P o p u la tio n a n d N u tr itio n : A C a se fo r I n te g r a tio n JA M E S E. A U S T IN F. JA M E S L E V IN S O N I n operat ional t erms, effect ive nut rit ion ser vices can incr ea se healt h w or ker cr edibilit y with mothers a nd incr ease t heir recept ivit y t ow ar d fa m il y pla n nin g. Am ong ot her syn er ­ gistic program r elat ionships, high I U D r em oval r at es a r e r elat ed to nut rit ional anem ia in women which could be cor r ect ed by nut rit ional supplem ent at ion. Fi n a lly, oper at ing efficiencies might be at t ainable in som e inst ances t hrough the use o f com m on per son n el and facilit ies. I nt egrat ion, alt hough desir a ble in m any ca ses, f a ces sever a l ba r r ier s: at t empt s to maintain separat e pr ogr am s in or der to pr eser ve independent inst it ut ional pr est ige a n d power ; unequal pr ior it y assignm ent to the differ ent pr ogr a m s; t he lack o f int egr at ed approaches by int ernat ional fu n din g a gencies. Addit ional informat ion w ou ld be useful on at t it udes in t he pa r en t a l pr ocr ea t ion decision-making pr ocess, m a na ger ial r equisit es o f int egr at ed deli ver y syst em s, bi ologi­ cal and physiological linkages bet ween fer t ilit y a n d nut rit ion, a n d im pact assessm ent o f integrated pr ogr am s. Two o f the most cr it ical pr oblem s fa cin g low-in com e count r ies t oday a r e w ide­ spread malnutrition and bur geoning populat ions. Pr ogr a m s h ave been m ount ed to at ­ tack both o f t hese int errelat ed pr oblem s, but lit t le has been done to coor dinat e a n d integrate t hese effort s. I n many sit uat ions t here a ppea r s to be st r ong r at ionale f o r such int egr at ion. Bot h are new pr ogr am s t rying to est ablish t heir pl a ces on the nat ional developm ent a gen da . Population cont rol is more r ea dily ju st ified by econ om ic cr it er ia wh ile nut rit ion is m or e socially and polit ica lly accept a ble. T h eir fu sion can a ch ieve a m ut ually r einfor cin g complementarity. Ther e also exist s a ser ies o f r elat ionships (wit h va r ying degr ees o f evidential st rengt h) among fer t ilit y, fa m i ly size, a n d m alnut r it ion: sm a ller fa m il ies result in better nutrition which r educes m alnut r it ion-relat ed mort alit y, t hus im pr oving ch ild survival pr obabilit ies and, in t urn, enhancing fam ily-pla n n in g m ot ivat ion. In a recent conversation w ith an executive o f a found ation involved in family-planning activities, w e inquired ab ou t the o rg an izatio n ’s in­ terest in program s jo in tly addressing po pu latio n and nu trition . H e re ­ plied that the foundation has no interest in n u trition , b u t w as interested in finding ways o f m aking fam ily -p lanning program s m ore effective. Shortly thereafter w e asked a n utrition-plann ing body in a L atin American country w hether it m igh t be w orth co nsid ering a jo in t d eliv ­ ery system o f nutrition and fam ily -p lanning services. T he grou p re­ sponded negatively, saying that successful nutrition p rogram s are dif­ ficult enough to bring abo ut and sh o u ld n ’t be saddled w ith the addi­ tional burdens o f a pop ulatio n-control pro gram .. M M F Q / H ealth and S o c ie ty / Spring 1974 169 170 Spring 1974 / Health and Society / M M F Q T h ese co m m en ts are no t atyp ical o f the attitudes o f many indi­ v id uals and org anization s op erating in the fields o f nutrition and popu­ lation and reflect the sig nificant gap in understanding and interaction w hich freq uently sep arates them . Like professionals in every field, they tend to stand guard o v er their bailiw icks and view with suspicion any attem p t at en cro ach m en t from outsiders. There are, of course, ex cep tion s, and a few projects have genuinely attem pted to bridge this d isciplin ary g a p ,1 bu t these efforts usually have been relatively limited in scope and resou rces. In this pap er, aim ed prim arily but no t exclusively at the planner, it is suggested that the com plem entarity o f population and nutrition o bjectives and program s argues fo r an integration o f inputs in some situ a tio n s,2 and that high research priority should be given to deter­ m ining specifically the nature o f such in te g ratio n .3 T he d esirability o f a closer interface betw een population-control efforts and nutrition-im p rov em ent program s stem s from four existing o r poten tial relationships. 1. B oth p op ulation and nutrition are relatively new policy areas attem pting to establish them selves as developm ent priorities and to integrate them selves into broader national planning. 