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Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
5
The Earth Team Invites
you to
The Earth Team
Invites you to
United States
Office of
News Division
NEWS
Department of
Public Affairs
Room 404-A
Agriculture
Washington, D.C. 20250
Release No. 0499.93
Remarks
Mary Dixon (202) 720-4623
Prepared for Delivery by
Secretary of Agriculture Mike Espy
National Hunger Forum
Washington, D.C., June 17, 1993
I am proud to welcome you to the National Hunger Forum. And proud that this
is one of the biggest gatherings on hunger since the Kennedy days.
You are such an illustrious and respected group the best minds the
warmest hearts that to recognize any one of you individually would mean
recognizing all of you -- so we'll just get right down to the business at
hand.
We have come together today to discuss hunger in America. Yet, hunger is a
feeling few of us here have ever really experienced. Most of us had at least
a cup of coffee and a muffin before coming this morning and of course,
we've scheduled an hour for lunch this afternoon.
WHAT IS HUNGER?
So, we might find ourselves wondering, "What IS hunger?" Is it that slight
pang that tells us it's time to head down to the cafeteria for lunch? Or is
it the gnawing pain of not having had breakfast or lunch?
Is it saying "no" to that second dessert so we can lose a pound or two? Or is
it chronic malnutrition from not eating enough, or eating too much of a
limited diet?
Is it wondering which carryout to stop at to pick up a bite before the movie?
Or is it wondering where in the world our next meal is coming from?
HUNGER EXISTS
Hunger may be hard to define but it is not hard to locate. Here in this
United States a country whose national anthem sings of "amber waves of
grain" and of "fruited plains" there are senior citizens who wake up hungry
in the morning working people who toil at their jobs hungry all day long --
and young children who go to bed hungry at night.
It's time we acknowledged our hunger problem. Some highly placed government
officials and national commentators have actually questioned whether it
exists. What planet do they live on? I'm only the Secretary of Agriculture
and I can tell you: Hunger exists in this country!
Look at the shamefully familiar facts and figures: One child in five lives in
poverty. The number of people on food stamps is at an all-time high of 27.4
million!! 12 million American children are going hungry. How can we not be
painfully aware that hunger is part of the daily lives of our fellow Americans
from Sacramento to Sioux City, from Sarasota to Cedar Falls?
- 2
USDA
Hunger exists. The next question is, what can we do about it? The U.S.
Department of Agriculture is one of the most powerful tools available in this
country to make a difference in the daily quality of lives of hungry people --
of real American families - - all American families.
I feel privileged to have the honor -- and the responsibility -- of overseeing
USDA. At the top of my agenda today and every day -- and for the next four
years is the overall health and well-being of our nation's citizens.
But government can't do it all. We surely have a role to play, but we must
also look for links with the private sector in fighting hunger through
economic development -- fighting hunger through health care -- fighting hunger
through food assistance programs -- fighting hunger through nutrition
education, -- and fighting hunger through welfare reform.
QUESTIONS
By making hunger the focus of the first of our series of issue forums, I am
honoring a passionate and personal commitment.
I am here to ask questions -- and to find answers.
- - How can we reduce administrative costs in the Food Stamp Program?
How can we - - and should we -- regulate fat and salt content in foods
produced for commodity distribution?
How can we encourage the use of Electronic Benefit Transfer systems to help
cut down on fraud and to remove some of the stigma of standing in the grocery
store line with a book of food stamps in your hand?
-- How can we convince farmers that it is to their benefit to support food
assistance programs -- to wipe out the false choice between farm programs and
food programs.
-- How can we help families move toward self-sufficiency and independence
empowering them to go from the welfare rolls to the payrolls?
How can we offer targeted assistance to the most distressed communities?
How can we ensure that the basic benefit levels allow people to purchase an
adequate -- though inexpensive -- diet at the end of the month as well as at
the beginning of the month?
-- How can we ensure that staying eligible for food stamps doesn't force
people to sell the very car they need to get out and look for work?
- - How can we make sure that the next generation of Americans doesn't have to
choose between heat for their home -- or food for their children?
How can we reach out so that every child in need receives the food he or
she needs to grow strong and healthy?
In short, how can we eliminate hunger in these United States?!!
Together we can find the answers. Together we can do it.
#
Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
Rural
PPEP TALK
Arizona
PPEP
News
Inc.
Published by Portable Practical Educational Preparation, Inc. (PPEP)
Dr. John David Arnold, CEO, 802 E. 46th Street, Tucson, AZ 85713 (602) 622-3553
Volume I, Number 2
"BACK TO BASICS"
May, 1993
Daya Con Dios, Amigo
PPEP,
INC.
SSENING
COUNCIL
ADVISORY
BUSINESS
EX
ADVISORY
COUNCIL
PPEP's Business Advisory Council
(BAC) was formed to provide input and
support for PPEP, its Training for
Employment Centers (PPEP TECs) and
MICRO. The BAC allows PPEP to main-
tain a close relationship with the business
community in order to continually evalu-
Cesar Chavez (L.) and Dr. John David Arnold, CEO of PPEP & Affiliates in March, 1992.
ate and develop a curriculum that best
CESAR CHAVEZ DIES IN AZ
meets the changing requirements of the
job market.
Current participating members in
Cesar Chavez, 66, farmworker labor organizer and activist, died on April 23rd,
PPEP's Business Advisory Council (BAC)
apparently of natural causes, in the San Luis home of a long-time friend, not far from
and their representatives are: AIRESEARCH/
Yuma where he was born. Called the "Martin Luther King, Jr. of the Chicano
TUCSON Div., Candy Adams; AZ DES/
movement," Chavez was eulogized by the poor and the powerful.
EMPLOYMENT & TRAINING ADMINISTRATION,
Senator Dennis DeConcini said, "Cesar Chavez was a leader whose legacy will
Alex Witzeman; AZ DES/ JOB SERVICE,
live on in the hearts of farmworkers. No one can dispute his absolute dedication to
Barry Batson; BANK OF AMERICA, Bob
the welfare of his followers. Congressman Ed Pastor called him "a leader who
Brauer; BURR-BROWN, Kathy Robinson;
belonged not only to the farmworkers who have toiled in unbearable working condi-
CITIBANK, Norm Rebenstorf; COLONIAL LIFE
tions, but to all Americans who believe in his philosophy of non-violent protest."
INSURANCE, Carol Van; DAVIS MONTHAN AFB,
Si se puede (yes, it can be done) is the slogan and legacy that Cesar Chavez
George Rodriguez; FIRST INTERSTATE BANK,
gave to PPEP's CEO, Dr. John D. Arnold, Chavez friend for 15 years. "There was no
Maria Alday; GALSETH & GREGSON INSUR-
single person who could take his place,' says arnold. "He was like David vs. Goliath,
ANCE; HUGHES AIRCRAFT, Jim Mize.
but he knew how to throw the rock and make people listen. He could use that
Also, IBM CORPORATION, Ricardo -
slogan, "si se puede," and draw both the common people and the Kennedys and
Ramon; KELLY TEMP SERVICES, Robin
(Jesse) Jacksons."
Jones; NATIONAL BANK OF ARIZONA, Don
Arnold met Chavez in 1978 when he went to install a solar water heater for a
Jenks; RICHARDS & PENNINGTON, Max
laundry for Chavez in California. "Chavez loved nature and hated to see a plant
Richards; TAD TEMPORARIES, Vera Martinelli;
disturbed," Arnold reminisced. He had to saw a small limb off a tree which was
TELESERVICES, Kathy Banks or Pamela
blocking to sunlight to the solar panel and Chavez noticed the loss immediately.
Gibson; TUCSON INDIAN CENTER, Rodney
'That taught me a lot about his perceptiveness on many issues," says Arnold.
Palimo; UNIVERSITY OF ARIZONA, Jay
(Continued on Page 3.)
McKenzie; UNIVERSITY OF Arizona, Dr.
Celestino Fernandez.
Page 1
"Dedicated to improving the quality of rural life"
PROJECT
John David Arnold, Ph.D.
PPEP
C.E.O.
Inc.
802 East 46th Street
Tucson, Arizona 85713
PHDC
(602) 622-3553
PSHSC
Fax (602) 622-1480
Since 1967
PRBDC
Weather
Today: Partly sunny, warm, late
thunderstorm possible. High 82.
Low 57. Wind northwest 7-14 mph.
Yesterday: Temp. range: 63-78.
AQI: 40. Details on Page C2.
The Washington Post
FINAL
Friday: Mostly sunny, less
humid. High 78. Wind 5-10 mph.
Diside: The Weekly, Classified,
Washington Home
Today's Contents on Page A2
116TH YEAR
No. 152
THURSDAY, MAY 6, 1993
Prices May Vary in Areas Outside
Metropolit in Washington (See Box on A4)
25c
Harvesting a Living From Seeds of Credit
Anti-Poverty Strategy Called Microenterprise Is Growing in U.S.
tract for pinto beans, and Magallanez finds them in the
By Guy Gugliotta
PPEP
MICRO
United States and sees that they are delivered.
Washington Post Staff Writer
"It's a good business," Magallanez said, and he thinks
NOGALES, Ariz.-Three years ago Julio Magallanez
it will get better. So does the Micro Industry Credit
almost died of a massive heart attack. Last year, heart
Rural Organization, a nonprofit development company
disease again almost killed him and kept him in bed
that loaned Magallanez $1,000 so he could buy a com-
most of the time.
puter to keep his records.
Sickness cost him his driver's license, and sickness
MICRO, now beginning its seventh year, is one of the
means he will never get it back. "More than 20 years'
nation's leading practitioners of "microenterprise de-
driving a truck, and all of a sudden no job," said Magal-
velopment," providing very small loans and, in most
lanez, now 39.
cases, business training, to low-income entrepreneurs
So he went into business for himself. Today Magal-
who have little or no access to banks or other forms of
lanez is a "bean broker," using a lifetime of experience
credit.
on both sides of the Mexican border to build a new ca-
Microenterprise, a tried-and-true Third World devel-
reer from his house trailer on a windswept stretch of
opment technique for more than three decades, is per-
BY EDWARD McCAIN FOR THE WASHINGTON POST
desert a few miles from Nogales. Mexican clients con-
See MICRO, A28, Col. 1
With $1,000 loan, Julio Magallanez became a "bean broker" in Nogales, Ariz.
