New evidence suggesting a relationship between malnutrition and mental retardation should be cause for major policy concern in a number of world capitals. The recognition that malnourished children may emerge from childhood lacking the ability to reach their full genetic intellectual potential introduces a new and perhaps frightening note into theories of national development.

The implications are ominous. For many years we have assumed that, given educational opportunities and environmental advantages, each normally born infant has every prospect of growing up to be bright and productive. It is now suggested that malnourished children may be basically dull. The significance of this can be appreciated when we recognize that as many as two-thirds of the children of most developing countries are now suffering from some degree of malnutrition.

The relationship of malnutrition to mental growth dramatizes the issue. However, the insidious drain of malnutrition on national development takes other significant forms. Half the deaths in the developing countries occur among children under six years of age. In certain African countries, Libya for example, a mother must have five children to assure that one reaches the age of fifteen. In Northeast Brazil, 48 percent do not survive the first year of life; by the age of four, 63 percent have succumbed. In parts of Southeast Asia, 40 percent of the children die of disease in their first four years. This is a proportion of deaths not reached in the United States until the age of sixty.

The vast majority of these child deaths are attributed to infectious diseases. Yet most of these diseases are relatively minor childhood ailments. The cause of the death, we now know, is not the infection itself, but usually the malnourished condition of the child when he contracted it. In other words, malnutrition debilitates the body to such a degree that it is incapable of resisting what would otherwise be a passing infection. In a country like Ecuador, child death due to measles is more than 300 times greater (per thousand of population) than in North America. Whooping cough is still a major killer in much of the world. Similarly, such childhood diseases as chicken pox are often fatal because of the child's malnourished condition.

For a sizable portion of the survivors, malnutrition permanently retards physical growth. In many countries the average twelve-year old has the physical stature of an eight-year old in Europe and North America. Indian nutritionist Dr. C. Gopalan reports that 80 percent of preschool-aged children in the rural areas of his country suffer from malnutritional dwarfism. The effect of this on productivity and the limits it places on the individual's potential contribution to his society are obvious.

An increasing body of evidence now suggests a similar relationship between malnutrition in the early years and mental retardation. During the months of breast feeding, children from the poorest areas grow at a rate comparable to the best nourished children elsewhere. Usually after six months of age, however, when breast milk is no longer a sufficient source of protein, growth is progressively retarded.

The result is an important and irretrievable loss of learning time during the most critical years of intellectual development. Further, some prominent nutritionists now suggest the damage may be irreparable (as is acknowledged in the case of physical retardation), even in the unlikely prospect that today's malnourished child eventually has access to proper nutrients. Dr. Joaquin Cravioto of Mexico, a pioneer and leading researcher in the field, says "sufficient evidence is already available to show that chances of permanent damage are high."

II

What does this mean to national development? How much more productive is a properly nourished man? How much more will a man with full mental and physical capacities contribute to his society? Conversely, what are the costs to the society of malnutrition in the form of medical treatment, welfare-type relief and waste through death of those who have a limited number of productive years? What would be the cost/benefit ratio of a $10 million investment in food enrichment, for example, as compared to other forms of development expenditure, e.g. spending the $10 million for fertilizer or dams or roads or schools? What, in fact, is the relationship of malnutrition to development-or, more specifically, what are the economics of malnutrition?

Unfortunately, little research has been directed to these questions. The scattering of peripheral studies, however, leads to certain inferences worth noting:

1. Limited life expectancy brought about by malnutrition limits the number of productive years. Recent calculations by Dr. Eugene Campbell show that the typical worker of Southeast Brazil will-because of improved health and resulting increased average life expectancy-produce nearly five times as much during his lifetime as the average person born in nutritionally deficient Northeast Brazil. Where malnutrition reduces life expectancy, the cost to society for education and other supporting expenses through the pre- productive years becomes proportionately more costly per year of productive output.