2. E vidence from various parts o f the w orld suggests important relationships betw een fam ily size and m alnutrition and bet­ w een m alnutrition -related child m ortality and high fertility. 3. The com p lem entarity o f prog ram inputs suggests that their com b ination often w ould increase the effectiveness of both ef­ forts. 4. Jo in t populatio n-nutrition delivery system s can achieve impor­ tant operating efficien cies, particularly given the similarity of p ro gram recipien ts and beneficiaries. The p aper exam ines each o f these relationships and then attempts to identify operation al research relevan t to the effective integration of nutrition and po pu lation program s. *An important example is the Rural Health Research Center in Narangwal, India, af­ filiated with the Johns H opkins University. 2There are, of course, many nutrition programs ( e.g., food fortification, plant breeding, agricultural price policies) and some population activities which don’t lend themselves to such interaction. The discussion here refers primarily to those population and nutri­ tion efforts earned out in an institutional setting. 3M any of the comments made here would argue for inclusion of public health inputs as well, or at least of selective aspects of public health directed primarily at young mothers and children. Such inclusion is important, and is implied in the discussion which fol­ lows. 171 M M F Q / H ealth and Soci et y / Sp r i n g 19 7 4 Establishing N e w P o lic y A rea s Unlike more established dev elopm ent program s (e .g ., agricultural and industrial developm ent and ed ucation ), po pu lation and nutritio n are relatively new policy areas in developing coun tries. B oth have con sid­ erable flexibility in the form they assum e as p ro gram s, and both are in need o f sizable governm ent and budg etary support. In this regard each might be strengthened by som e degree o f association w ith the other. Population program s today, w hile b etter supported than nutrition activities, still are neither u niversally accepted nor adequately funded in most countries. As indicated in T able 1, few er than h alf o f the developing countries (although these included to d a y ’s heavily p o pu ­ lated countries) had an antinatalist policy o r sizable fam iy-planning program by 1970.* 4 O f the 14 countries w ith m ajor p ro gram s, only tw o (India and Pakistan) allocated o v er 1 p ercen t o f th e ir national bud gets to population co n tro l.5 W ith respect to n u trition , abo ut 100 low income countries engage in som e form o f child feeding, but few er than a half dozen have form al national n utrition o b jectives, p olicies, and programs. T ABLEl Governmental Positions on Family-Planning Programs and Policies— 1970 P o p u la t io n D e v e l o p in g C o u n tr ie s M illions Percentage Official antinatalist policy and family-planning programs 24 1,8 38 72 No official policy but support of family-planning programs 23 213 9 No policy or support for family­ planning programs Total 55 491 19 10 2 2,542 100 Source: B a se d o n T h e P o p u la tio n C o u n c il ( 1 9 7 1 : T a b le 3 ) . One reason these program s have not fared b etter at the national level is their new ness p er se. The d ynam ics o f p op ulation and nutrition 4A report from The Population Council (Stamper, 19 73) reveals that, of 70 developing countries covering 45 percent of the world’s population, only 27 countries recognize any population problem in their development plans and only 18 countries have explicit policies and programs in these development plans to reduce fertility. 5While India allocated 49 percent of its health budget to fam ily planning, population programs in nine of the other 13 countries surveyed received less than 4 percent of health outlays. 172 Spring 1974 / Health and Society / M M F Q p ro gram s are still relatively u n fam iliar to governm ent planners, who are g en erally eco n om ists, law yers, o r en g in eers by training. National plan ning b od ies seldom include d em o g rap hers o r nutrition personnel, and there is an u n d erstan d ab le reluctance to venture deeply into these un charted w aters, particularly w hen o th e r im portant and more familiar sectors m ake claim s on the sam e resources. In b u ilding an econom ic case fo r accelerated investm ent, popula­ tion ad vocates have a less d ifficult p ro blem than nutritionists. Most b asically, the case fo r po pu lation is increased p er capita income result­ ing from lo w er b irth rates as national incom e is spread among fewer peo ple. A lth ou gh the p lan n er m ay no t alw ays respond to notions of net disco unted value o f averted b irth s, he will see the obvious savings in stabilized capital o utlays fo r scho ols, health facilities, transportation