A28 THURSDAY, MAY 6, 1993
THE WASHINGTON POST
U.S. Has 150 Microenterprise Groups, Most Less Than 3 Years Old
Col. 2
PPEP MICRO, From A1
Program that-in a relatively short
conventional to be poor and self-em-
ica has been trying to perfect and
To build competitive skills, virtu-
rewarding their creativity. And de-
time-can operate independently.
ployed in the United States."
expand its social safety net, devel-
ally all U.S. microenterprise organ-
spite the impossibility of cloning the
haps the hottest anti-poverty strat-
Accion and other organizations
Also, Third World informal sectors
oping countries have to create strat-
izations have a training regimen to
international models, the U.S. organ-
egy in the United States today.
have discovered basic differences be-
include legions of highly motivated
egies that work without one."
complement banking activities.
izations have shown that many of the
Experts list about 150 microen-
tween microenterprise in the Third
and trained people whose only real
And finally, Third World entrepre-
Coalition executive director Fo-
Third World concepts can work.
terprise organizations nationwide,
World and the United States, chief
need is credit. For them, a microen-
neurs usually know how to use a loan
rescee Hogan-Rowles, like many ex-
Chief among these is the idea that
most of them less than three years
among them the size and nature of
terprise program simply is a finance
once they get it, but even without
perts, accords training and banking
it is possible to loan money success-
old. The Small Business Administra-
the potential client base, the "infor-
company with reasonable interest
business basics they can succeed in
equivalent priorities. Her borrowers,
fully at market rates to people who
tion last year authorized a $15 mil-
mal sector" of self-employed people
rates. "In Latin America you can
an environment where regulations
she said, are embarked on a long-
are excluded from the mainstream
lion pilot program. Legislation to en-
who are trying to earn a living on the
break even with a portfolio of $1 mil-
are mostly honored in the breach.
term "development process," involv-
banking system. Most U.S. micro-
courage microentrepreneurs is pend-
fringes of the mainstream economy.
lion, and you can put $1 million out in
In the United States, by contrast,
ing "60 percent training and 40 per-
entrepreneurs, as in the Third
ing in Congress. Secretary of Agri-
In the Third World, experts say,
two years," said Accion associate
microentrepreneurs often need busi-
cent lending." Clients must attend
World, have little or no formal credit
culture Mike Espy is a leading advo-
the sector easily can include more
director Maria Otero. "You're giving
ness training, both to learn how to
four to 10 weeks of business instruc-
history, and virtually all of them
cate, and President Clinton, as gov-
than one-third of the labor force, ev-
ernor of Arkansas, actively encour-
people a lifeline and an opportunity."
handle money and to prepare for the
tion before they can get any money.
want loans so small that banks can-
erything from street vendors to free-
It's different in the United States,
intrusion of the real world. "Very
Most experts agree that microen-
not justify the costs of processing
aged a microloan program for rural
areas of his state.
lance plumbers and portrait painters.
where a highly developed social wel-
soon you start to rub up against the
terprise is not the "magic bullet" that
them.
Using a variety of training pro-
In the United States, by contrast, the
fare program takes away the sense
formal economy," O'Regan said.
will end national poverty, but, they
MICRO operations director John
grams and loan guarantee devices,
sector is relatively tiny: "We don't
of urgency. Accion researcher Elis-
"The competition is fierce every-
add, it is as good, if not better, than
Newsome, a former banker, said Ar-
the organizations have achieved ex-
have these massive informal sectors
abeth Rhyne described the differ-
where; even poor neighborhoods
any other current policy at bringing
izona banks will not issue a business
traordinary results. MICRO, based in
here," O'Regan said. "It's very un-
ence in a recent essay: "While Amer-
have a 7-Eleven."
poor people into the work force and
See MICRO, A29, Col. 1
Tucson and operating in rural and
border areas of Arizona and eastern
California, has made $1.6 million in
go to top
loans over the life of its program, and
has a cumulative default rate of 2.89
this Columns
percent.
#2
to Continue
clients include near-rookies
like Magallanez and seasoned pros
like Danny Renteria, a onetime
"shade-tree mechanic" who has
opened his own garage in Nogales
with MICRO loans. MICRO also
helps a man who buys Mexican char-
coal for resale in the United States, a
woman who grows squash and sells
gourds to novelty shops, and a man
who makes his own lace and grosses
$2,000 a week from amateur dress-
makers and local milliners.
In Los Angeles, the Coalition for
Women's Economic Development
reports no defaults during almost
four years of operations, and has
$260,000 on loan, much of it to low-
income women running tiny busi-
nesses in inner-city neighborhoods.
Many coalition clients are Latinas,
selling clothing or jewelry door-to-
door at lower than retail prices and
accepting installment payments.
Zoila Perez bought a load of T-shirts
inscribed with California motifs, trav-
eled to her native El Salvador and
sold them, then picked up a load of El
Salvador T-shirts and sold them in
East Los Angeles.
What makes microenterprise pro-
grams alluring is that they success-
fully promote jobs for poor people, an
area of particular futility in tradition-
al anti-poverty policy. "We have a
terrible record of placing people in
the mainstream economy," said Mar-
garet Clark, director of the Aspen
Institute's Self-Employment Learn-
ing Project. "Microenterprise can do
But not in overwhelming numbers,
and not cheaply. MICRO, perhaps
the largest program in the country,
has made 900 loans since 1987 and
has 200 loans outstanding. Interest
and fees cover 15 percent of
MICRO's operating expenses, as
close to profitability as any organi-
zation in the industry.
By contrast, the Los Angeles co-
alition, a model among newer organ-
izations, has 100 active borrowers.
Interest received in 1992 was
$7,600, less than 1 percent of oper-
ating expenses. This is a typical per-
centage for microenterprise pro-
grams, all of which rely on grants for
most of their working capital.
"It's one of the most adaptable
anti-poverty strategies, and that's a
reason it's proliferated," said Fred
O'Regan, who studies microenter-
prise and other jobs strategies for
the Aspen Institute. "But expecta-
tions in terms of scale and sustain-
ability have been higher than most
programs can meet."
Inflated hopes probably arose be-
cause of the spectacular success of
the Third World's model microen-
terprise programs. The prototype
Grameen Bank, of Bangladesh, has
loaned more than $400 million to
more than 1 million clients since its
founding in 1976. Indonesia's Bank
Rakyat has 2 million borrowers and 8
million savers.
In Latin America, the Cambridge,
Mass., based Accion International
has set up microloan programs that
have 147,000 borrowers in 14 coun-
tries. Seven of their programs are
paying for themselves, and Banco Sol
in Bolivia has evolved into a full-scale
that."
THE WASHINGTON POST
THURSDAY, MAY 6, 1993 A29
With $1,000 Loan, Julio Magallanez Built a Career as a 'Bean Broker'
PPEP MICRO, From A28
credit needs of disadvantaged neighborhoods.
clothing vendor, two custom clothing design-
community. One key to the coalition's suc-
ployees. She is bidding large jobs, and needs
Clinton has spoken of passing a "more pro-
er/seamstresses and a jewelry business. Each
cess is that it has encouraged its Latin bor-
only one long-term contract to hit the big
loan for less than $25,000, also the minimum
gressive" act, and microenterprise may prove
woman used a $2,000 loan to buy inventory.
rowers to replicate the informal street econ-
time. "We are a phone call away," she said.
for a Small Business Administration-backed
to be a useful way for banks to comply with
Peer group lending substitutes shared re-
omy most of them knew as youngsters in
Already in the big time is MICRO's Danny
loan. At MICRO the average loan is $1,600,
the law.
sponsibility for the collateral that the borrow-
Mexico and Central America.
Renteria, who used to fix cars on the street
at 13 percent interest.
"We could act as an intermediary between
ers do not have. It is, program supervisors
Perez would like to become a full-scale
and now has a garage with two lifts and seven
MICRO, like many microenterprise organ-
banks and borrowers, because we have the
agree, the main reason microentrepreneurs
importer-exporter, carrying goods to and
full-time employees wearing blue "Danny's
izations, would like to forge an alliance with
infrastructure to manage a small loans port-
seldom default. "Besides the payments, they
from El Salvador on a regular schedule.
Service Center" uniforms.
mainstream banks-offering to run a micro-
folio," said Accion's Otero, who has recently
develop solidarity and learn about bookkeep-
MICRO's Magallanez, as a facilitator in the
Renteria is a microenterprise "graduate"
loan program using bank funds-and is ex-
received several bank inquiries about the
ing and planning," said Paula Sirola, El Pro-
bean trade, is filling a market niche that no-
working on a $10,000 loan, his fourth from
MICRO and the biggest loan the program can
ploring a statewide relationship with Ari-
program's activities.
greso's supervisor. "Bit by bit they develop."
body else has discovered. "I'm taking a very
A large number of U.S. microenterprise
If they wish. For most microenterprise
tough gamble here, but I'm almost sure that
provide. He is tired of paying rent on his ga-
zona's Bank One.
programs, including the coalition, have adopt-
organizations, goals are fuzzy. Experts speak
it will work," he said.
rage ($28,000 last year) and would like to
"We think our program trains future bank
ed the Grameen Bank's "peer lending group"
of bootstrapping first-time business people
Also running a gamble are Valerie Holton
buy it from his landlord along with the rest of
customers," said MICRO executive director
technique, in which a small number of bor-
into the mainstream, of stabilizing fragile
and Ava Jackson, partners in the coalition's
the building.
Frank Ballesteros. "There is an untapped
rowers (generally four or five) guarantee
family incomes, of nurturing self-image, of
"Five Star Unlimited" peer group. Holton
He figures he will need at least $300,000
market out there, and banks see the hand-
each other's loans and meet periodically to
encouraging asset building and weaning poor
runs "Black L.A. Tours" for visitors to Los
and he will have to borrow it from a bank. No
writing on the wall."
discuss business strategies and give each oth-
people from welfare.
Angeles ("They don't have to be black!") and
bank has ever granted Renteria a loan, but he
Maybe so, but a more likely inducement is
er pep talks. Zoila Perez's group, called "El
At El Progreso, the women speak of sta-
is interested in negotiating a deal with Ra-
thinks maybe this time will be different:
the Community Reinvestment Act, requiring
Progreso de Bellas Ilusiones" ("the Progress
bility, extra spending money and modest ex-
mada Inns. Jackson has a maintenance com-
"They couldn't find a better candidate than
banks to use some of their resources to meet
of Beautiful Dreams"), includes one other
pansion, always within Los Angeles's Latino
pany that has expanded from two to five em-
me," he said.
Congressional Record
United States
of America
PROCEEDINGS AND DEBATES OF THE
102ᵈ
CONGRESS, SECOND SESSION
Vol. 138
WASHINGTON, WEDNESDAY, AUGUST 12, 1992
No. 119
House of Representatives
ices, food, clothing, etc., to Braceros (Mexican
Going out and starting a business was not
farm laborers). After 10 years of working di-
the first thing she thought of-nor would it
rectly with the migrant workers, John Amold
be the first thing the United States welfare
approached community leaders for support to
system would prescribe for the former farm
worker, who speaks only Spanish and has
initiate a mobile, or Itinerant, school to serve
minimal business qualifications.
the various labor camps. Thus emerged
What Mrs. Barajas didn't recognize, until
Project PPEP. This school was unique be-
the Micro Industry Credit Rural Organiza-
cause it went to where the people worked and
tion (MICRO) stepped in to show her, was
lived, and provided instruction in practical edu-
that the small sewing jobs she had taken in
cational experiences which prepared the farm-
for years were a business she could develop.
workers in basic survival skills. In PPEP's
It's this kind of entrepreneurial seed that
humble beginnings, with a $19,000 annual
MICRO, a Tucson, Ariz., nonprofit develop-
ment group, cultivates through small, bust-
budget, John was the bus driver, mechanic,
ness loans. On collateral as small as a wed-
janitor, and teacher.
ding band or a color television, low-income
Today, PPEP has grown with rural commu-
and disadvantaged people, who would qualify
nity support to serve farmworkers and rural
quicker for welfare than a traditional bank
poor throughout Arizona, the Navajo Nation
loan, can get business loans as small 88 $500.
and the Imperial Valley in southern California.
Barajas's first loan of $500 three years ago
During this, the 25th anniversary of PPEP, 10
allowed her to buy more fabric at & lower
price than she was used to. This increased
million people will benefit from their services.
her profit on the brightly colored bedspreads
United States
Because of this success, dozens of third world
she makes. Demand for her work increased,
countries have been advised by the State De-
80 she bought a better sewing machine with
of America
partment to examine PPEP's rural self-help
her second loan of $1,000. Having paid off her
projects.
first loans, with a third loan of $2,000 she was
To point directly to one successful program
to travel to Los Angeles from this remote
sponsored by PPEP, I would draw my col-
area to buy cheaper fabric and supplies.
