Fighting World Hunger Through Micronutrient Fortification Programs

As we enter the new millennium, there are roughly 840 million chronically undernourished people in the world, 799 million of them in developing countries (FAO, 2002). The remaining 41 million are found in industrialized countries and in states undergoing transition, including the former Soviet Union and Eastern Europe.

That the total number of undernourished people is 20 million lower than it was in 1990–92 is both good news and bad news. The good news is that there has been a decline in the number of hungry people in the past decade despite rapid population growth (there are more people around today than in 1992); despite natural disasters, such as hurricane Mitch, floods in China, and droughts across Africa; and despite an upsurge of armed conflicts in countries like Liberia, Bosnia, Chechnya, and Sudan. It should at least be recognized that some progress is being made against very difficult odds.

But the bad news is that progress remains patchy and very slow—far too slow, in fact, to meet the internationally accepted target of halving rates of hunger by the year 2015 (UN, 2000). A great many efforts are being made across the globe to bring about increases in agricultural productivity through research and extension, reductions in poverty through, for example, microfinance schemes, and reductions in the disease burden through vaccination campaigns. However, even if all such efforts were to succeed in coming decades, hungry people need to eat today to benefit from, and contribute to, those gains. Indeed, poverty reduction efforts remain stymied by the persistence of hunger that prevents millions of people from participating in processes of change.

That is where the World Food Program (WFP) comes in. WFP is perhaps best known as the United Nations agency that responds to humanitarian emergencies by delivering food aid to hungry people all over the globe. In 2002, WFP fed 44 million individuals through emergency operations. Yet WFP also seeks to remove root causes of hunger by using food in development programs. In both contexts, getting enough food to people who need it is critical. But quantity of food is not all that matters—so, too, does quality. As a result, WFP has increasingly turned to state-of-the-art milling, extruding, and fortification technologies to support some of its food aid activities. This article briefly describes what WFP does and the challenges it faces in addressing hunger with food aid, then presents three recent initiatives in the micronutrient fortification of food aid that offer some hope for making faster progress against hunger in coming years.

--- PAGE BREAK ---

Getting Food to Hungry People
In the 40 years since it was founded, WFP has acted to redress the devastating impact of hunger on the world’s poorest people. The numbers involved are so large as to be mind-numbing. Consider, for example, the entire population of the U.S. and Canada going hungry. Then double it. Then add the population of Mexico. Even that total does not match how many undernourished people there are in developing countries.

As a UN institution, WFP embodies the principle that food should reach hungry people when they need it, wherever they may be—not only in the context of disasters, but also where grinding poverty and ill-health inhibit access to food on a daily basis. While WFP is not the only agency that dedicates itself to this ideal, it is the largest multilateral player where food aid is concerned. Between 1962 and 2002, WFP delivered more than 65 million metric tons of food to people in 100 countries.

In recent years, the bulk of WFP’s food assistance has been for addressing emergencies. The 1990s saw a large increase in the number of refugees and other people displaced by political instability or war. Humanitarian crises in Somalia, the Great Lakes region of Africa, the Balkans, the Democratic People’s Republic of North Korea and, elsewhere meant that WFP channeled almost $12 billion of humanitarian assistance during the decade. Sadly, the trend continues: simmering crises in Afghanistan, Angola, and Sudan were joined in 2002 by renewed large-scale emergencies in Ethiopia/Eritrea and southern Africa.

Always on the front line in emergencies, WFP staff often face logistical and personal nightmares. For example, during Afghanistan’s winter of 2001 (after removal of the Taliban regime), there was a serious threat of famine. To meet the threat, WFP had to airlift food from Pakistan to Turkmenistan when WFP warehouses in Central Asia ran dry; snow and avalanche experts were brought in from Sweden and Canada to help keep the mountain passes open during the depth of winter; commercial trucks braved storms at high altitude because WFP fitted snow blowers and subsidized their fuel; and donkeys were hired to carry food where trucks could not proceed through the deep snow. And as in many conflict zones, personal insecurity from land mines, bombing, and armed engagements led to some tragedies. Since 1988, more than 60 WFP staff members have been killed in the line of humanitarian duty.

Quality, Not Just Quantity
A large part of helping people better withstand shocks involves building up human capacity—the health, nutrition, education, and skills that are essential if poor people are to pull themselves out of poverty. Enabling girls to get into school, providing skills training to widows, offering nutritional rehabilitation to those who are seriously ill—all such activities represent investments against the return of hunger. With that in mind, WFP has become increasingly focused on the need to ensure not just enough food, but also the most nutritious food possible.