system s, and o th er form s o f social in frastru c tu re .6 The nu trition advocate orients his case tow ard human capital form ation , p o stulating that m alnu trition am ong adults reduces physical w ork cap acity, and that m alnu trition am ong young children may result both in physical stunting and decreased learning capacity. In both cases future lab or prod uctivity is redu ced . It also is argued that in­ v estm ent in nutritio n boosts the effectiveness o f other development sectors, particularly public h ealth, by redu cing the dem and for curative m edicine, and edu cation th ro u gh in creased m ental capacity (Selowsky and T ay lo r, 1 9 7 3 ).7 W h ile n utrition co nscio usness has increased significantly among planners in m any cou ntries, expen ditures still represent a tiny fraction o f w hat is needed. In part this is because m ost planners and eco no m ists still regard nutrition ex pen ditures as consum ption (a taboo in traditional d evelopm en t m odels) rather than investm ent. In addition, g overnm ents often view the m aln utrition problem as too unmanageable an u ndertaking and see no inexpensive solutions. A ltho ug h easier to ju s tify in econom ic term s, population pro­ gram s have encoun tered m ore serious po litical obstacles. Population control and artifical con tracep tion are, for m any, em otionally charged issues and often encou n ter strong resistance. In som e cases there is a religious basis for this o pposition. In others, political spokesmen attri6For a thorough discussion of the measurement techniques for quantifying the economic impact of birth-rate reductions see Robinson and H orlacher ( 19 71) . 7W ray and Aguire concluded from a survey of 1,0 94 children under six years of age in Colombia that “ children from large families are more likely to be malnourished than those from smaller fam ilies.” Also, see Ramathibodi H ospital Faculty of Medicine and Disease ( 1969) ; W yon and Gordon ( 1962) ; Levinson ( 1974) . M M F Q / Health and S ociety / Spring 1974 173 bute genocidal m otives to national go vernm ents o r to bilateral assis­ tance agencies prom oting fam ily -p lanning program s. N utrition p ro ­ grams, by contrast, are generally m uch less controv ersial, and in som e countries, notably C hile and India, have been agg ressively advo cated in political party platform s. Even though population and nutrition program s have been lim ited in magnitude thus far, they show every pro m ise o f com m an ding in­ creasing shares o f national budgets in the future. D om estic resources are likely to be augm ented by a greater flow o f po pu latio n and nutri­ tion assistance from international ag encies, w h ich already have played an important catalytic role in draw ing attention and resources to these problems. Thus, it is im portant at this tim e to m ake rational decisions about the direction o f these program s and about any interaction that should take place. Aside from the often increased effectiveness o f com b ined inputs, which is discussed below , the forego ing co m m ents w ou ld sug gest that government support for integrated p rog ram s m ay exceed th at given fo r population and nutrition w hen pursued indepen dently . P opulation pro­ vides a more com pelling econom ic rationale than nu trition, w hile nutri­ tion provides governm ents w ith great political capital and m akes popula­ tion programs more acceptable. The L inkages: Family S iz e — M alnutrition — M o rta lity — F ertility An important justification for populatio n-nu tritio n p ro gram interaction is their mutual reinforcem ent o f program objectives. S m aller fam ilies result in better nutrition, w hich reduces m aln utrition-related m ortality, in turn enhancing fam ily-planning m otivation. Looking first at the effect o f in creased po pu lation on m aln utri­ tion, it is reasonably clear that larg er fam ily size ex acerb ates n utri­ tional status. N ot only a given quantum o f resou rces b u t also a lim ited availability o f tim e and attention m ust be divided am ong a larger number o f children. A s a resu lt, fam ily size appears to have im portant effects both on food intake and m o rbidity, the direct determ inants o f malnutrition. With respect to food intake, larg er fam ilies lead to decreased p er capita consum ption unless the d eficit is m ade u p b y additional incom e. With less food to go around, the vu lnerable infants and young children 174 Spring 1974 / H ealth and Society / M M F Q usually suffer m ost. (G o sp alan , 1968) H o w ever, it is also likely that the n utritio nal status o f m others is adv ersely affected, especially high p arity w om en w ho generally are m ore prone to anem