"I never thought someone would lend me
leagues' attention to an ambitious program
the money," says Barajas. "This has moti-
called Micro Industry Credit Rural Organization
vated me to work more, whereas before I had
[MICRO]. Through MICRO, economically dis-
to take from my food money to invest and
advantaged residents of these areas can re-
sometimes there just wasn't any." She would
ceive loans to start their own small busi-
never have considered asking a bank for
nesses. As an outgrowth of the PPEP pro-
money after having been turned away by &
gram, MICRO's purpose can best be summed
local bank when she tried to open a savings
account with a crisp $20 bill and was told it
up by its mission statement-"To enhance
wasn't enough.
family self-sufficiency and quality of life by fa-
Microenterprise development in many
cilitating the development, growth, and partici-
cases can substitute a ladder of opportunity
pation of family-based micro and small busi-
for the dependency fostered by the welfare
ness enterprises in their local economies".
safety net, says Robert Friedman, founder
MICRO seeks to assist the disadvantaged by
and chairman of the board of the Corpora-
THE 25TH ANNIVERSARY OF
having them rely on their own hard work and
tion for Enterprise Development. a Washing-
PROJECT PPEP PROVIDING HELP
ton policy advocacy group that also sponsors
ingenuity, not on seemingly endless govern-
FOR RURAL POOR IN THE
demonstration microenterprise projects.
ment handouts.
"Microenterprise [development] crosses
SOUTHWEST
There is increasing evidence that small
both liberal and conservative lines," he says.
businesses, known as microenterprises, are
For conservatives, he adds, "it's quid pro
HON. JIM KOLBE
an important option for many of the unem-
quo. It's not a handout. And for that part of
OF ARIZONA
ployed and working poor today.
the liberal establishment that simply looks
IN THE HOUSE OF REPRESENTATIVES
Microenterprises are businesses that are usu-
at income redistribution, it works."
ally family-owned, employ 10 or fewer people,
Microenterprise, which 18 free enterprise in
Wednesday, August 12, 1992
its most basic and spontaneous form. is a
but are too small to get bank financing.
Mr. KOLBE. Mr. Speaker, by now we all are
sort of business counterpart to subsistence
The success of the program to date has
aware that many regions of the United States
farming: It exists in pockets of poverty all
been phenomenal. Business loans of $500 to
over the world where the unemployed must
have suffered serious declines in jobs in the
$10,000 have been provided at market interest
use their wits to survive. The informal sec-
last decade. Particularly hard hit are areas de-
rates to nearly 400 small business owners,
tor-that market in which microenterprise
pendent on agriculture, mining, or traditional
with a default rate of less than 3 percent.
exists off the books, outside taxes and gov-
manufacturing. Many of these declines are not
ernment regulation-is believed to con-
MICRO clients have created an estimated 400
short-term, cyclical or recession-related de-
stitute 30 to 50 percent of the economies of
jobs in the rural areas of the Southwest, fos-
clines, but are due to fundamental structural
developing nations.
shifts in the local economic and industrial base
tering the American tradition of free enterprise
In Latin America, for example, Peruvian
among our Nation's disadvantaged citizens.
economist Hernando de Soto's studies of the
of many regions around the country. Given
I would like to submit for the RECORD two
informal sector (documenting the capitalis-
these economic conditions, I would like to take
articles detailing the success of John Amold,
tic nature of upward mobility among squat-
this opportunity to pay tribute to a longstand-
PPEP, and the MICRO program, one from the
ter settlements in Lima) became the inspira-
ing and very successful program that has
Christian Science Monitor, the other from the
tion for a whole school of international de-
been providing assistance to the rural poor in
Arizona Daily Star. in honor of their 25th anni-
velopment that has grown up around
the deserts of Arizona and southern California.
microenterprise.
versary, I commend the attention of my cot-
Known as Portable Practical Educational Prep-
The Grameen Bank in Bangladesh, on the
leagues to project PPEP and the
other hand, has been the international model
aration (PPEP) this program serves the rural
microenterprise concept. I believe that pro-
for how to loan to the poor. It pioneered the
communities of the Southwest by offering lit-
grams demonstrating this kind of success rate
idea of giving credit-in amounts as little as
eracy and life skills training, GED and ESL
deserve our attention and support.
$50-to the poor when it began offering loans
classes, and practical education to the dis-
[From the Christian Science Monitor,
in 1975 to peasant women who made bamboo
advantaged residents of the region.
July 30, 1991]
furniture. Today, reaching perhaps 500,000
On the occasion of the 25th anniversary of
POOR TAKE MICRO-STEPS OFF WELFARE
people. the bank offers loans to small groups
the PPEP program, we can look upon its
of people who are trained together in basic
(By Clara Germani)
many achievements and those of its founder,
business procedures, divide the money
Dr. John D. Amold. From a young age, John
When Catalina Barajas's husband left her
among themselves for this own businesses,
to raise the last three of seven children
and are responsible for the collection and re-
Amold has taken it upon himself to provide as-
alone, she was forced onto welfare and into
investment of the money. The incentive of
sistance to the working poor and disadvan-
public housing. But to make ends meet, she
future loans maintains discipline within the
taged of our region. At age 16 he had his own
knew she was going to have to find another
groups, which have a repayment rate of 98
church-bus ministry that provided social serv-
means of income.
percent.
NATIONAL ASSOCIATION OF WIC DIRECTORS
1627 Connecticut Avenue, NW, Suite 5
P.O. Box 53405
Washington, DC 20009-3405
FAX 202 387.5281
202 232.5492
ASSOCIATION
92-001
NATIONAL
DIRECTORS WIC no
POSITION PAPER
NATIONAL ASSOCIATION OF WIC DIRECTORS
The Role of Infant Formula in the WIC Program
28 August 1992
The WIC Program and the National Association of WIC Directors (NAWD) promote breast-
feeding as the optimum infant feeding choice, unless medically contraindicated. If a
woman cannot, or chooses not to, breastfeed her infant, WIC recommends and provides
iron-fortified formula as the best alternative to breastfeeding. The fact that WIC promotes
breastfeeding yet provides infant formula has generated discussion and debate among
breastfeeding advocates.
Promoting sound infant feeding practices is a major educational objective of the WIC
Program. The primary means of achieving this objective has been through breastfeeding
promotion and support activities. The "Position of the National Association of WIC
Directors on Breastfeeding Promotion in the WIC Program" and the "Guidelines for
Breastfeeding Promotion in the WIC Program" outline strategies for promoting and sup-
porting breastfeeding in all program management areas. Public Law 101-147, the WIC
Reauthorization Act of 1989, further strengthened breastfeeding promotion in the WIC
Program.
The Special Supplemental Food Program for Women, Infants, and Children (WIC) has
provided supplemental foods, nutrition education, and linkages to preventive health care
for economically disadvantaged families throughout the United States since 1974. The WIC
Program is unique among food assistance programs because it integrates nutrition educa-
tion with food assistance and serves as an adjunct to preventive health care services.
The nutrition education component of the WIC Program is designed to achieve two
broad goals:
NAWD
1. Stress the relationship between proper nutrition and good health with special emphasis
1627 Connecticut
on the nutritional needs of pregnant, postpartum, and breastfeeding women, infants and
children under five years of age.
Avenue, NW
Suite 5
2. Assist the individual who is at nutritional risk in achieving a positive change in food
habits, resulting in improved nutritional status and in the prevention of nutrition-related
P.O. Box 53405
problems through optimal use of the supplemental foods and other nutritious foods.
Washington, DC
This paper presents the position of the National Association of WIC Directors (NAWD)
20009-3405
that the WIC Program must continue to provide infant formula to ensure the best possible
FAX 202 387.5281
nutrition for infants whose mothers cannot, or choose not to breastfeed.
202 232.5492
POSITION PAPER
The Role of Infant Formula in the WIC Program, 28 August 1992
The Infant Feeding Decision
The infant feeding decision reflects many personal issues, ethnic and culture-specific val-
ues, beliefs, and lifestyles. It is a decision that each woman, whatever, her socioeconomic
status, has the right to make for her infant.
The benefits of breastfeeding for mother and infant are so great that one might expect all
mothers to breastfeed. At this time, almost forty-seven per cent of mothers do not initiate
breastfeeding.
Women choose not to breastfeed for many different reasons, including societal barriers,
health care barriers, psychological barriers, and economic and cultural barriers. These bar-
riers are well documented elsewhere.
The role of the WIC Program in the infant feeding decision is to provide all pregnant
women with accurate information about breastfeeding so they can make an informed deci-
sion. Once a woman chooses a feeding method, the WIC Program staff provide support
and guidance so that she can succeed with her chosen method.
Infant Feeding Practices
In the early 1970s, only twenty-five per cent of newborn infants were breastfed in the
hospital. Bottle-fed babies were introduced to whole cow's milk at an early age (by six
months of age or even earlier). This feeding practice, along with a diet low in iron, resulted
in a high prevalence of anemia in infants and toddlers. One goal of the newly created WIC
program was to improve the health status of low-income infants by providing commercial
iron-fortified formula for formula-fed infants (consistent with the recommendations of the
American Academy of Pediatrics, Committee on Nutrition).
By 1980, more than half of United States mothers giving birth in hospitals initiated breast-
feeding. The upward trend continued until 1984 with sixty-three per cent breastfeeding at
discharge. It seemed likely that this country could meet the Department of Health and
Human Services objective of a seventy-five per cent breastfeeding initiation rate by 1990.
New breastfeeding promotion and support programs, projects, and activities were spurred
by this goal yet by 1989, only half of new mothers were initiating breastfeeding in the hos-
pital. In-hospital breastfeeding rates had declined for all income groups as had breastfeed-
ing duration rates.
Iron-fortified Formulas
The American Academy of Pediatrics recommends iron-fortified formula for infants for
the first year of life when mothers choose not to breastfeed, can not breastfeed, or wean
their infants before their first birthday. This recommendation is based upon the uncertain-
ty of solid food intake and iron intake during the second half of the first year. Iron-fortified
formula augments iron stores and helps prevent later development of iron deficiency, the
most common pediatric nutritional problem in the United States.
2
POSITION PAPER
The Role of Infant Formula in the WIC Program, 28 August 1992
The WIC Program provides iron-fortified formula because it provides a constant and pre-
dictable amount of iron. Its use has contributed to the declining prevalence of iron-defi-
ciency anemia in the United States. Any restriction of its distribution for the high risk pop-
ulation served by WIC would contradict the preventive role of the WIC Program.
Removing infant formula from the WIC food package could increase the use of cow's milk
for infant feeding because commercial infant formula is so costly. Some mothers would
purchase formula but could not afford to purchase a sufficient supply of formula and may
overdilute it, unintentionally causing water intoxication in their infants. The net effect of
removing infant formula could be an increase in the risk of inadequate nutrition, including
iron-deficiency for thousands of infants and health problems related to water intoxication.
The question is not whether the WIC Program should provide or eliminate infant formula
from the infant's food package. The issue has always been how to ensure the best possible
nutrition for at-risk infants. Some women on WIC will choose not to breastfeed or not to
exclusively breastfeed for the first year of life. For the infants of these mothers, the WIC
Program must continue to provide the option of iron-fortified formula to assure their
health and well-being.
The WIC Program continues to work towards establishing breastfeeding as the norm for
infant feeding in this country. Breastfeeding promotion and support activities are a major
priority for the program and for the National Association of WIC Directors. NAWD is com-
mitted to encouraging breastfeeding as the preferred method of infant feeding. All WIC
personnel have a role in promoting and providing support for the successful initiation and
continuation of breastfeeding.