2. Malnutrition decreases a worker's productivity. The body, weak from lack of proper nutrients, protects itself by avoiding the expenditure of energy. This results in apathy, lethargy and lack of initiative-characteristics commonly found in poorly fed groups in protein-deficient countries. In the past, this apparent sluggishness was frequently attributed to laziness, indolence or other so-called "ethnic traits." The Food and Agriculture Organization now reports that those countries with the lowest per capita daily protein (and caloric) consumption are also those with lowest productivity. An interesting demonstration of the relation ship was noted during the construction of the Pan American Highway. The disappointing output of local laborers was quickly remedied with the introduction of three well-balanced daily meals. Within a few months, workers averaged an increase in concrete paving from 1.8 to 5.9 cubic yards per day.

3. Malnutrition lowers a worker's resistance to disease and, relatedly, increases his rate of absenteeism from the job. Further, accident rates are higher among those who tire quickly due to malnutrition. A study of the old East African Carrier Corps re ported that those laborers who supplemented their rations with herbs and green leaves showed a lower hospitalization rate- 10 percent compared to 40 percent for those who did not.

4. The medical costs necessary to treat the effects of malnutrition-either through hospitals or health centers-are many times greater than the cost of providing the necessary nutrients to pre vent the malnutrition initially. One estimate, in Guatemala, is that the cost of 90 days of hospitalization for each case arising from inadequate nutrition is $600, compared to an annual cost of $7 to $10 to prevent the malnutrition in the first place.

5. Certain nutritional deficiencies, such as acute vitamin-A deficiency which results in blindness, limit opportunities for productivity. In India alone there are at least one million preventable cases of blindness attributable to this cause alone. In East Pakistan, 50,000 children every year are threatened with a possible lifetime of blindness due to their precariously low vitamin-A intake. The blind have few opportunities to contribute to society and, in one form or another, they usually become a drain on that society. Yet for a few pennies a year, this blindness could easily be prevented.

The Philippine Government is attempting to pin a cost tag on its major diseases. To arrive at a figure, it combines production loss, manpower fatality loss, cost of medical care and burial expenses. Using this calculation, total economic loss per year for beri beri, for example, is estimated to be more than 44 million pesos ($11 million). This is only for those cases reported or recognized. Probably there are many others.

The late Dr. R. R. Williams, synthesizer of thiamine, reported: "Deficiency diseases are extremely insidious in that they are sapping the vitality of Asians to an unknown degree. My conviction is that there are scores of millions, perhaps hundreds of millions, in Asia who are suffering from mild beri beri, and have done so for years, and they still do not know they have it. ... As a drain on the vitality of many people who suppose they are well, the deficiency diseases are a tremendous handicap to the struggling millions of Asia."[i] Interestingly, due to Dr. Williams' discovery, beri beri could be significantly controlled. Experimental enrichment of rice in seven municipalities in Bataan was responsible for a 76 percent to 94 percent decline of the disease. In one year, the beri beri fatality rate fell to a tenth of what it had been.

A cursory look at some of the other literature suggests: In Newfoundland, compulsory enrichment of flour is credited with a striking 40 percent decline in infant mortality, In Madagascar, a sugar refinery is reported to have reduced the turnover rate of migrant labor from 60 percent to 6 percent by the introduction of a balanced cooked meal. In Indo-China during World War II, study of a rubber plantation showed that there was a 50 percent increase in work output after the opening of a canteen which provided a liberal diet. In Costa Rica, a public works project showed over three years an increase in work output-from 240 to 1,157 cubic meters of earth moved per man per day-primarily as a result of improved sanitation and provision of substantial meals to the laborers. Other studies in Uganda, Kenya, Brazil and the old Belgian Congo come to comparable conclusions.

Apparently, no one has computed the monetary loss to economic development caused by malnutrition, but one can be sure it is considerable. Mr. George Verghese, Information Adviser to India's Prime Minister, recently reported after a trip to drought-plagued Bihar that "It is quite common to be told that the people are lazy, indolent, stupid. Angry words, but true-and the result of malnutrition over several generations. . . . The economic cost to the nation of the consequent human inefficiency has never been calculated. It must run to hundreds of crores of rupees [hundreds of millions of dollars] each year. . . "

III

Although malnutrition is brought about by a number of dietary deficiencies, the most serious and challenging to scientists at the moment is the inadequacy of protein-the critical nutrient for both physical and mental growth. Protein need cannot be divorced from general food intake-but once the minimum number of calories is available to sustain life, it is the quality of the food which becomes all-important.