ia; poor maternal n utritio n, in tu rn , con trib utes to com p lications in pregnancy, delivery, and p uerperium (Siegel and M orris, 1967). L actation can also be re­ strained , thus red ucing a critical pro tein source for infants as well as rem ov in g the contraceptive effect present during lactation (Salber et a l., 1965). A s regards health, evidence from India, Colombia, and T h ailand suggests that the general health status o f children, and par­ ticularly the prevalence o f diarrheal disease, is, to an important extent, a function o f fam ily size. T his m ight indicate both that the spread of infection is facilitated by the crow ding found in densely populated h ouseh olds, and that parents in a poverty situation often provide less care to later-bo rn children (see W ray, 1971). W hile population pressure aggravates nutritional status, the re­ verse also takes place, thus creating a vicious circle. Malnutrition has been cited as “ the biggest single co ntributor to child mortality in the d evelop ing co u n tries” (C rav ioto and D eL icardie, 1970:25). In Latin A m erica, fo r exam ple, m alnutrition has been identified as a major cause o f 57 percent o f the deaths o f children aged one to four as well as “ a co ntribu tor to the im m aturity responsible for half to threequarters o f the deaths in the first m onth o f life” (B erg, 1973:4). There is som e evidence that the m alnou rished state o f the child is related to virtually the entire child -m ortality differential between low-income and industrialized countries. A study by Sloan (1971:58) of mortality d ata in Puerto R ico , M exico, C osta R ica, and E ast Pakistan (Bang­ ladesh) concluded that “ the m ost clearly evident relationships are the effects o f fem ale literacy and nutrition on m ortality of infants and pre-sch oo l children . . . sanitation and housing variables provide no ex planation o f variation in the m o rtality .” T he often cited five-year IN C A P study o f three G uatem alan villages (Scrim shaw et al., 1968) found that preschool child-m ortality rates decreased more, both rela­ tively and abso lutely, in the village w here supplem entary feeding alone w as used than in the control village o r the village where various public health care m easures and m edical care services were employed. W ith m alnutrition so im portant a contributing factor to child mor­ tality , som e m igh t contend that im proved nutrition and the resultant d ecrease in d eaths, although desirable from a hum anitarian point of view , w ould sim ply exacerbate the population problem . In fact, the lim ited evidence available suggests the reverse. A m ajor study carried o ut by W y on and G ordon (1971), provides M M F Q / Health and S ociety / Spring 1974 175 considerable insight on this m ortality-fertility relationship. T his study, carried out in rural Punjab in N orth India betw een 1953 and 1959 w ith follow-up investigation in 1969, proposed to test the effectiven ess o f existing contraceptive m ethods in changing birth rates in a rural, low income society and to identify o ther facto rs w hich influence p opula­ tion dynam ics. The authors reported (W yon and G o rd on , 1971: 197, 200, 206) that their “ findings leave no do ub t that loss o f children by death was a pow erful influence controlling fam ily size . . . Fam ilies apparently replaced children w ho died , or lim ited further births w hen they had the num ber o f surviving children that satisfied them . . . T he conclusion seem s clear: until they have goo d assurance that liv e-b orn sons, and daughters, w ill survive, coup les in K hanna are unlikely to be interested in restricting the nu m b ers o f th e ir child ren beyond their present p ractice.” W ray (1972), in an ex cellen t survey o f sim ilar studies, cited research by H assan in E gy pt ind icating that a m o ther who has lost at least one child w ill desire a larg er n um b er o f surviving children and will have m ore su bsequent births than w om en w ho have not lost children. A nother study by Schultz and V anzo in B angladesh revealed a direct relationship betw een the death o f a child and the probability o f a birth in the sam e fam ily d u ring the su bseq uent year (Wray, 1972). H arrington (1971) p resents sim ilar data fo r W est A frica which reveals that early experience o f child loss tends to inflate fertil­ ity behavior. Even those w ho argue that d ecreased child m ortality w ill lead to lower fertility concede the inevitability o f som e lagtim e fo r reproductive-age parents to recognize the lo w er m ortality in the co m ­ munity and to relate this to their ow n procreative situation. T h e q u es­ tion is the length o f the lagtim e. U ntil recently