3
ASSOCIATION
92-002
NATIONAL
DIRECTORS WIC 70
POSITION PAPER
NATIONAL ASSOCIATION OF WIC DIRECTORS
Breastfeeding Promotion in the WIC Program
9 October 1992
Goal
Breastfeeding has been shown to have significant advantages for women and infants. As health
professionals have a responsibility to provide services designed to optimize the health of their
clients, WIC health professionals are committed to encouraging breastfeeding as the preferred
method of infant feeding. Therefore, the National Association of WIC Directors (NAWD) calls for
all WIC state and local agencies to aggressively promote breastfeeding.
Introduction
The Special Supplemental Food Program for Women, Infants and Children (WIC), authorized
by Public Law 95-627, as amended, makes cash grants to state agencies to provide supplemen-
tal foods, nutrition education, and referrals. Those eligible for the program include pregnant,
breastfeeding, and postpartum women, and infants and children up to the age of five, who are
low-income and at nutritional risk, as determined by a health professional. The WIC Program
serves as an adjunct to good health care during critical periods of growth and development (1).
WIC regulations require that all pregnant participants be encouraged to breastfeed unless
contraindicated for health reasons (1,2). Because WIC provides services to over 1 million
women, two-thirds of whom are pregnant, a unique opportunity exists to influence decisions
on infant feeding.
The nutritional and immunologic components of human milk and the physiological, psychoso-
cial, hygienic and economic benefits of breastfeeding make it the optimal way to nurture infants
(2,3). Human milk contains the ideal balance and form of nutrients for infants and breastfeeding
affords a unique occasion for mother-infant interaction and bonding (4). Lactation can enhance
self-esteem (5) and facilitates the mother's physiologic return to the pre-pregnant state. Beyond
these positive health benefits, breastfeeding offers economic advantages such as lowering WIC
NAWD
food costs through decreased infant formula expenditures and minimizing health care costs by
improving health and decreasing morbidity in the pediatric population (6). From the standpoint
1627 Connecticut
of sanitation, breastfeeding should be recommended even more strongly in situations where
Avenue, NW
facilities in the home for preparation, storage, refrigeration, and cleanliness of infant formula
are questionable. There are also environmental advantages to breastfeeding. For example, no
Suite 5
containers to wash, heat, or dispose of with breastmilk.
P.O. Box 53405
Many major professional organizations have position papers and/or statements which recom-
Washington, DC
mend breastfeeding as the preferred method of infant feeding, including: the American
Academy of Pediatrics, the American Dietetic Association, the American College of Obstetrics
20009-3405
and Gynecology, etc. (7,8,9,10,11,12). The United States Department of Health and Human
FAX 202 387.5281
Services has identified breastfeeding promotion as a high-priority health objective for the
nation, with a goal set for 2000 of increasing to at least 75% the proportion of women who
202 232.5492
POSITION PAPER
Breastfeeding Promotion in the WIC Program, 9 October 1992
breastfeed their babies in the early postpartum period and to 50% the proportion who continue
breastfeeding until their babies are five to six months old (13). To work toward these goals,
the WIC Program must serve as an advocate for breastfeeding, ensuring that women have the
ability to make informed decisions about infant feeding, and supporting their decision.
NAWD Position on Breastfeeding Promotion in the WIC Program
An Overview of Breastfeeding in the WIC Program
In the United States, the incidence of breastfeeding at hospital discharge declined to 25% in
1971 and gradually increased to 61.9% in 1982; there has been a gradual downward trend since
1982. The most recent national data show that 52.2% of women in the United States are breast-
feeding at hospital discharge and only 18.1% of women were still breastfeeding when their
infants were 5-6 months of age (14). The breastfeeding rate among WIC participants in 1987
was 37.3% in the early postpartum period and 11.5% at 5-6 months postpartum, compared to
the non-WIC population rates of 64.9% and 27.2% respectively (14). Many socio-economic char-
acteristics common to the WIC population are associated with lower rates of breastfeeding and
may contribute to this discrepancy (14,15). These include race (specifically Black), age (younger
than 20 years), family income (less than $7,000 per year) and education (grade school level) (14).
Numerous barriers to breastfeeding have been identified, such as: (16,17,18)
Lack of knowledge about breastfeeding among health care professionals and the
population in general.
Lack of consistent and accurate information about breastfeeding.
Hospital practices which are oriented toward bottle feeding.
Lack of a support network during the critical postpartum period.
Psychosocial barriers including misconceptions, negative attitudes, low self-esteem,
and lack of flexibility in the work place.
Cultural barriers including sexual connotations associated with the breast and/or lack
of role models or family support.
The ready availability and conspicuous display of infant formula and formula advertising
in hospitals and public health programs.
Despite these and other barriers to breastfeeding, reports indicate that special targeting and
promotion initiatives have increased the rates of breastfeeding among low-income participants.
In WIC, a variety of approaches such as peer support counselors, special incentives, prenatal
classes, toll-free telephone lines, and health professional training sessions have been success-
ful in both prenatal and postpartum support programs (17,18,19,20,21,22,23).
A number of state WIC agencies support breastfeeding via food package tailoring policies.
This involves adjusting the amount and/or type of infant formula provided for the breastfed
infant in proportion to the frequency of breastfeeding. Several state WIC Programs have imple-
mented innovative clinical and administrative approaches. Other states have used designated
formula rebate dollars to fund local breastfeeding activities. Many states have developed
breastfeeding policy statements, lactation training centers, statewide breastfeeding task forces,
lactation resource kits for professionals, breast pump loan programs and peer counselor
programs, etc.
2
POSITION PAPER
Breastfeeding Promotion in the WIC Program, 9 October 1992
The federal government historically has supported breastfeeding promotion initiatives in state
and local programs as well as in collaboration with the private sector. Specifically, the United
States Department of Agriculture (USDA) has promoted breastfeeding through WIC Program
regulations, technical assistance publications, cooperative efforts with the National Health
Mothers, Healthy Babies Coalition and the Department of Health and Human Services (DHHS),
and through breastfeeding promotion research (19,23). Other federal breastfeeding promotion
initiatives targeting low-income mothers are supported by DHHS through the Maternal and
Child Health Services Block Grant. These include provision of leadership through development
of policies and guidelines, consultation and technical assistance, research studies, education of
health professionals, demonstration projects, and breastfeeding support services integrated
into state and local health programs (24). The WIC Program can be most effective in breastfeed-
ing promotion and education by working with other relevant organizations and agencies.
USDA has supported regional breastfeeding conferences and has new incentive demonstration
projects in place. They have established an interdisciplinary Breastfeeding Consortium which
is working to develop a national breastfeeding promotion media campaign. USDA recently
announced their intent to enhance the food package for exclusively breastfeeding women.
USDA-Food and Nutrition Services has also established policies supporting breastfeeding in
the workplace.
Public Law 101-147, passed in November 1989, contained a number of breastfeeding provisions
that have put the WIC Program in a better position to establish and maintain breastfeeding pro-
motion and support programs. Based on the legislation, new regulations mandated the estab-
lishment of a standard definition of breastfeeding, earmarked monies for breastfeeding promo-
tion and support, required designation of state and local agency breastfeeding coordinators,
required an annual evaluation of breastfeeding programs, developed standards for training and
orientation of staff, required plans to be in place assuring all women have access to breastfeed-
ing promotion and support activities during the prenatal and postpartum periods, and added a
lactation expert to the National Advisory Council for WIC.
Both USDA and NAWD participated in the Maternal and Child Health Inter-Organizational
Nutrition Group (MCHING). MCHING recently published a number of nutrition recommenda-
tions including breastfeeding promotion and support. In an effort to help WIC Programs better
promote breastfeeding, NAWD published and distributed "Guidelines for Promoting
Breastfeeding in the WIC Program" in 1990.
In summary, establishing breastfeeding as the norm for infant feeding continues to be a major
priority in the WIC Program. All WIC personnel have a role in promoting and providing support
for the successful initiation and continuation of breastfeeding.
3
POSITION PAPER
Breastfeeding Promotion in the WIC Program, 9 October 1992
Recommendations
Role of NAWD/USDA
1. Encourage the reporting of optional Breastfeeding data in the WIC Minimum Data Set.
2. Develop a standardized national definition for exclusive and partial breastfeeding to
improve the data collection and make state data comparable.
3. Support the establishment of a clearinghouse to distribute and disseminate information
on breastfeeding promotion and support projects, programs, and products.
4. Encourage support for breastfeeding women in the worksite at all levels.
5. Designate a portion of the research funds from the Office of Analysis and Evaluation
for conducting Food and Nutrition Service studies and technical assistance in the area
of breastfeeding.
6. Continue to support and monitor monies earmarked for breastfeeding promotion and
support programs.
Role of State Staff
1. Adopt and implement the "Guidelines for Promoting Breastfeeding in the WIC Program."
Role of Local Staff
1. Adopt and implement the "Guidelines for Promoting Breastfeeding in the WIC Program."
References
1. Federal Register, Department of Agriculture, Food and Nutrition Service, 7 CFR Part 246,
Special Supplemental Food Program for Women, Infants and Children, Sept. 1990.
Proposed Regulations, Non-Discretionary Items, July 1990. Proposed Regulation,
Enhanced Food Package, Dec. 1991.
2. Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation,
Department of Health and Human Services, 1984.
3. Lawrence, Ruth A., Breastfeeding: A Guide for the Medical Profession. The C.V. Mosby
Company: St. Louis, 1989.
4. Williams, Sue R., Worthington-Roberts, Bonnie, Nutrition Throughout The Life Cycle.
Times Mirror/Mosby College Publishing, 1988.
5. Bryant, C. et al. Best Start: Breastfeeding Promotion in the Southeast - A Program Brief
of the Southeast Regional Breastfeeding Promotion Project. Lexington-Fayette County
Health Department, Lexington, KY (unpublished), 1989.
6. Analysis of the Potential Cost Savings of Breastfeeding - Medical Literature Review and
Assessment - Renewable Technologies, Inc. (RTI), June 1988.
7. American Public Health Association Policy Statement: Infant Feeding in the United States.
American Journal of Public Health 71:207, 1981.
4
POSITION PAPER
Breastfeeding Promotion in the WIC Program, 9 October 1992
8. American College of Obstetricians and Gynecologists and American Academy of
Pediatrics, Guidelines for Perinatal Care, 1988.
9. American Academy of Pediatrics. "The Promotion of Breastfeeding," Pediatrics 69(5):
654-661, 1982.
10. American Dietetics Association. "Position of the American Dietetic Association: Promotion
of Breastfeeding." Journal of American Dietetic Association 86 (11): 1580, 1986.
(Reaffirmed 1991).
11. National Association of Pediatric Nurse Associates and Practitioners, Position Statement
of Breastfeeding, February 20, 1981.
12. World Health Organization. Resolution of the 34th World Health Assembly, International
Code of Marketing of Breastmilk Substitutes, Fifteenth Plenary Meeting, 21 May, 1981.
13. Public Health Service, U.S. Department of Health and Human Services. Healthy People
2000, National Health Promotion and Disease Prevention, 1990.
14. Ross Laboratories, Mother's Survey, Pediatrics, Vol. 88, No. 4, Oct. 1991.
15. Public Health Service, U.S. Department of Health and Human Services. Report of
the Surgeon General's Workshop on Breastfeeding and Human Lactation. Pub. No. HRS-
D-MC 84-2, 1984.
16. Arango, Joyce O., M.P.H., R.D. Promoting Breastfeeding: A National Perspective. Public
Health Reports 1984; Vol. 99, No. 6.