--- PAGE BREAK ---

Since its first operations WFP has made a point of delivering a nutritionally balanced food basket. WFP’s main food commodities are cereal grains, pulses (beans of varying kinds), vegetable oil, salt, sugar, and blended foods used for nutritional rehabilitation of malnourished children and mothers. The typical food ration is designed to provide at least 2,100 kcal (the minimum acceptable level of energy needed by most people to maintain light activity and remain healthy), while providing sufficient diversity such that minimal levels of fat and protein are achieved. Great care has always been taken in ensuring local palatability/acceptability and food safety. In 2002, WFP purchased (rather than had donated in-kind) 41% of all the food delivered to recipients; of that, 67% was obtained from within developing countries.

However, with all the care in the world, food rations cannot always meet all nutrient requirements of people who have been depleted by months, perhaps years, of hunger. That is especially true of refugees who often rely almost exclusively on food rations for their consumption needs. This is where micronutrient fortification becomes an option.

• Micronutrient Problems. While undernutrition—a continued shortage of food—becomes all too visible when a child is thin or sickly, there are also other forms of malnutrition that are less visible but equally devastating: micronutrient deficiencies. Vitamins and minerals such as iron keep children active and help with mental development; vitamin A prevents blindness and strengthens the immune system; iodine stops goiter and cretinism (problems rarely seen in richer countries, since most salt was fortified with iodine long ago), and zinc helps young children’s physical growth.

Everyone needs micronutrients, if only in minute quantities. But when the minute quantities are not met, problems arise. According to the World Health Organization, deficiencies of iron, vitamin A, and zinc rank among the top ten leading causes of death through disease in developing countries (WHO, 2002). Where iron is concerned, at least half of all pregnant women and young children around the world are deficient. Children under 24 months of age are especially at risk of anemia, which impairs their mental and physical development, reduces their ability to resist common childhood diseases, and lowers their ability to concentrate and perform well in school (Mason et al., 2001). Anemia is a serious risk to mothers in childbirth, and it impairs the health and labor productivity of other working adults. As a result, countries like Bangladesh lose 1–2% of their annual gross national product directly because of high levels of anemia (FAO, 2002). Similarly, removing zinc deficiencies would prevent around 800,000 deaths per year, and eradicating vitamin A deficiency would cut child deaths from measles by 50% (UNICEF, 2002).

--- PAGE BREAK ---

• Potential Solutions. In the longer term, enhancing the amount and variety of local foods produced should be the desired goal. When people have access to more and better foods, the micronutrient problem becomes manageable. But in the absence of sustained poverty reduction and greater food access in most poor countries a number of agencies such as WHO, UNICEF, the Micronutrient Initiative (MI), Helen Keller International, and others continue to be actively engaged in supporting developing countries to distribute supplements (often capsules) containing vitamin A or iron through clinics and sometimes schools. Great progress has been made in tackling vitamin A deficiency around the world through this means, but iron and other deficiencies are proving to be more difficult to tackle via supplements (sometimes because of poor compliance among recipients), and coverage remains limited in many places.

In industrialized countries, most people are not deficient in micronutrients, partly because of a normally varied and rich diet, and partly because most such nations have for decades been fortifying widely consumed foods like flour, salt, margarine, sugar, and even ketchup (salt has been iodized in the U.S. and Switzerland since the 1920s, and mandatory fortification of various foods with vitamins A and D, iron folate, and other micronutrients followed not long afterward).

During the 1990s interest in fortification grew in developing countries, and quite a few have now begun to enact national policies that require fortification of major food commodities, such as maize meal in South Africa and Namibia, sugar in parts of Central America, Nigeria, and Zambia, and vegetable oil in Morocco. However, such initiatives are still relatively limited, largely because they require coordinated efforts from many stakeholders, including governments, the private sector, and consumer organizations, which is not always easy to achieve. What is more, the foods fortified often do not reach the very poorest consumers—the people helped by WFP are not going to the grocery store to buy processed, packaged foods that would include fortified bread or sugar. People who rely on food aid cannot go long distances in search of more nutritious food. It is up to WFP to try to bring more nutritious food to them.