it w as assum ed th at the lag period m ight be a generation. T here is som e ev id en ce, how ev er, that at least in certain situations the period m ay be consid erably shor­ ter. Wray cites studies in T u rk ey and Puerto R ico th at show a threeyear lag period. S chultz’s (1971) analysis o f data from T aiw an , indi­ cates a lag o f two to four years. These m ultifaceted and circu lar relationships betw een m alnu tri­ tion and fertility are presented in Fig. 1. A ro u g h app ro xim ation o f the strength o f existing research evidence is also in dicated in the diagram . Starting with the m alnutrition o f the m o th er, line a suggests th at non­ pregnant wom en in an anem ic status w ill have lo w er energy stores and thus be less apt to p rovide physical care and social stim u lus w hich in turn can lead to o r exacerbate a m alno urished co nd itio n. W hile re­ search to date is incom plete, studies on relation ships betw een m alnu- 176 Sp r i n g 19 7 4 / H ealth and Soci et y / M M FQ -------------------------- 1 (0 a (/> c o ■4— a <1) c o ao> a> o a> 9) [O T3 > O a> 2 c o» N u tr itio n -fe r tility 1. > > <D F ig Malnutrition of mother co r e la tio n s h ip s . o* c a) k. M M F Q / Health and S ociety / Spring 1974 177 trition and mental d ev elopm ent suggest that environm ental and p articu­ larly parental stim ulus is critical to a ch ild ’s cog nitive d evelopm ent. Line b indicates that m alnourished pregn an t w om en m ore frequently give birth to low er-w eight babies w ho in turn have a h ig her incidence of malnutrition and m ortality. L ines c and d indicate that p o or m ater­ nal nutrition increases the likelihood o f p regnancy w astage and d e­ creased reproductive capacity. Line e is the relatio nship betw een in­ fant and child m alnutrition and h ig her m ortality. Pregnancy w astage and infant m ortality com bine to create an in creased desire to have more offspring ( l i n e / ) , i.e ., the “ child survival h y p o th e sis.” Preg ­ nancy wastage m eans no lactation (line g), thereby losing the co n ­ traceptive effect o f delayed return o f ovulation and m en struation and thus narrowing child spacing (line h). D ecreased rep ro ductive capacity (due to irregular anovulatory m enstruation) w ould tend to reduce the number o f pregnancies and increase child spacin g, w hile the increased desire for procreation w ould have the op po site effect (line i). F in ally , the net increase in fam ily size and the n arro w ing o f child spacing take their toll on the nutritional status o f the m o ther and h er children through decreased per-capita availability o f reso u rces, and throug h further w eakening o f the m o th er’s cond ition (line j) . O f cou rse, the diagram is not an isolated p henom enon; e .g ., m any o ther factors influ­ ence the m alnutrition o f m o ther and child and the procreation decision-making process. W hile the com plem entarity o f nutrition and po pu lation program objectives suggested by these relationships do es not argue for integra­ tion per se, it does underline the need to pursue b oth program s even if the community o r country concerned is only interested in one o f them . C om plem entarity o f Program Inputs In a practical, operational sense, the integration o f po pulation and nu­ trition inputs m ay increase the effectiveness o f both. M any population programs around the w orld have ru n into difficulties b ecause services provided were lim ited exclusiv ely to loop in sertions and vasectom ies, sometimes pursued in a h eavy-handed m an ner in o rd e r to m eet pro­ gram quotas. O ften the result has been to antagonize potential reci­ pients and to decrease the effectiven ess and m orale o f the w orkers. A center capable o f caring fo r a young m o th e r’s child ren w ith d em on str­ able results through b etter nutrition w ill be in a fa r b etter p osition to successfully dissem inate the fam ily -p lanning m essag e. T he N arangw al 178 Spring 1974 / H ealth and Society / M M F Q R ural H ealth R esearch C en ter in India (B erg, 1973:36), for example, “ found that w ith nutritio n services ‘the dram atic improvement in a child w ith m arasm u s has m ore im p act on general rapport and relation­ ships w ith village fam ilies than anything else w hich we have tried to do in active m edical care. T he change in the children is so obvious, and the w hole pro cess is so readily un derstood, that such efforts do lend con siderab le cred ib ility to w hat o u r village w orkers say on other m a tte rs .’ ” In addition to increasing cred ib ility, ongoing nutrition services m ay facilitate acceptor follow -up. D rop out rates in family planning p ro gram s are one o f the m o st serious problem s. It has been demon­ strated that m others are m ost receptiv e to fam ily planning advice dur­ ing p ost partum ; h ow ever, the favorable psychological milieu subse­ q uently disapp ears and often contribu tes to the cessation of contracep­ tive p ractices. M ore frequ en t contact w ith the m other might help to reinforce the desirability o f contraception . B ecause nutrition programs g enerally have such high p atient-contact frequency (unlike the threeto six-m onth intervals o f fam ily-planning program s), they might be used to reiterate the fam ily-plann ing m essage and thus help reduce the accep to r dro pou t rate. There is o ther specific interaction o f inputs relating to contracep­ tion p er se. H igh rem oval rates o f intrauterine devices may be largely related to nutritional anem ia in w om en, w hich could be reduced by iron and vitam in su pp lem entation at an integrated center (Wishik, 1972). C areful m onito ring o f nu trition and health status at such a cen ter could decrease the likelihood o f vaginal bleeding (which further ex acerbates m alnutrition) from IU D s o r o f reduced lactation (and hence d ecreased infant nutrition) w hich can accom pany the use of birth control pills high in estrog en (C h op ra et al., 1970). M aternal ed ucation co ncerning breast feeding is an important as­ pect both o f fam ily -p lanning and nutrition program s. From the nutri­ tion p erspective, early w ean ing denies the child a high-quality protein source w hich is d ifficult to replace fo r low -incom e families. The result is a h igh incidence o f nu tritional m arasm us and subsequent child mor­ tality. From the fam ily -p lann ing view point, as noted earlier, nursing lengthens the tim e o f anovulatory cycles after parturition, and thus serves as a partial contraceptive m echanism . This could help avoid closely spaced births w hich often result in low er birth weights, and w hich in turn are associated n o t only w ith high child mortality but also w ith a g reater incidence o f neurological and physical handicaps than is fou nd at norm al birth w eights (F risch , 1971). Educating pregnant and 179 M M F Q / Health and S ociety / Spring 1974 lactating m others o n the im p o rtan ce o f breast fe e d in g rep resents an area o f lo g ica l o verla p b e tw e e n nutrition and fa m ily p la n n in g . Another lin k m ay b e the fo llo w in g : im p ro v ed n utrition m a y d e ­ crease the ed u catio na l d rop ou t rate, w h ic h m ig h t in turn lea d to a delay in the age o f m arriage. S u c h a p o stp o n e m e n t m a y h av e a d am ­ pening effect on p op u la tio n in crea se. T h e in crea sed ed u c a tio n a l le v e l may also increase recep tiv ity to fa m ily -p la n n in g se r v ic e s or the a b ility to benefit m ore q u ick ly fro m the ed u ca tio n a l d im e n sio n s o f su c h ser­ v ices. Operating E ffic ie n c ie s Population and nutrition p rogram s b a sica lly are a im ed at the sa m e target group: the lo w e r-in c o m e re p r o d u ctiv e-a g e m o th er and her y o u n g offspring. B oth program s m a y d ep en d sig n ific a n tly o n the d isse m in a ­ tion o f su fficien t und erstan d ing and tec h n ic a l sk ill to p erm it, o n a long-term b a sis, a p p lica tion o f the n e c e ssa r y p r ev en tiv e m ea su res in the hom e. G iv en the m a g n itu d e o f th e se program u nd ertak in g s it seem s clear that co nsid era ble e c o n o m ie s c o u ld resu lt fro m th e u se o f com m on p erson n el, tran sp ortation, eq u ip m en t, and p h y sic a l fa c ilit ie s in m any program s. C o m m o n ed u ca tio n a l m ateria ls a lso m ig h t b e d e ­ signed for the y o u n g m o th er in n eed o f b o th k in d s o f in fo rm a tio n . In addition, integrated coo rd in a ted inputs c o u ld e c o n o m iz e o n w h at is often the scarcest resou rce o f a ll, n a m e ly , sk illed and e x p e r ie n c e d ad­ ministrative talent (A u stin , 1 9 7 3 ). C o m m o n ly op era ted p rogram s could result in im portant sa v in g s b y red u cin g bureaucratic d u p lica tio n and adm inistrative h ierarchy. F in a lly , the c lie n t c o u ld m ak e b etter u se o f her tim e by d ea lin g w ith tw o fa m ily p ro b lem s s im u lta n eo u sly in­ stead o f ha ving to incur the extra tim e , in c o n v e n ie n c e , and transporta­ tion costs o f separate v isits. Barriers to Program In tegration Even if planners, p o lic y m a k ers, and a d v isers r e co g n iz e d (an d m a n y have) the a fo rem en tio ned in terrela tio n sh ip s and p oten tia l b e n e fits fro m integrating certain typ es o f nutrition and p o p u la tio n p rog ram s, there are som e additional barriers