17. Food and Nutrition Service, U.S. Department of Agriculture. Promoting Breastfeeding in
WIC: A Compendium of Practical Approaches. Pub. No. FNS-256, 1988.
18. University of Georgia Center for Continuing Education, et al. Proceedings of Regional
Nutrition Conference, Atlanta, GA, 1986.
19. Efforts to Promote Breastfeeding in the Supplemental Food Program. Food and Nutrition
Service, U.S. Department of Agriculture, Washington, D.C. FNS-236, 1988.
20. Barron, Sharon P., M.S., et al. Factors Influencing Duration of Breastfeeding Among Low-
Income Women. Journal of American Dietetic Association 1988; Vol. 88, No. 12, p. 1557.
21. Winikoff, Beverly, M.D., M.P.H., et al. The Obstetrician's Opportunity: Translating "Breast
Is Best" from Theory to Practice. American Journal of Obstetrics and Gynecology. 1980;
Vol. 138, No. 1, p. 105.
22. Breastfeeding: SPRANS Abstracts Fiscal Year 1989, National Center for Maternal and
Child Health. 38th and R Streets, N.W., Washington, D.C., 20057.
23. WIC Breastfeeding Promotion Study and Demonstration, Phase IV Report. Food and
Nutrition Service, U.S. Department of Agriculture, Alexandria, VA, 1990.
24. Brannon, Elizabeth, M.S., R.D., et al. OMCH Promotes Breastfeeding Through Grants to
16 Varied Projects. Public Health Reports 1988; Vol. 103, No. 5.
25. Bevan, Mary Lundquist, M.P.H., R.D., et al. Factors Influencing Breastfeeding in an Urban
Population. 1984; Vol. 84, No. 5, p. 563.
26. Institute of Medicine, Nutrition During Lactation, National Academy Press, Washington,
D.C., 1991.
5
ASSOCIATION
92-003
NATIONAL
DIRECTORS WIC no
POSITION PAPER
NATIONAL ASSOCIATION OF WIC DIRECTORS
Cost Allocation Systems
9 October 1992
The Special Supplemental Food Program for Women, Infants and Children (WIC), authorized
by Public Law 95-627, as amended, provides supplemental foods, nutrition education, and
referrals. The WIC Program serves as an adjunct to good health care during critical periods of
growth and development. Those eligible for the Program include pregnant, breastfeeding, and
postpartum women, and infants and children up to the age of five, who are low-income and at
nutritional risk, as determined by a health professional.
In carrying out its mandate, WIC regulations (246.4 (a) (8)) require that State agencies describe
how they plan to coordinate program operations with special counseling services and other
programs, including, but not limited to, the Expanded Food and Nutrition Education Program
(EFNEP), the Food Stamp Program, the Early Periodic Screening, Diagnosis and Treatment
(EPSDT) Program, the Aid to Families with Dependent Children (AFDC) Program, the Maternal
and Child Health (MCH) Program, the Medicaid Program, Family Planning, immunizations, pre-
natal care, alcohol and drug abuse counseling, and child abuse counseling. At the Federal level,
there has recently been an increased effort to promote further coordination and integration of
Program services. Federal regulations have been amended to require very specific efforts con-
cerning Program coordination. In addition, there are other initiatives underway to determine
the best methods for insuring coordination of service delivery.
The National Association of WIC Directors (NAWD) believes that WIC plays an important
role in preventive health services and is encouraged to see coordination initiatives underway.
However, NAWD also feels that there are inherent barriers within and between Programs con-
cerning allocation of resources that must be addressed in order to meet the intent of Congress
for individual Programs and to insure that each Program's integrity is protected. Many Federal
Programs have evolved so that regulations may be in conflict or lack uniformity or consistency.
In addition, there is a lack of common guidance and significant disparity in financial resources
between Programs.
NAWD
In association with the Department of Agriculture, Department of Health and Human Services,
1627 Connecticut
and Office of Inspector General, the NAWD wishes to participate in the development and
Avenue, NW
enhancement of procedures that will guide and fairly allocate costs within and between Federal
Programs. The guidelines developed should include as part of its basic precepts the following:
Suite 5
Rules must be clear, concise and common to all Federal programs. The present problem
P.O. Box 53405
in adhering to current rules seems to be due to differing interpretations of terminology,
Washington, DC
language and what is acceptable in those rules. Rather than creating new rules, the exist-
ing rules, such as those found in OMB Circular A-87, should be reexamined with the goal
20009-3405
that fiscal guidance be consistently applied to all Programs.
FAX 202 387.5281
202 232.5492
POSITION PAPER
Cost Allocation Systems, 9 October 1992
Training and policy guidance regarding cost allocation and accountability must be
provided to all Federal Programs. The guidance should be as simple and understandable
as possible and address the needs of varying health delivery systems. For example, the
WIC Program operates in both separate and integrated health care delivery systems. The
regulations should be such that they are interpreted in a consistent, uniform and standard
manner, so costs can be fairly shared regardless of the delivery system in place at the
State and Local level.
Written guidance must meet audit standards. NAWD realizes that written guidance for
accountability and allowability must meet audit standards. However, auditing agencies
should not be setting Program standards and policy as to allowability of cost. The primary
objective from the audit standpoint should be to eliminate as many "judgement calls" as
possible. Auditing is not always definitive, therefore, great care must be taken to ensure
that cost allowability rules are interpreted and consistently applied in the same manner
to all Programs by auditors.
Shared costs must be based upon a sound consistent method. In order to avoid duplica-
tion of services, mutually benefiting Programs must pay a fair and equitable allocation of
costs. However, each Program's integrity must be protected so it can remain within its
intended specific Congressional mandate.
Prioritization of services must be considered in order to meet each Program's
Congressional intent. Congressional intent of a specific Program must be the highest
priority before integration of other services can occur. The concept of shared costs should
not be defined as one Program's funds substituted for another's shortfall. Rather funding
for shared costs needs to be treated as an augmentation with equitable contributions
from all sources.
A system to allocate and document costs must be in place. Resources used in establish-
ing and maintaining a cost allocation system cannot outweigh the benefits received.
A system to allocate and document costs that is labor intensive and burdensome defeats
the purpose for which it was created. Any cost allocation system developed must be as
clear and concise as possible to both the user and reviewer.
Summary
NAWD recommends that a partnership between USDA, HHS, and representatives of other
programs be formed to cooperatively coordinate and integrate related services to meet mutual
needs and fairly allocate costs. It is incumbent upon the Federal agencies to develop regula-
tions and procedures that are consistently interpreted and applied across all Programs at all
levels and to insure that the intent of Congress is carried forth and Program integrity remains
intact. Without application of uniform and specific cost allocation guidance, Program integra-
tion, coordination and services will be impeded. If State and Local Programs are to achieve the
goal of effective Program coordination and integration, they require clear and concise guidance
and technical assistance from the Federal agencies in order to comply with audit standards. In
turn, auditors, should have direction so interpretation of regulations leads to the same conclu-
sion for all Federal Programs.
2
ASSOCIATION
92-004
NATIONAL
DIRECTORS WIC no
POSITION PAPER
NATIONAL ASSOCIATION OF WIC DIRECTORS
Vendor Management in the WIC Program
9 October 1992
The National Association of WIC Directors (NAWD) supports the development and main-
tenance of efficient and effective vendor management systems that prevent error and abuse
and focus on improving vendor management outcomes. NAWD encourages the United States
Department of Agriculture's (USDA) support of state efforts in developing innovative approach-
es to vendor management which encompass the elements of accountability and adaptability.
Key to the design of an effective vendor management system are the following considerations:
Vendor management is an inclusive, evolutionary process and there is no single system
beyond which there can be no progress.
Cooperative efforts between the federal and state governments represent the most
productive approach to the advancement of vendor management.
USDA should hold states accountable for results rather than require adherence to a
prescribed set of activities.
The majority of vendors operate reputable businesses, and vendors should serve as
a resource for food delivery system planning and development.
The most cost-effective way to control error and abuse is through a preventive approach.
WIC staff at all levels can contribute to the success of food delivery systems, and USDA
staff should become specialized in vendor management.
State agencies should regularly exchange information on technical and procedural
advances in vendor management.
USDA should continue to provide incentive funding for the enhancement of vendor
management and avoid policies that create disincentives.
NAWD
The strength of a system's design should be validated through a review of the individual
state's performance.
1627 Connecticut
Avenue, NW
Historical Perspective
Suite 5
WIC is unique in that program resources must be committed to both direct client health and
P.O. Box 53405
social services and to the establishment of a comprehensive food delivery system encompass-
ing a large number of private, for-profit vendors. It is necessary when operating a food delivery
Washington, DC
system to establish internal controls that prevent error and limit opportunities for abuse.
20009-3405
FAX 202 387.5281
202 232.5492
POSITION PAPER
Vendor Management in the WIC Program, 9 October 1992
USDA's primary focus in the area of vendor management has been on abuse detection, investi-
gation and sanctions. NAWD believes that while it is necessary to have the ability to monitor
the success of any vendor management system, the most cost-effective way to control abuse is
through a preventive approach.
In recent years, many state agencies have made significant progress in designing and imple-
menting improved automated systems for certification, check issuance, and reconciliation. The
loss of program funds through identification of vendor abuse has been significantly reduced
based on stronger pre-payment edits and variable limits being placed on check redemption val-
ues. It is recognized that the objectives of food delivery system enhancements are:
improved client access to services and foods;
reduced food costs;
increased efficiency;
maximal use of existing resources;
minimal levels of fraud, abuse, and waste.
Standards for Vendor Management
USDA and state agencies share the common goals of efficient and cost-effective vendor man-
agement systems. NAWD supports cooperative efforts between the states and USDA and rec-
ognizes the most effective and desirable systems use abuse prevention through program
design rather than relying solely on punitive methods after a loss or misuse of program funds
has occurred.
In 1985, the USDA and NAWD began work on the Focus on Management (FOM) project and
produced standards for vendor management and a self-assessment tool for state agencies.
The general goals of the FOM Vendor Management Standards were to ensure that states would
have (1) a manageable number of vendors, (2) compliant vendors, (3) compliant participants,
and (4) reasonable food costs.
The FOM Vendor Management Standards called for goal-oriented rather than process-oriented
systems. The standards served to foster dialogue between the states and Food and Nutrition
Services. For each key component of vendor management, from authorization to sanctions,
state agencies were challenged to identify potential weaknesses and to develop implementation
strategies for enhancements in consultation with FNS. The standards were also described as
having an underlying statement of values. NAWD and USDA reached agreement on the values
that should shape management decisions, such as exhibiting good management of the food
grant through the practices governing vendor selection, performance, and sanctions. NAWD
and USDA worked closely together to identify essential standards and to assist states with the
development of effective vendor management systems.
The USDA Inspector General's Office (OIG) has made recommendations that are very similar
to the FOM vendor management standards, such as:
enhanced FNS role in providing reviews and guidance
development of basic criteria for the identification of high-risk vendors
2
POSITION PAPER
Vendor Management in the WIC Program, 9 October 1992
requirement for monitoring vendor prices and prevent overcharges
requirement to perform compliance purchases and sanctions for abuse on identified
high-risk vendors
A resurrection of the highly regarded FOM methodology of cooperative effort between
State and Federal agencies is recommended as a means of effecting good vendor
management practices.
Measuring Achievement
States should be held accountable for results rather than adherence to a prescribed set of
activities which may or may not be cost-effective. It is undeniable that when USDA dictates the
exact manner in which limited funds are to be used, state agencies are constricted in their abili-
ty to enhance food delivery and vendor management systems through alternative designs.