Dr. Aaron Altschul, the protein chemist, has calculated that more than half of the 80-odd million tons of protein consumed in the world every year is in the form of grain-not because grain is so high in protein (on the order of 10 percent) but because wheat, rice, corn and other grains are consumed in such enormous quantities. If one could somehow enhance the protein quality of this grain, considerable progress could be made in the battle against protein malnutrition.

The value of protein in foods varies widely. It depends on a series of so- called "essential amino acids"-the value of the protein being only as great as the smallest of these. Envisioning this as a bar chart, with a number of tall bars and one short one, the value of the total protein is only as great as the shortest bar. The rest is wasted. In the case of most cereal grains, this limiting amino acid is lysine.

In one of the most significant scientific discoveries of this generation, Dr. Edwin Mertz and his associates at Purdue University recently developed, through genetic selection, a strain of corn with a substantially increased lysine content. As a result, the protein value of corn can be nearly doubled-i.e. corn may provide a source of protein almost as good as milk. Presumably this genetic approach to protein improvement can be applied also to rice, wheat and other grains. Tests are now being conducted in several countries to see whether such application is possible. As significant as such steps may be, it must be recognized that even under the best of circumstances, the world is still a number of years away from growing a sufficient quantity of such high-protein seed to make the kind of impact required now.

Happily, a short cut may be possible-that is, by adding nutrients synthetically. The technology now exists to incorporate amino acids such as lysine during milling or by treating the whole grain. In processed foods, the system is even simpler. In the United States and Japan, a few commercial firms are already adding lysine to breakfast cereals, drinks, breads and soups.

A number of other possibilities also are under study. Many of them are based on the notion that inexpensive oil seeds-such as peanut, cottonseed, chickpea, soybean, sesame, sunflower and cocoanut-if processed and formulated into acceptable foods, can meet a protein requirement at considerably less cost than milk. (Milk is a luxury that most people in developing countries will not be able to afford for many years.)

After the oil is extracted from these seeds, little use is made of the residue for human feeding. Yet this material, properly processed, contains up to 50 percent good quality protein suitable for the human diet- particularly if combined with other foods. The cost of oilseed protein is well under one-fourth that of dry milk, and less than a tenth that of most other animal protein. The present supply of oilseed meal alone, properly processed, would be sufficient to meet more than twice the world's total protein deficit.

This oilseed principle has been employed by a number of companies in various countries to produce a variety of commercial, low-cost, protein products. The most successful of these is Vitasoy, a soy-based Hong Kong beverage sold in a typical soft-drink bottle and given a typical soft-drink promotion. Its sales keep pace with the major international soft drinks, and it outsells all others in the Hong Kong market. In South Africa, a line of foods, including soups, candies, beverages and cereals, under the label Pronutro, has been commercially successful-multiplying its sales ten times in the past two years. And in Latin America, Incaparina-a cottonseed-based beverage patterned after the atole, a drink the Mayan Indians have taken for centuries-has begun after years of development (and evangelism by the Quaker Oats Company) to be accepted.

There is not a conspicuous number of such projects. There has been enough experience, however, to conclude that certain elements are essential to success: the product must be palatable; it must be inexpensive; it should be similar, if possible, to products already known; it should incorporate ingredients that are locally available (or potentially so); it must be nutritionally potent.

Although this approach offers exciting possibilities, its significance should not be viewed out of context. The claim of some food scientists that this is the answer to the protein problem is perhaps a bit optimistic-at least for the present. Although the commercialized, formulated protein food can be of significant value to the urban poor, it offers less hope to the malnourished multitudes living in non-monetized rural areas.

Another interesting use of oilseeds in some countries could be the "toning of milk." In India, for example, the butterfat content of buffalo milk is more than double that of cow's milk. By adding additional protein, one can dilute the butterfat content and stretch the available milk supply. Toning has been accomplished in the past with non-fat dry milk-now unfortunately in short supply throughout the world. However, Indian food scientists have devised the technology to use oilseed isolate in place of powdered milk-at considerable economy.