in tra n sla tin g th is r e co g n itio n in to p ro g­ ram action. Spring 1974 / Health and Society / M M F Q 180 O n e su ch barrier to in te g r a tio n , referred to earlier, is a desire on the part o f co u n try p rog ra m o f fic ia ls (b y n o m ean s unique to the de­ v e lo p m e n t c o n tex t) to m ain ta in th eir areas as sep arate, in order to re­ tain the p restig e and p o w e r a sso cia ted w ith organ ization al indepen­ d en ce and id en tity . In stitu tio n s, o n c e crea ted , h a ve an am azing tena­ c io u s n e s s . A se co n d p ro b lem in heren t in in teg ra tio n is unequal priority as­ sig n m e n t and resou rce a llo c a tio n a m o n g the co m p o n en ts, e .g ., family p la n n in g , n utrition , and cu rative m ed ic in e . In o n e Central American co u n try , fa m ily p la n n in g w a s in corp orated in to an o n g o in g maternalc h ild h ea lth care p rogram , but r e c e iv e d o n ly sporadic attention from the m ed ica l p e r so n n e l. T h es e p e r so n n e l, alread y in short supply, were cau gh t up in th eir m ore im m ed ia te cu ra tiv e resp o n sib ilities, knew little ab ou t fa m ily p la n n in g , and had little a d d ition al fu nd in g to provide the n e w s e r v ic e s . T h u s , the in teg ra tio n w a s in n am e o n ly , and the quality o f fa m ily -p la n n in g se r v ic e s b e c a m e le s s ad equ ate than before the in­ teg ratio n . It is q u ite p o s s ib le that in so m e in sta n c es integration will not in crea se the e ffe c tiv e n e s s o f b o th p ro gra m s, but w ill benefit one pro­ gram co n s id era b ly w h ile the im p a ct o f the other rem ains largely un­ c h a n g e d o r w ill b e red u ced so m e w h a t. T h e task o f the planner is to ev a lu a te the n et o v e ra ll im p a ct o n the tw o p rogram s. A third p rob lem rela tes to the intern ation al assistan ce agencies. T h ese in stitu tio n s h a v e p la y e d a critica l fu n d in g role for population and nutrition p ro gra m s, but h a v e rarely integrated their assistance p a c k a g e s. F u n ds h a v e flo w e d to p o p u la tio n and nutrition programs from separate o rg a n iza tio n s o r d ep a rtm en ts, and th is, in turn, has had so m e in flu e n c e o n the m an n er in w h ic h recip ien t countries have or­ g a n ized th eir p rogram s in th e se fie ld s . In th is regard, present explora­ tio n o f in teg ratio n p o s s ib ilitie s b y sev era l o f the assistan ce agencies is a p ro m isin g d e v e lo p m e n t. R ese a rc h A g e n d a W h ile fin d in g s to date o n p o p u latio n -n u tritio n lin k ag es indicate the p oten tia l b e n e fits o f program in teg ratio n , there is a need for further research to cla r ify the d y n a m ic s o f p op u lation -n u trition interaction and to d eterm in e the fo rm su ch in teg ra tio n sh o u ld take. T h is n ee d ed research and ex p er im en ta tio n cuts across several dis­ c ip lin e s and h as an a p p lied o rien ta tio n . In m o st ca ses it w ould take the form o f fie ld o p era tio n s d e liv e r in g b e n e fits to clien ts w h ile gathering n e ed e d in form a tio n and e x p e r ie n c e . S u ch research m igh t fall into these g en eral c a te g o r ie s. M M F Q / Health and S ociety / Spring 1974 • 81 Attitudes One o f the m o st critical d im e n s io n s o f the p o p u la tio n -n u tritio n , o r more broadly, the p o p u la tio n -h ealth care re la tio n sh ip is the p r e v io u sly discussed effe c t o f d ecrea sed c h ild m o rta lity o n fer tility . T h e h an d ful o f m icro-level stu dies w h ic h h av e p rob ed m o rta lity -fertility rela tio n ­ ships in different co u n tries, u su a lly after the fa ct, h av e b e en u s e fu l but not yet co n c lu siv e , as w a s su g g e ste d in F ig . 1. A dditional research is n e ed ed to corrob orate th ese fin d in g s w ith explicit longitudinal in v estig a tio n . In a d d itio n , there is n eed fo r s e n s i­ tive inquiry into the nature o f parental a ttitu d es w h en m o rta lity rates decline, sp e cifica lly in the c o n tex t o f the c o m p le x s o c io e c o n o m ic and cultural factors ( i .e ., ev ery th in g fro m r e lig io u s ritual to a n ticipa ted social secu rity in o ld a g e) w h ic h co n stitu te the p aren ts’ p rocrea tio n decision-m aking p ro c ess. S u c h an in q u iry a lso w o u ld a s s e s s the lik e li­ hood o f a ffectin g such facto rs throu g h g o v er n m e n ta l p o lic y and pro­ grams. Here the d is cip lin es o f s o c io lo g y , a n th r o p o lo g y , and p s y c h o l­ o gy are particularly releva nt. F in a lly , u tiliz in g the a b o v e in fo rm a tio n , it would be p