In promulgating regulations, USDA should describe desirable outcomes rather than essential
processes. NAWD is concerned that statistical comparisons can be misleading and that a state
agency's initiatives to prevent error and abuse (such as tight authorization criteria) may be
overshadowed by another state's emphasis on investigating abuse after the fact. Emphasis
should not be placed on investigations at the expense of other important vendor management
activities, such as routine monitoring. The fact that one state has reported a higher number of
sanctions than another state is meaningless in determining which systems are cost-effective
abuse prevention systems. NAWD believes a more realistic approach for measuring effective
vendor management centers on preventive systems that are implemented and evaluated on a
comparative basis across state agencies.
The strength of a system's design should be validated through a review of its results. The
State Plan of Program Operations and Administration provides the mechanism for USDA to
evaluate the vendor management program which is being developed and implemented in each
state agency with regard to vendor issues. Beyond this, on-site management evaluations and
data provided to USDA in a variety of areas, ranging from food costs to vendor review activi-
ties, provide extensive opportunity for USDA to exercise its authority over states which fail to
meet basic vendor management principles and requirements. NAWD encourages USDA in its
continued utilization of these review mechanisms.
Funding for Vendor Management
Vendor management, as a component of a state's food delivery system, is an area that
requires extensive preventive controls if the objectives of a food delivery system are to be met.
However, state agencies cannot be expected to design and implement innovative systems for
vendor management without adequate financial and technical assistance from USDA. NAWD
believes it is the responsibility of USDA to provide state agencies with the supportive environ-
ment which allows and encourages effective vendor management systems to evolve.
In the absence of increased funding, multiple program components increasingly compete for
available resources. Increases in federal requirements (i.e., drug abuse education and referral,
new mandates for providing services for homeless individuals, working persons, and the rural
3
POSITION PAPER
Vendor Management in the WIC Program, 9 October 1992
poor) without additional funding have resulted in the various program components competing
for the same dollars. These conflicting priorities result in food delivery systems that have been
designed using remnants of resources after other administrative obligations have been met.
NAWD encourages USDA to make the funding and ideological commitment necessary for state
agencies to implement long-term vendor abuse prevention systems.
It must be universally recognized that all funding resources should not be committed to achiev-
ing only process-oriented federally mandated activities. USDA should continue to provide
incentive funds for the enhancement of vendor management. NAWD opposes any federal poli-
cies that would discourage state agencies from advancing or sustaining vendor management
efforts. An enormous potential exists at this time for NAWD and USDA to advance the science
of vendor management as proponents of preventive systems that allow states agencies to exert
maximum authority and control over vendor abuse.
Need for Technical Assistance
State agencies need to provide each other with technical assistance on vendor management.
NAWD supports regional and multi-regional meetings as forums for the exchange of informa-
tion and experience. NAWD is willing to work with USDA to establish guidelines for effective
vendor management practices and to provide technical assistance to any state or group of
states that is attempting to develop a more effective system.
State agencies and USDA have jointly participated in national and regional meetings for vendor
specialists. These examples of cooperative efforts between federal and state government repre-
sent the most productive approach to the advancement of vendor management. The coopera-
tion and exchange of information which occurs at these meetings and between state agencies
on their own initiative exemplifies the approach NAWD endorses as necessary to effect good
vendor management.
WIC Program staff at all levels can make a contribution to successful food delivery. Due to
the growth in program funding and the need to remain accountable for these funds, NAWD
encourages specialization of USDA staff at the regional as well as the national level in order to
promote effective vendor management and to facilitate technology transfer among the state
agencies.
Vendor Participation in Program Planning and Development
NAWD believes that the majority of vendors operate reputable businesses and that most ven-
dors can be expected to make a reasonable effort to comply with program rules. These vendors
are essential to the successful outcome of WIC Program objectives and represent an untapped
resource. NAWD recommends that vendors be utilized as a resource in the development of
future error and abuse prevention systems. In this vein, USDA and state agencies should avoid
any actions which would create antagonistic relationships with "mainstream" vendors as cur-
rently would exist with a "sanction" centered vendor management system.
NAWD endorses the participation of vendors in focus groups, planning and policy formation,
and the development of preventive measures over process-oriented investigations and sanc-
tions. This proposal to include vendors in future system development to enable more effective
state agency vendor management and oversight.
4
POSITION PAPER
Vendor Management in the WIC Program, 9 October 1992
NAWD recommends reorientation of current USDA philosophy from one of "sanction" to one
of "error and abuse prevention" is necessary in order to accomplish this cooperative interac-
tion. A vendor management system which has as its only component investigations and sanc-
tions is, by its very nature, adversarial and counterproductive to inducing vendor support of
accountability objectives.
System Design and Further Development
Vendor management is an evolutionary process. Those changes that are regarded as
enhancements today may be regarded as elementary in the future. NAWD believes that there is
no single system beyond which there can be no progress. Fundamentals have been described,
although changing times and circumstances are making some of the older precepts unstable.
The basic elements of effective vendor management, however, will continue to include process-
es for vendor selection, training, monitoring, and sanctions. There may be a need for USDA to
support contracts between selected state agencies (representing a variety of types, sizes, prob-
lems and strengths) and outside consultants who could develop core (rather than "model")
systems, identify the essential resources for successful operation of the system, and provide
documentation for other states to examine. "Core" systems should lend themselves to modifi-
cation and adaptation.
NAWD recognizes that prevention of vendor abuse involves more than vendor monitoring
activities; vendor management is interrelated with other program components, and vendor
management cannot be examined outside the context of the whole food delivery system.
Food instrument design, data processing, payment services, and participant education, notifica-
tion and sanctioning all have a role in the prevention and detection of abuse and, as such,
NAWD supports their integration into future vendor management systems.
Summary
It is NAWD's position that accountable, adaptable, vendor management systems, designed
to prevent vendor error and abuse, will safeguard the integrity of the WIC Program. Effective
vendor management systems in the present and in the future must be innovative, flexible, and
interrelated to all areas of WIC program management in order to respond to and oversee an
ever-changing vendor environment.
5
Clinton Presidential Records
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marker by the William J. Clinton Presidential Library Staff.
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of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
8
Impoving a Quality of Life
IMPROVING
A
QUALITY
OF
LIFE
JEFF GRESSER
NAWD
National Association of WIC Directors
Clinton Presidential Records
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This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
f
10
N AWD Focus
Winter/Spring 1993 Volum 3 No. I
NAWD NATIONAL ASSOCIATION focus
ASSOCIATION
OF
CELEBRATING A DECADE OF DIVERSITY
WIC
NAWD's Tenth Annual Conference
Over 600 participants attended this
NATIONAL
year's annual NAWD conference,
"Celebrating a Decade of Diversity,"
held in Washington, DC, February
Winter/Spring
7-10. The first evening's Awards
Banquet set the tone for the celebra-
1993
tion with a tribute to John Barr,
NAWD's departing President, by
the Native American WIC directors
Dave Thomas, 1992 NAWD Treasurer and Montana
Volume 3
carrying the flags of their nations.
State WIC Director, presents 1993 NAWD
Leadership Award to Dennis Bach, NAWD Past
The Native American drummers
President and lowa State WIC Director
and singers led by Bea Carson and
Number 1
Pat Ocumma were highlights of
the evening.
Plenary speakers also built on
the theme of "Diversity," with
William "Sonny" Walker from the
National Alliance of Business and
Dr. Maxine Hays of the Washington
State Department of Health sharing
Debra Stabeno, Southwest Regional Board
the podium to discuss the benefits of
Representative, presents NAWD Leadership
Award for WIC Volunteer Mildred Robinson to
cultural diversity in a session titled
Texas County WIC Program Representative
"Appreciating the Value of Diver-
sity." While participants enjoyed the
stories shared by Walker, his talk
focused on the need to recognize
the contributions made by various
cultural groups in the work environ-
ment. Hays gave participants a
means for determining cultural com-
petency in the workplace.
Jill Leppert, Local Agency Section Board
Marian Wright Edelman,
Representative, presents NAWD Leadership
Award for the Dade County WIC Program Staff to
Director of the Children's Defense
Denise West, Program Director
Fund, was the featured speaker at
the conference's luncheon on
February 8. Edelman received a
standing ovation from conference
attendees for her moving call to
"Leave No Child Behind," which
included statistics illustrating the
extent of child poverty and neglect
in the United States with an outline
Indian and Native American Coalition Chair Bea
for ways of addressing these prob-
Carson, Mississippi Choctaw State WIC Director
and Pat Ocumma, Coalition Member and Eastern
lems.
Band of Cherokee Director, present NAWD
Nutrition issues were also
Leadership Award to 1992 NAWD President
John Barr
featured at the conference. Ellyn
NAWD Focus is generously sponsored by General Mills
ASSOCIATION
FY '93.01
NATIONAL
DIRECTORS WIC no
FY'93 LEGISLATIVE AGENDA
NATIONAL ASSOCIATION OF WIC DIRECTORS
Three Percent Versus One Percent Carry-Forward/Spend-Back:
Change Section 17, (i), (3)(A)(i) and (ii), page 39 of the Child Nutrition Act of 1966, dated
August 17, 1992.
NAWD's proposal would allow states to carry-forward or spend-back three (3) percent of the
total federal grant payment versus the current allowable limit of 1 percent. The current carry-
forward/spend-back provision does not include rebates. The NAWD proposal also does not
include rebates.
The proposed change to three (3) percent would serve as an excellent management tool,
enhancing states' abilities to more effectively manage and stabilize caseload at maximum lev-
els. This, in turn, would reduce the possibility of drastic caseload increases or reductions. When
drastic changes occur, participants may have to be removed from the program in the summer
only to be put back on the program in October when more funds are available. This is a disser-
vice to the women, infants and children we serve.
Often, young children are removed from the program mid-way through their certification to
satisfy budgetary constraints. A more flexible carry-forward/spend-back provision would not
force WIC managers to use children as pawns to balance program budgets. Because inflation
is erratic, the current one (1) percent carry-forward/spend-back provision does not provide suffi-
cient management flexibility to effectively and efficiently manage the program. The carry-for-
ward/spend-back provision applies to federal funds only. States may receive as much as one-
third of WIC funds from infant formula rebates. This results in a carry-forward of less than one
percent of the total WIC funding in any given year.
Most federal programs have a multi-year grant expenditure. The NAWD proposal would place
the WIC program more in line with other grant programs managed by state agencies.
NAWD's proposed change would not have any bearing on the current regulatory provision
which allows five (5) percent for the first year of cost containment implementation and three
(3) percent for the second year.
NAWD
1627 Connecticut
Carry-Forward/Spend-Back: When There is a Significant Reduction
Avenue, NW
in Rebate
Suite 5
Change the language in paragraph (D), page 39, Section 17, Child Nutrition Act of 1966.
P.O. Box 53405
NAWD's proposal would allow states to carry-forward/spend-back five (5) percent of the total
Washington, DC
federal food grant during the first year if there is a significant reduction in the amount of rebate
20009-3405
revenues. Current language allows only for increases in rebate revenues. The current United
States Department of Agriculture working definition of significant increase is fifteen (15) percent
FAX 202 387.5281
or more in rebate revenues. This definition should also apply to a decrease in rebate revenues.
202 232.5492
FY'93 LEGISLATIVE AGENDA
NATIONAL ASSOCIATION OF WIC DIRECTORS
Grants for Special Projects
Change paragraph (g)(5), page 33, Section 17, of the Child Nutrition Act of 1966 dated
August 17, 1992.