WFP’s Food Fortification Efforts
WFP has a long history of distributing micronutrient-fortified foods. It requires that vegetable oil procured from industrialized nations, like the U.S. or the Netherlands, be fortified with vitamins A and D, and that all of the salt be fortified with iodine. WFP is the leading purchaser worldwide of fortified blended foods, mainly from Norway, France, and the U.S. Blended foods (such as corn–soy blend), contain extra protein and are typically fortified with multiple vitamins and minerals. WFP has now developed local capacity to produce fortified blended foods in 13 of the world’s poorest countries, including India, Nepal, Madagascar, Ethiopia, and Malawi.

However, the bulk of food commodities donated to WFP or procured take the forms of whole-grain cereals, which are not fortified. Thus, local-level milling and fortification close to the consumer may offer an answer to micronutrient deficiencies among the target groups. Three examples of this approach are illustrated below.

--- PAGE BREAK ---

• Milling and Fortifying Emergency Relief. At its peak, the food crisis in Southern Africa during 2002–03 affected more than 15 million people. More than 1 million metric tons of food has been delivered to Lesotho, Swaziland, Zambia, Zimbabwe, Malawi, and Mozambique, where it was distributed to critically hungry people by government agencies and nongovernmental organizations (NGOs). Indeed, NGOs such as CARE, Catholic Relief Service, World Vision, and Project Concern International were instrumental in implementing the successful relief activity.

Yet even here, micronutrients were an issue. On the one hand, the nutritional requirements of beneficiaries in this region are more exacting than usual because of the unusually high rates of HIV/AIDS. It has been argued that the onset of the disease might be delayed in a well-nourished individual and that sound nutrition may reduce opportunistic, secondary disease infections among AIDS patients, thereby potentially delaying mortality (Allen and Gillespie, 2001; Webb and Rogers, 2003). While it can correctly be argued that food security is also affected by malaria, tuberculosis, and other diseases, HIV/AIDS is unique in the scale and severity of its impact and because of the lack of low-cost and reliable medical (or indeed non-medical) responses tailored to low-income countries. In this sense, good nutrition is arguably both the first line of defense and the first line of attack against the epidemic.

On the other hand, some drought-stricken countries were concerned that if imported food aid contained any genetically modified material, and if recipients were to plant such grains rather than eat them, then this might affect their ability to trade in grains on the international markets. Respecting beneficiary country sovereignty, WFP therefore sought alternatives. To some degree, it was possible to purchase grain within the region and move it from South Africa, say, to Zambia for distribution. In other cases, where countries decided to accept milled maize (since that cannot be planted), WFP decided to take advantage of the milling process to also fortify the meal. Agreements were reached with five large roller mills in South Africa, Malawi, Lesotho, and Zimbabwe to fortify the maize. To date, more than 70,000 metric tons have been milled, fortified, and distributed—by far the largest distribution in history of micronutrient-fortified cereals in an emergency context.

• Milling and Fortifying in a Refugee Camp. Even when emergencies are over, their effects sometimes linger for years. That is especially the case with civil wars. Refugees who cross borders to escape conflict can rely on food aid for the majority of their food for long periods of time. The resulting lack of dietary diversity can sometimes lead to outbreaks of scurvy, a deficiency of vitamin C seen in refugee camps in Somalia in 1992 and Kenya in 1994; beriberi, a thiamine deficiency, recorded among Bhutanese refugees in Nepal in 1999; or pellagra, a skin disorder due to a lack of niacin, outbreaks of which occurred in Mozambique in 1996 and Angola in 2003.

Since most refugee camps are located in remote regions, it is a challenge to ensure a smooth and unbroken flow of food. WFP therefore decided to install a mill and fortification unit to a camp housing 26,000 Angolan refugees in Western Zambia. Because of the harsh environmental conditions (dry, sandy soil) and the absence of employment opportunities, the refugees are almost totally dependent on WFP for food. Yet the camp is located at least 12–15 hours travel from the capital, Lusaka. It has to be reached along extremely poor roads and a precarious ferry-crossing over the Zambezi river. When the Zambezi is flooded, food convoys cannot cross for long periods of time.

--- PAGE BREAK ---

As a result, stocks of whole maize kernels had to be kept in the camp. Since whole grain has a longer shelf life than milled flour, it was best to stock up grains. Upon receiving their maize rations, refugees went to one of six small-scale hammer mills set up inside the camp by WFP to convert whole kernels into meal. Those small mills, with a capacity of about 300 kg/hr, could not keep up with the need, and some refugees would wait two weeks before they could have their entire twice-weekly ration milled.