o ssib le to fo c u s d irec tly o n m ea n s o f o r g a n izin g and timing program s and in fo rm ation d is se m in a tio n in w a y s w h ic h w ill have the greatest in flu en ce o n p rocrea tio n d e c is io n s . E ffo rts th en could be m ade to d es ig n integrated ed u c a tio n a l p a ck a g es and to carry out n ecessary training for fie ld p erso n n e l. M anagem ent Research in the m a n a g em en t area w o u ld attem p t to d eterm in e th e p o ­ tential ec o n o m ics and im p act o f va riou s ty p e s o f in tegrated d e liv e r y system s. T he relative e ffic ie n c y and e ffe c tiv e n e s s o f altern a tive or­ ganizational form s ( e .g ., m u ltip u rpose cen ters and m o b ile c lin ic s ) could be ex am in ed as w e ll as the a d m in istra tiv e im p lic a tio n s o f d iffe r­ ent degrees o f program d ecen tra liza tio n . In addition, the n eed fo r lo w -c o s t d e liv e r y sy s te m s and the scar­ city o f p rofession al m ed ica l p erson n el su g g e s ts the n e e d fo r sy ste m a tic com parison o f p h y sicia n -ce n tered , W estern -o rie n ted h ealth d e liv e r y with that o f param ed ical or v o lu n tee r -sy ste m s w h ic h h a v e b e e n e m p ­ loyed in C hina, C o lo m b ia , G u a tem a la , and e ls e w h e r e (P o p k in and Latham, 1973; S cr im sh a w , 1 9 7 3 ). B iological-P hysiological D im e n sio n s The p reviou sly d iscu sse d in tera ctio n b e tw e e n nu trition al status and fer­ tility clearly requires further in v e stig a tio n as in d ica ted in F ig . 1. O f particular relev an ce to program in teg ra tio n are th e e ffe c ts o f d ifferen t Spring 1974 / Health and Society / M M F Q 182 ty p e s o f p ills o n la cta tio n and the e ffe c ts o f nutritional status on the reten tio n o f I U D s . R e se a r ch m ig h t a lso b e d esira b le on the technolog­ ica l fe a s ib ility and the nutritional d e sira b ility o f u sin g contraceptive p ills as carriers o f certa in v ita m in s or m in era ls. T o ta l P ro g ra m Im p a c t W h ile resea rch in the s p e c ific areas d is c u ss e d a b ov e is vital, it also is im p ortan t to b e a b le to a s s e s s the im p act o f integrated as opposed to n o n in tegrated p rog ram s. T h is req u ires lo n g itu d in a l stu dies, such as that carried o u t at N a ra n g w a l, w h ic h co m p are integrated programs w ith th o s e p ro v id in g o n ly p o p u la tio n inputs and those providing only n u trition al in p u ts, and u sin g appropriate con trol g r o u p s.8 The critical n ee d in th is c o n tex t is to d e sig n p rog ram -evalu ation methodologies w h ic h ca n m easu re c h a n g e s in o u tco m e varia b les ( e .g ., fertility and n u trition al sta tu s), q u a n tify program c o s ts , and translate these into c o s t-e ffe c tiv e n e s s ratios. A lth o u g h lo n g itu d in a l stu d ies are expensive and tim e -c o n s u m in g , th ey are n e ce ssa ry to p rovid e the policy maker w ith returns o n in v e stm en t in nutrition and p op u lation pursued sepa­ rately and in co m b in a tio n . W ith the lik e lih o o d o f in crea sed interest and program activity in p o p u la tio n and n u trition , the ad d itio n a l ex p er ien c e and information g a in ed fro m this resea rch w ill b e u sefu l to planners and assistance a g e n c ie s and w ill fa cilita te w h at co u ld b e im portant interaction be­ tw e e n th ese d is c ip lin e s . J am es E . A u stin , D .B.A . G raduate S c h o o l o f B u sin e s s A d m in istra tio n H arvard U n iv e r sity S o ld ie r s F ield B o s to n , M a ssa c h u setts 0 2 1 6 3 F . J a m es L e v in s o n , PH .D . D ep a rtm en t o f N u trition and F o o d S c ie n c e s M a ssa ch u setts Institute o f T e c h n o lo g y E 5 3 -4 6 5 3 0 W a d sw orth Street C a m b rid g e, M a ssa c h u setts 0 2 1 3 9 8Two such additional nutrition studies are currently being conducted: one in Bogota, Colombia by the Institute Colombiano de Biniestar Families, by the Department of Nutrition of the H arvard School of Public H ealth, and by the Institut fur Emahrungswissenschaft 1 der Justus Liebig Universitat; and a second study in Guatemala in four ladino villages by the Division of Human Development, Institute of Nutrition of Central Am erica and Panama. 183 M M F Q / Health and S ociety / Spring 1974 R eferences Austin, J. E. 1973 The Management Bottleneck in Family Planning Programs. Studies in Family Planning, Vol. 4, No. 12. New York: The Population Council. Berg. A. 1973 The Nutrition Factor. Washington, D .C.: The Brookings I nstitution. Chopra, J. G ., R. C a m a cho , John K e v a n y , and A . 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