Recently much attention has also been given to fish protein concentrate, another good and inexpensive protein suitable for infants. The development of F.P.C. has followed a rocky road-especially in the United States. However, even here the earlier esthetic objection to consuming the whole fish apparently has now been overcome. The same is true of various technical obstacles, as is reflected in the recent approval of two F.P.C. processes by the U. S. Food and Drug Administration. Fish is the most underutilized conventional food source-accounting for only 1 percent of the world's total food consumption. Assuming that widespread cultural and religious taboos can be overcome, the use of fish in combatting malnutrition has great potential.

A number of other protein discoveries have been made of late-some at this point laboratory curiosities, others verging on science fiction. But their potential is too important to overlook. Receiving considerable attention is the prospect of producing edible protein by growing single-cell organisms on natural gas, petroleum, vegetable wastes or even coal The Dutch Shell Group, for example, has found a bacterium which uses methane, a natural gas, as its sole source of energy for reproduction. These bacteria contain about 50 percent protein, and, according to U. S. nutritionist Dr. Nevin Scrimshaw: "There is little doubt that wholesome and nutritious single cell products utilizing energy from petroleum or natural gas can be developed and produced in almost unlimited quantities within a decade."[ii] Some scientists are talking in terms of three to five years. Already, two million pounds of petroleum-based feed are being used to fatten cattle and poultry in a Russian research project. A similar "petroleum diet" experiment is being conducted with pigs in Nigeria.

The potential advantages are many: the relative abundance of petroleum, even in food-short countries; the independence from climatic uncertainties; the small space requirement; the need for only a few technicians; and the rapid growth rate. All these suggest the possibility of unlimited man-made protein production. Most of the world's large petroleum companies are deeply engrossed in protein projects. Some are actively collaborating with major food companies-such as the current Esso/Nestlé liaison. The president of Gulf Oil recently predicted that protein food will become a significant by-product of the oil industry.

Scientific imagination has gone further. "Milk" has been produced from water-soaked leaves. Seaweed and algae are other protein possibilities currently being examined. (A French company recently discovered an entire West African village successfully using algae as its basic protein source.) Much work remains, however, to improve palatability and to find ways of producing economically feasible products.

IV

Required changes of food habits, indispensable to the success of many of the above approaches, present an imposing obstacle. Although there is an important correlation between dietary standards and per capita income, food habits also have deep psychological roots and are associated with love, affection, warmth, self-image and social prestige. As a result, there is perhaps no aspect of personal life less flexible than one's eating pattern. Behavioral studies of Tunisian immigrants to France demonstrated that changes in their food habits occurred long after they had accepted the language and newspapers of their adopted country. Change comes hard, even among the most sophisticated elements of society. How many doctors, for example, have altered their breakfast habits-their consumption of eggs, butter, cream, sugar (and the after-breakfast cigarette) in the face of health warnings circulated in recent years? Resistance to change is even stronger in traditional societies lacking the advantages of extensive communications.

To bypass what Dr. Margaret Mead refers to as "the irrational rigidity" of inadequate diets, one might conclude that, when possible, emphasis should be placed on food fortification and the development and multiplication of new varieties of high-protein seed. Neither the color, texture nor taste of the food need be affected. Similarly, no change would be required in existing buying, cooking or eating habits.

This does not eliminate the need for other approaches or for a strong educational effort. In Africa, for example, some believe that mangoes produce jaundice. In India, one of the few foods accepted throughout the country is dal, very high in protein, but rarely fed to the weaning infant because of unfounded fears that it will cause digestive problems and eventual death. In this instance, the necessary protein to keep the child healthy is literally in the mother's possession. Yet dal typically is fed only to adults of the family-even though the protein requirements of the infant are two and one-half times greater per kilo of body weight.