Consequently, WFP decided in 2002 to bring a new, larger mill to the camp to pilot-test an on-site maize fortification program. A milling/fortification unit was designed in collaboration with the Natural Resources Institute (affiliated with Greenwich University), and T.H. White Installation Ltd., both in the United Kingdom, MI, the Canadian government, the UN High Commission for Refugees (UNHCR), and CARE/Canada.

Supplied in a space frame with most components installed and pre-wired, the unit was transported in two pieces in a container on the back of a large truck. The unit consists of two hammer milling and mixing units, each with a capacity to mill 1 metric ton/hr. The mills were erected in a Rub-Hall mobile warehouse, a sturdy 10-m x 24-m tent with a height of just over 5 m that is widely used for storage in humanitarian operations.

The mill is currently in operation, with labor provided by the refugees themselves, and a fine meal is produced at a rate that does not keep families waiting for weeks. A study of the impact of the fortification on micronutrient status in the camp is ongoing. If the project is successful, similar units could be produced, packed in a container, and shipped to other emergency sites.

• Village-Level Milling and Fortification. One way that WFP tries to minimize the threat of emergencies is to remove the worst hunger before it reaches an intensity that triggers famine. Development interventions are designed to allow hungry people to send their children to school (by providing school meals), to attend clinics (offering rations for the mother and child), or to reduce soil erosion (offering work on tree-planting or water-control activities in return for food). In Bangladesh, WFP supports an activity that reaches around 500,000 extremely poor women. It has for many years been providing 30 kg of whole wheat per month to support literacy training, while also off-setting startup costs for income-generating activities, like raising poultry or vegetable gardening.

However, since vitamin A and anemia were found to be widely prevalent among the target group, a pilot project was established in 2002 to fortify whole-meal wheat flour (atta). Working on a “no-loss/no-profit” basis, local NGOs (BRAC and Jagorani Chakra) set in place four small hammer mills equipped with a novel “fail-safe” fortification device. Designed by former WFP staff member Pieter Dijkhuizen in collaboration with ABC Hansen, a Danish mill-producing company, the units have a capacity of about 750 kg/hr and use a blender to fortify batches of 500 kg at a time. Since the fortification device can only be used once per batch, possible overdosing of the flour with micronutrient premix is avoided (Dijkhuizen and Afsar, 2003). This can be important, since overdoses of some micronutrients, such as vitamin A and iron, could lead to harmful health effects for some people.

--- PAGE BREAK ---

Poor local women enrolled in development programs supported by WFP are employed to implement the milling and fortification process. They now provide 28,000 families with 25 kg of milled, fortified flour each month at a total processing cost of less than $20 (U.S.)/metric ton. The cost of the micronutrient premix is small (about $5/ton of grain), but WFP also has to cover the cost of milling and bagging, typically about $25/ton. The Bangladesh village-level operations (with low overheads) show that it can be done cheaper than that. Although ration size was cut from 30 kg of unmilled wheat to 25 kg of flour, the cost savings to beneficiaries where they had to pay for milling themselves represent a 50% increase in the transfer value.

Studies carried out by USAID/MOST show that the cost savings are recognized by beneficiaries, and an efficacy study by ICCDR/B confirms the beneficial impact on vitamin A status. WFP is therefore planning to expand the project to 40 units, thereby meeting the needs of 430,000 participants per year.

In sum, WFP’s goal in food fortification is to make food aid a tool that not only reduces immediate hunger but also allows children a better chance to survive the ravages of disease and grow into healthy and productive adults. Small- and large-scale milling and fortification technologies have a growing and important role to play in that goal.

The views expressed in this paper are those of the authors and should not be interpreted as reflecting those of the World Food Program. The authors are grateful to the many individuals who made the initiatives described here possible, especially Pieter Dijkhuizen, Francesca Erdelmann, John Wood, Anne Callanan, and Rita Bhatia.

by Tina van den Briel and Patrick Webb
Author Tina Van Den Briel ([email protected]) is Senior Program Adviser and Patrick Webb ([email protected]) is Chief of Nutrition, Policy, Strategy, and Program Support Div., United Nations World Food Program, Via Giulio Cesare Viola, 68/70, 00148 Rome, Italy. Send reprint requests to author Webb.

References