NAWD proposes that at least $2 million of those funds which are available to the Secretary
for the purpose of program evaluation (currently one half of one percent, not to exceed $5 mil-
lion) be made available to states in the form of special projects grants. These grants would be
available on a competitive basis to all states for special projects of up to two years in duration.
Qualifying projects would have regional or national significance and be directed toward
improving the services of the WIC Program. Under this proposal, states should have a mini-
mum of two years to expend grant resources and complete approved projects.
Full Funding Versus Entitlement
NAWD continues to advocate for the five year full-funding plan the Association presented
to Congress in 1991. This plan stressed the need for incremental funding increases for the
program in order to reach full funding (serving 85 percent of the in-need or eligible population)
by 1996.
NAWD urges Congress and the Administration to consider mechanisms for fully funding the
program. These might include increased domestic discretionary resource commitments, legisla-
tion which would provide for mandatory funding commitments, or entitlement grants to the
states. NAWD is opposed to converting the WIC Program to an entitlement program for individ-
uals. Alternative funding mechanisms which focus on commitments to the states rather than
the individuals would:
1. Maintain the program's focus on nutrition.
2. Maintain program quality. NAWD's full-funding plan is a practical approach to incre-
mentally add caseload without placing an undue burden on WIC clinics and undue hard-
ship on participants. It would avoid service delays and potentially long waiting periods.
3. Maintain targeting and tailoring. Under entitlement programs directed toward
individuals, state's lose flexibility and management control. The WIC Program's docu-
mented accomplishments demonstrate its high level of success. The Program is proud
of its record of accountability. Full-funding mechanisms will maintain the integrity of
the Program and the quality services it delivers to participants.
4. NAWD urges Congress and the Administration to exempt WIC from all budget
balancing legislation or agreements.
2
FY'93 LEGISLATIVE AGENDA
NATIONAL ASSOCIATION OF WIC DIRECTORS
Option for States to Use Food Dollars for Purchase of
Breast Pumps
In keeping with a recommendation from the WIC National Advisory Committee, NAWD urges
Congress and the Administration to authorize states the option to use food dollars to buy man-
ual or electric (with disposable accessories) breast pumps.
Breast pumps are a clear benefit for participants. They assist breast-feeding mothers to contin-
ue providing healthy mother's milk for their infants in spite of timing constraints or logistical
considerations caused by employment, school or other considerations. Breast milk is consid-
ered the healthiest and best source of nutrition for infants.
This proposal would exclude the purchase of shells, pads, or similar devices. Electric pumps
would be loaned to participants.
Program Name Change
In an effort to maintain the Congressionally mandated focus of the WIC Program, NAWD
urges that the Program's name be changed from the "Special Supplemental Food Program
for Women, Infants, and Children" to the "Special Nutrition Program for Women, Infants,
and Children".
Issue of Concern
The Cash Management Improvement Act's objective or goal is to prevent the federal govern-
ment and state governments from having to pay interest to each other through the mechanism
of a zero balance. NAWD is concerned that the Cash Management Improvement Act has failed
to consider the uniqueness of the WIC Program's income. For example, the Act has not consid-
ered income from infant formula rebates; nor has it taken into consideration other program
incomes, such as monies collected from vendors for overcharges, civil money penalties on
vendors, and collections from participants for obtaining unauthorized benefits. NAWD recom-
mends that the Cash Management Improvement Act exempt these two categories of funds
received by the WIC Program.
While it is reasonable to expect that states anticipate expenditures on a daily basis and draw
down federal funds accordingly so that there would not be a balance for which states would
be responsible for paying interest - it is unreasonable to expect states to expend one to three
million dollars in lump sum rebate payments within one day of receiving the rebate check.
If the check amount is not spent in a day, the state must pay interest. States should not be
expected to pay interest to the federal government on these funds. The same logic applies to
other program funds, such as civil money penalties, collection of overcharges from vendors,
and collection from participants.
3
₽НОТОСОРУ
PR ESERVATION
GREGORY'S SUNSHINE, INC.
DICK GREGORY
P.O. BOX 3270
PLYMOUTH, MA 02361
(508) 746-7427
DICK GREGORY'S END-HUNGER SUNSHINE CORP.
P.O. Box 3270
Plymouth, Massachusetts 02361
OPENING STATEMENT
Dick Gregory, Activist and Entrepreneur
Hunger forum: Agenda for the Future
June 17, 1993
Good Morning. I am pleased to be here
are frequently associated with malnutrition
this morning to focus attention on this critical
and other forms of ill-health. The most basic
issue. We will articulate the effects hunger
and widespread manifestation of hunger today
has on our nation, hear from experts on what
- and the least recognized - is chronic under-
the causes of hunger are, and seek concrete
nutrition. Another "invisible" form that
solutions on what should be done to eradicate
hunger can take is malnutrition, a condition
this problem. The panel that I'm on; Extent
that occurs when an individual's diet has a
and Consequences of Hunger: Connections to
relative deficiency or excess of specific nutri-
Poverty, Agriculture, Health, Education and
ents vital to good health. If we are to gain the
Community Development will cover a broad
trust of poor folks we need to also undertake
range of topics. I will necessarily have to
the more serious and far-reaching policies to
concentrate on a few highlights in this brief
eliminate the poverty which underlies hunger.
statement.
We also must expand our educational efforts
I will begin by stating that over 30
to teach people the importance of eating for
million people are going hungry in our nation
nutrition and not for taste.
and more than 12 million are children. I am
One of the most important things that
here today not to be involved in another
we can do to start turning this around is to
committee on hunger, but to say that its time
look at the sad plight of our farmers. They are
to end hunger. We have an opportunity to
losing their land to banks and large corpora-
transcend the differences of politics and na-
tions, losing their health through toxic
tions, and religions and ideologies by finally
chemical exposure and stress; and their way
working together to address the most funda-
of life is vanishing. In a personal sense, I feel
mental need of all - the need for nutritious
sorry for anyone who falls on hard times and
food. We have an opportunity to make our
suffers economicinjustice in this land of plenty.
lives matter, to recognize our own personal
However, when I see the American farmer
power and responsibility for our nation, to
losing his land today, realize that he actually
perceive what needs to be done and do it.
lost it a long time ago. We all reap what we
Many people believe that hunger exists
sow.
because there's not enough food to go around.
The American farmer began to lose his
The real cause of hunger is a scarcity of
land the first time he trusted the plant instead
justice, not a scarcity of food. Hunger is really
of the soil. He lost it the first time he poisoned
a social disease caused by the unjust, inefficient
his land for short-term profit.
and wasteful control of food.
No serious investigation into hunger
If you look at poor folks down through
can be made without a thorough knowledge of
the years it seems that nobody has come up
the principles of soil health and its relation-
with programs for their benefit-there's always
ship to the food produced. Yet not one in a
some motive behind it. Hunger and poverty
thousand nutritionists or dieticians has ever
studied the soil and plant relationship. No
liberated.
civilization has ever lived beyondthe health of
A policy of favoring diversified, sus-
its soil.
tainable agriculture will make the nation's
I favor methods of agriculture that improve
farmers more economically stable by reducing
the long-term profitability of agriculture, such
the impact of price fluctuations, and will
as crop diversification, conservation tillage
eliminate the threat of widespread erosion,
methods, and low-cost integrated pest man-
soil depletion, and health problems due to
agement systems that are safer, organic, and
build-up of toxic chemicals in the food chain
sustainable over the long term.
and in the environment. The savings to the
Agriculture has drifted away from
nation from these policies over the long term
natural rhythms and processes that support
will be incalculably great; the risk to future
soil fertility and crop production and that
generations of not adopting them is equally
sustain the life of the farmer and the nation.
great. These policies of favoring natural,
Chemical fertilizers and pesticides pose in-
diversified, efficient agriculture will help to
creasing problems to farmers. They add to the
preserve the American farm as a fundamen-
operating expenses of the farmer, yet are
tal institution of the vital life line in our
becoming less effective by breeding increas-
nation. In order to move our nation along this
ingly resistant strains of weeds and insects.
direction, I would call upon the Honorable
Agricultural chemicals are a major source of
Michael Epsy, Secretary of Agriculture, to
pollution to ground and surface water. Heavy
reinstitute the funding for The National Or-
reliance on chemical fertilizers may be de-
ganic Production Program and The National
pleting the natural life and fertility of the soil
Organic Standards Board. The lack of fund-
and may pose a serious hazard to future
ing has raised strong questions about the
generations.
commitment of Congress and the U.S.D.A. to
To support agricultural prices, the
organic agriculture.
federal government has put millions of acres
As an individual I have run from Los
into the conservation reserve and other set-
Angeles to New York City, a total of 3,300
aside programs, paying farmers not to produce.
miles, averaging 50 miles every day to focus
Thus an artificial economic imbalance is cre-
attention upon hunger and malnutrition. In
ated in the U.S. agricultural economy while
1981, for 54 days and 54 nights, I starved
people in other parts of the world starve.
myself for science. To the amazement of
Traditions of rural American farm
scientists and technicians who monitored my
communities and small towns are eroding -
54 day water fast at New Orlean's Flint-
yet federal policies are not helping to sustain
Goodridge Hospital, I demonstrated my
the small farmers and their way of life.
physical fitness by walking and jogging from
I also favor locally grown and marketed
New Orleans to the state capital of Baton
foods, and I support the re-institution of local
Rouge, a distance of some 100 miles eight days
farmer's markets. I would like to see a program
after the completion of my water fast. During
to train the homeless and veterans in organic
the eight day period I took only juices and a
farming methods. We could also set up a
mixture of vitamins, minerals, and herbs to
foreign farmers corps and give farmers train-
show that the body can recover quickly when
ing in soil health and nutrition and send them
provided with the proper energy substrate of
around the world - wherever nations would
nutrients. I didn't do this to prove that I'm a
accept them - to grow food for the people. It's
superhuman. I did this to let doctors know
one thing to deal with hunger and malnutri-
what happens during the starvation process.
tion and it's another thing to liberate nations
In 1985, in collaboration with Dr. David
from hunger, which is the only way it can be
Allen, Ralston Purina and their division, Pro-
Dick Gregory's End-Hunger Sunshine Corp. - page 2
tein Technologies, I used a modification of my
in the political and public policy area. I call
Bahamian Diet (soybean formula with 4-X) to
upon our political leaders to be responsible for
do a clinical trial in Ethiopia under Dr.
ending hunger.
Demmissie Habte, who is now the Director of
Finally, I would like to end by stating
the International Center for Diarrheal Dis-
the following facts:
eases Research (ICDDR), in Bangladesh. The
*
Nearly 40 percent of the world's grain and
modified Bahamian Diet reversed the clinical
nearly 70 percent of U.S. grain are fed to
and biochemical features in the children with
livestock.
Kwashiorkor or marasmus, despite the fact
that the majority had associated complicating
*
Almost half the energy used in American
conditions such as infections. Infections are
agriculture goes into livestock production.
known to increase the energy and protein
It takes the equivalent of 50 gallons of
requirements in a child. The success in di-
gasoline to produce the red meat and poul-
etary rehabilitation is related to the quality of
try eaten by the typical American each year
nutritional food consumed.