In a fascinating study of changes in Israeli food habits, Dr. Sarah Bavly concluded that the most important influence in the introduction of new foods-weighed against the influence of newspapers, radio, husbands, neighbors, etc.-is the exposure of the child to nutrition education in school. Second in rank is the provision of a school lunch, even without formal nutrition instruction.

The large programs of child feeding now under way in most developing countries are themselves helping to improve standards of nutrition-but many believe they could be accomplishing more. Unfortunately, such programs frequently connote relief or charity. As a result, the food is usually provided as an end in itself, rather than to accomplish other important goals-viz. intentionally reorienting eating habits, incorporating nutrition education into the curriculum, encouraging the use of local commodities, and helping to establish the necessary agencies to continue a program after current sponsors no longer are involved.

In the critical role played by agriculture in economic development, primary attention is and should be given to greater farm yields. However, the need for more attention to the qualitative side of food production is becoming increasingly apparent. Provision of adequate supplies of grain staples is not enough, as has been demonstrated in Mexico, where the enormously successful campaign to increase overall food production has not resulted in significantly alleviating widespread malnutrition among children. An item on the current agenda of the U.N. Economic and Social Council implies that in agricultural planning, the nutritional needs of the population and particularly of the preschool child should be taken into account.

Finally, no discussion of increasing protein supply is appropriate without some mention of the work needed to prevent sizable protein loss to insects, rodents and mold. In India, this has been estimated at up to four million tons a year. Although there are many questions yet to be answered concerning the most effective techniques, sufficient information is already known-especially in the context of proper storage facilities and environmental control-for major steps to be taken immediately.

V

Although most of the necessary resources to combat malnutrition may be readily at hand, the solution to this problem is by no means simple. Unlike the successful program to eradicate malaria, more than a can of spray is needed to conquer this more pernicious enemy. Malnutrition is a multifaceted problem requiring a coördinated approach. Other than in a superficial sense, this does not now exist.

One of the basic difficulties is the lack of consensus among the many disciplines working in the field, and often among many of the scientists within the same discipline. Malnutrition is an interdisciplinary problem, but each discipline-nutrition, food technology, health education, marketing- tends to be a bit over-disciplined in prescribing its own solution. There is a kind of unrealistic parochialism that prevents a clear view of the aggregate problem.

Another impediment is the gap frequently existing between the scientific community and the food industry-or stated another way, between the laboratory and the child's stomach. In essence, the difficulty is one of mutual suspicion. Food industrialists frequently regard nutritionists and food technologists as academic, ivory-towered types who lack any understanding of the problems of marketing. The premium placed on a signed journal article is generally much greater than that given for the sometimes tedious follow-through required to put these findings to use. In turn, food executives are often perceived as onerous "profiteers," or at best as "tradesmen." The result, in many countries, is a serious lack of substantive collaboration.

Still another difficulty in many protein-poor countries lies in the policy and communications gap between government and the fledgling food industry. In some nations, policies relating to licensing, pricing and food standards often cause interminable delays and frustration. The result is a severe inhibition of growth. In these countries, the percentage of earnings going into pioneering work, product development and market testing is considerably smaller than it is in countries with fewer restrictions.

Thus, while promising nutrition activities are taking place in a number of countries, the accomplishments so far fall considerably short of the need. Technologically, malnutrition can be overcome. The arduous and expensive task of doing it has hardly begun.

The basic fact, perhaps, is that governments which have discussed the need in principle have not faced up to the magnitude of their role. Although governments recognize that an educated populace is important for development-and hence give substantial support to educational systems-there is not yet the same awareness that a well-nourished population has comparable importance. Perhaps this lack of governmental focus on the importance of nutrition for national growth reflects only an information gap between the laboratory and the political leader that will be overcome in time. Meanwhile, the consequences for national development are increasingly clear. Without improved nutrition in the less favored two- thirds of the world, the development of human resources-and the development of the nations themselves-is sure to be retarded.

[i] Federation of American Society for Experimental Biology, Proceedings, n. 20, 1961 (Supplement 7: 323).

[ii] "Increasing the Production and Human Use of Protein." Working Paper for U.N. Advisory Committee on the Application of Science and Technology to Development, October 5, 1966, p. 21.

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