lyzing the country's proposed legislation to fortify food with micronutrients. Her planned two-day study stint, however, extended unexpectedly to nine days and culminated in her testifying before a subcommittee of the Philippine House of Representatives.
Nathan's experience in both law and public health - what she calls a "fluky combination of skills" - made her a valuable expert witness. With a JD degree from George Washington University National Law Center, she practiced law for 12 years, most recen tly with Legal Aid in Atlanta. Two years ago, she decided to pursue a different career, one that would take her to developing countries. She enrolled at the Rollins School of Public Health, receiving her master's degree in May 1994, along with the Eugene Gangarosa Award for Excellence in International Health.
For her master's thesis, Nathan completed a manual on food fortification legislation and regulations for developing countries. She designed the manual as a guide for governments that wanted to in sure that their food control laws and regulations contained appropriate provisions for food fortification activities. According to Dr. Maberly, chair of the Department of International Health, Nathan's manual has become the global standard for countries a ttempting to address problems of micronutrient malnutrition.
After analyzing the proposed legislation in the Philippines, Nathan found a major problem. The law emphasized offering incentives to industry rather than compelling industry to iodize salt. And it created no penalties for noncompliance. "I proposed making the law mandatory so there are no loopholes," Nathan says. She also shared with the subcommittee her research on food fortification that she had completed for UNICEF, which had funded her t ravel. "The Philippine subcommittee seemed receptive to my suggestions," Nathan says.
That receptiveness fits another pattern. Philippine leaders also have embraced the Program Against Micronutrient Malnutrition (PAMM), which Dr. Maberly co-directs an d with which Nathan is affiliated. PAMM - a collaborative effort among the School of Public Health, the Centers for Disease Control and Prevention, and the Task Force for Child Survival of the Carter Center - supports the World Health Organization's globa l goal to eliminate micronutrient malnutrition by the year 2000. The specific micronutrients targeted by the initiative include iodine, vitamin A, and iron.
In the Philippines, where PAMM has trained a multidisciplinary team to strengthen food program s, upper-level cabinet officials as well as President Fidel Ramos have supported those efforts through a massive campaign, Sangkap Pinoy. Culminating in a National Micronutrient Day, the campaign launched a supplementation program throughout the country.
"It is clear from participation in events, meetings, and review of the documents that substantial progress towards the elimination of micronutrient malnutrition is underway in the Philippines," Dr. Maberly and Nathan concluded in their report to UNICEF .

Ending malnutrition by the year 2000

According to Glen Maberly, prevention o f the nutrient deficiencies of iodine, vitamin A, and iron "is potentially the most important achievable international health goal of the decade, conceivably exceeding the impact of the global eradication of smallpox in the 1970s."

Philippine leaders, including President Fidel Ramos (cent er) and the country's agricultural minister (right front), have strongly supported PAMM's efforts to decrease micronutrient malnutrition in their country.

n adequate intake of the micronutrients iodine, vitamin A, and iron is of immense importance to global development," writes Dr. Maberly in Programs Against Micronutrient M alnutrition: Ending Hidden Hunger. "Prevention of these nutrient deficiencies is potentially the most important achievable international health goal of the decade, conceivably exceeding the impact of the global eradication of smallpox in the 1970s. "
Iodine malnutrition, according to Dr. Maberly, affects some 20% of the world's population, causing not only goiter but also decreased brain development in children. Only during the past decade have iodine deficiency disorders been recognized as the leading cause worldwide of intellectual impairment, Dr. Maberly says.
Lack of vitamin A, an essential nutrient for the immune system, can lead to blindness, increased rates of mortality, and decreased brain development as well. "Vitamin A deficiency i s the most preventable cause of blindness worldwide," Dr. Maberly says.
Iron deficiencies, which affect some 30% to 40% of the world's population, also lower intellectual function. They dramatically reduce productivity by causing anemia, which results in reduced levels of hemoglobin, an essential gas transport mechanism for respiration. Maternal anemia, aggravated by hemorrhage and sepsis at child birth, plays a key role in maternal mortality worldwide. Some 20% of all maternal deaths may be attribute d to iron deficiency anemia during pregnancy.
"These deficits are keeping entire populations from reaching their intellectual capabilities," Dr. Maberly says. "They are age-old problems, but their significant impact has only been appreciated since aro und 1990."
Dr. Maberly underscores his point in Programs Against Micronutrient Malnutrition: "While prevention of micronutrient malnutrition is no panacea for such ills of the Third World as famine, AIDS, political strife, and poverty," h e writes, "the normal intellectual functioning and well-being associated with micronutrient sufficiency may be essential to long-term resolution of these national and regional problems."
PAMM assists countries in attacking these deficiencies by provid ing a multidisciplinary team from a particular country with the skills needed to strengthen their programs. The three-month-long core training sessions approach the problem of micronutrient malnutrition from many directions: communications and marketing, laboratory and monitoring skills, and information on food and nutrition. At the end of the training sessions, PAMM invites upper-level cabinet officials from the participating countries to join their team of trainees in the United States to participate in an advocacy week for the elimination of micronutrient malnutrition. After the representatives return home, faculty from the program continue to support them with advice, consultations, and site visits.
One of PAMM's follow-up strategies is to develop a dialogue in developing nations among government, industry, and agencies, such as nongovernmental organizations, to make micronutrition an issue in both the public and private sector. Nathan will be involved in that dialogue in the Philippines and other countries. "To make food fortification more prominent in developing countries, we have to overcome any historical mistrust between government and industry," she says. "We want to establish a dialogue and create a collaborative link that promotes mutual i nterests and balances competing interests."
Through her consultations in the Philippines, Nathan exemplifies what the Department of International Health hopes for its graduates. "We want to be more than an academic place where students come," Dr. Mabe rly says. "We want to provide active programs with which students can connect." Other students have brought their combinations of skills to departmental programs in Cameroon, China, Ethiopia, Mexico, Poland, Uganda, and other parts of the world. Nathan, with her background in law and public health, has now served as a consultant in China, Pakistan, Malaysia, and the Philippines. And that's just the beginning.