- and twice that much to process, package,
We know that our Feeding Mixture can
transport, sell, store and cook it.
be produced cheaper than milk-based wean-
ing foods. By the way, one of the main reasons
*
Half of the continental United States is
for the famine in East Africa today is lack of
used for feedstock, pasture and range. Half
topsoil brought about by massive deforesta-
of U.S. cropland grows animal feed and hay.
tion. At the turn of the century, 90 percent of
This land is eroding quickly. For each
Ethiopia's land was covered by forests. Less
pound of red meat, poultry, eggs and milk,
than a century later, not 5 percent of that
farm yeilds lose five pounds of prime topsoil
forest remains. How did this occur? With the
trees cut down for easy profit, the rainwater
*
270 million acres of public land in the
instead of soaking into the topsoil - rushed
western United States are leased to ranch-
down the hillsides, flooded the valleys, and
ers for grazing. Ten percent of this land has
carried the earth off with it. The trees had
already been turned into desert by live-
shaded the soil, and the roots had acted as
stock; 70 percent is severely degraded.
pumps, drawing water up near the surface of
the ground, keeping the water table high. But
*
Livestock produce 158 million tons of waste
now they were gone. Without tree roots to
a year, some of which contaminates under-
keep the water table high, the soil was ex-
water tables with nitrates. Animal waste
posed to sun, wind, and rain. It was baked
and feed fertilizers account for 40 percent of
dry, washed away into streams, rivers, and
the nitrogen and 35 percent of the phos-
oceans, or simply blown away. Without soil in
phorus released into American rivers, lakes
which to grow plants to feed animals and
and streams.
humans, mass starvation soon resulted. Care
of our forests cannot be overstressed. This is
*
Sixty million people will starve to death
because the destruction of any kind of forest
this year. Sixty million people could be
causes great imbalance in the planet's ecosys-
adequately fed by the grain saved if
tem.
Americans reduced their intake of meat by
I believe that hunger and related ill-
10%.
health have no place in a democratic society,
especially one with the resources of the United
States. I am pleased that we are addressing
this issue today. Hunger must be dealt with
Dick Gregory's End-Hunger Sunshine Corp. page 3
TRH, REVERSE T3, AND
LEUENKEPHALIN LEVELS AND
OTHER PHYSIOLOGICAL CHANGES
IN A MALE ADULT DURING
PROLONGED FASTING
James P. Carter, MD, DrPH, and Joseph Allain, MD
New Orleans, Louisiana
In spite of numerous studies of short-term
Normally, during the first five days in such a
(less than 30 days) fasts, current knowledge of
fast. the body's primary need is for glucose to
prolonged fasting, the mechanisms of adapta-
supply energy for the brain. as glucose is as essen-
tion, and the causes of death are limited.
tial as oxygen. A rapid drop in blood sugar level
A healthy 48-year-old man fasted voluntar-
can bring about behavioral changes, confusion.
Ily, on water only, for 54 days, during which
convulsions. coma, and possibly death. In the
time he offered himself as an experimental
body, at rest, the brain consumes about two thirds
subject. Numerous metabolic parameters
of the total circulating glucose supply. Most of the
were measured, and his mental state was
remaining third goes to the skeletal muscles and
evaluated. Those parameters not generally
red blood cells.
measured in previously published fasts are thy-
During the initial stages of fasting. earlier stud-
rotropin-releasing hormone levels (TRH), re-
ies have demonstrated a rise in the blood levels of
verse T3, and leuenkephalin levels.
amino acids (especially alanine) released from
Without experiencing any major difficulties,
muscle cells.2 As fasting continues. the basal
the subject completed a 20-mile jog and a
metabolic rate declines, and the body's need for
60-mile walk eight days after the completion of
calories is further reduced by a loss of metabolical-
his water fast, during which time he "weaned"
ly active tissue.
himself on juices and a mixture of vitamins,
In prolonged fasting, the body takes steps to
minerais, and herbs.
control its loss of protein. The skeletal muscle
cells reduce their release of alanine, and gluconeo-
genesis in the liver declines.³ By the fifth or sixth
The human body has a remarkable capacity for
week of an adult fast. gluconeogenesis drops to the
surviving without food for long periods. In 1912.
point where the liver and kidney produce only 24 g
Benedict' conducted and reported a classic study
of glucose per day, which is used almost exclusive-
on a normal man who fasted voluntarily for 31
ly by the brain. For the brain and the resi of the
days, during which time his only intake was 900
body to make up for the deficit, ketone bodies pro-
mL of water daily. As his fast progressed, it was
duced from adipose tissue are utilized as energy
noted that fat provided more than 75 percent of the
sources.
calories utilized after the first few days of food
deprivation. A progressive decrease in the daily
urinary nitrogen excretion suggested an increasing
CASE REPORT
conservation of body protein.
On July 21, 1981, a healthy, nonobese, 48-year-
old black male subject was admitted to Flint
Goodridge Memorial Hospital, New Orleans,
Requests for reprints should be addressed to Dr. James P.
where he undertook a voluntary fast that lasted for
Carter. Department of Nutrition. School of Public Health
and Tropical Medicine. Tulane University, 1430 Tulane Ave-
54 days. One week prior to the onset of the fast,
nue. New Orleans. LA 70118.
the subject consumed his own formula known as
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL. 75. NO. 12. 1983
1161
CHANGES IN PROLONGED FASTING
TABLE 1. BASAL METABOLIC RATE STUDIES
Surface
O2
Basal
Basal
Area
Consumption
CO2
Expenditure
Metabolic
Respiratory
Day
M²
L/min
Production
(calories)
Rate
Quotient
6
1.82
0.22
0.20
36.0
- 12
0.9
13
1.78
0.17
0.13
27.7
- 32
0.77
20
1.74
0.16
0.13
27.0
-34
0.80
27
1.72
0.17
0.13
29.0
-29
0.77
34
1.71
0.15
0.16
25.9
- -30
1.05
41
1.67
0.12
0.10
20.1
45
0.82
49
1.64
0.18
0.17
32.0
- 15
0.92
55
1.60
0.12
0.09
22.0
-41
0.72
62
1.59
0.15
0.13
27.5
-27
0.87
69
1.56
0.18
0.22
34.0
- 10
1.19
Basal metabolic rate declined within the first 55 days of the fast. Between day 62 and day 69 the subject was
breaking the fast and BMR values increased within that week.
30
16
25
14
20
15
4x FORMULA
NO WATER
12
END FAST
10
10
8
5
4x FORMULA
WATER ONLY
WATER ONLY
6
s
0 I 2 3 4 5 6 7 8 9 10
NO WATER
END FAST
2
Weeks
Figure 1. Beta-hydroxybutyrate leveis (µmol)
0 I 2 3 s 5 6 7 8 9 ю
Weeks
Figure 2. Hemoglobin levels (g/dL)
the "4X formula" (a mixture of vitamins, herbs,
and aquatic plants) and a combination of fruit
juices. fresh vegetables. and grains totaling ap-
complete nutritional assessments weekly from
proximately 1.500 kcal per day. The subject fasted
day 1. This assessment included the following pa-
on 1.5 to 2.5 gal of water per day for the next 48
rameters: height, weight, triceps skinfold, mid-arm
days. For the next four days (days 49 to 52), the
circumference. mid-arm muscle circumference.
subject fasted completely without water. and for
percent body fat. Body Mass Index, serum albu-
the next two days (days 53 and 54). he fasted with
min, total lymphocyte count. total iron-binding
water. On day 55 the subject broke the fast with
capacity. and creatinine/height index.
Welch's grape juice (20 oz). and on the second day
In addition, basal metabolic rate, basal oxygen
postfast. he added orange juice to his diet, foi-
consumption, carbon dioxide production, and
lowed later by fresh peach juice. V-8 juice. and a
respiratory quotient were measured once weekly
little olive oil. Gradually. fresh carrot and cucum-
(Table 1). Beta-hydroxybutyrate levels were also
ber juices were added.
measured on three occasions during the fast to
One week later. the subject began a jog-walk to
confirm that the subject was indeed fasting: the
Baton Rouge, 80 miles away. The subject had
results are plotted in Figure 1.
gained 4 lb since ending the fast, and had increased
In addition, a hematological examination was
his caloric intake to 1,800 kcal.
performed on the subject at the start of the study
While in the hospital. the subject was given a
and every week thereafter. Parameters measured
1162
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL. 75. NO. 12. 1963
CHANGES IN PROLONGED FASTING
TABLE 2. SERUM VITAMIN LEVELS
Vitamin A
Carotene
Vitamin c
Serum Folate
RBC Folate
µg/dL
µg/dL
mg/dL
ng/mL
ng/mL RBC
(Normal =
(Normal =
(Normal =
(Normal =
(Normal =
20-80
50-300
0.4-1.0
7-16
126-600
Day
µg/dL)
µg/dL)
mg/dL)
ng/mL
ng/mL)
10
64.4
80
0.76
8.1
403
24
65.4
56
0.63
22.0
537
80
60
70
50
WATER ONLY
60
40
50
30
40
30
= FORMULA
WATER ONLY
NO WATER
END FAST
20
4x FORMULA
NO WATER
END FAST
10
20
10
0 I 2 3 s 5 6 7 8 9 10
Weeks
0 I 2 3 4 5 6 7 8 , 10
Figure 5. Leuenkephalin levels (pmol/mL)
Weeks
Figure 3. TRH levels (pg/mL)
40
50
30
WATER ONLY
40
20
FORMULA =
NO WATER
20
30
END FAST
10
4x FORMULA
NO WATER
END FAST
WATER ONLY
0
I 2 3 4 5 6 7 8 9 10
10
Weeks
0 I 2 3 4 5 6 7 8 9 10
Figure 6. Growth hormone levels (ng/mL)
Weeks
Figure 4. Reverse T3 levels (ng/dL)
releasing hormone (TRH). serum T3. serum T..
and reverse T3. Serum T3 and serum T. levels were
normal. The changes in the levels of TRH and re-
included hemoglobin. hematocrit, RBC. RBC in-
verse T3 are illustrated in Figures 3 and 4. Levels
dices. and reticulocyte count. The hemoglobin
of leuenkephalin and growth hormone were also
level fell gradually. steadily. and slightly through-
measured (Figures 5 and 6). There is a rise in leu-
out the study, and the cause was felt to be iatro-
enkephalin levels. but it is not statistically signifi-
genic (Figure 2). Levels of vitamins A and C. caro-
cant. There was a sharp rise in growth hormone
tene. serum folate. and RBC folate were also
levels when the subject began to train for his jog-
measured. as well as amino acid levels and serum
walk to Baton Rouge.
electrolytes. The levels of carotene and vitamin C
The subject's psychological status was eval-
decreased but these levels never fell into the defi-
uated by reports from two psychologists and one
ciency ranges (Table 2).
psychiatrist. They made observations during the
Thyroid regulation. control, and function were
fast and interpreted data obtained on a multiple-
also evaluated by examining levels of thyrotropin-
adjective list for assessment of mood and levels of
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL. 75. NO. 12. 1983
1163
CHANGES IN PROLONGED FASTING
TABLE 3. RESULTS OF MULTIPLE-ADJECTIVE
strikers. it appears that they reached their fatal
CHECKLIST ASSESSING MOOD
stages when their body fat was completely ex-
hausted. It was found that death occurred when
Day
Anxiety
Depression
Hostility
approximately 19 percent of the body protein and
15
0
0
about 70 to 94 percent of the body fat stores were
0
17
0
0
0
diminished.⁷
21
1
1
1
Throughout the fasting period the subject's
29
0
1
3
plasma amino acid levels remained within normal
31
0
0
1
limits. with a general tendency to an early slight
35
0
0
1
increase. The normal levels of plasma amino acids
38
0
0
2
42
0
0
2
could relate to the timing of the drawing of blood
45
0
0
6
specimens. A decline in alanine after the first week
49
2
0
4
may have been missed. The importance of eluci-
52
3
2
4
dating the mechanisms. other than insulin, for con-
61
0
1
4
trolling amino acid catabolism in fasting is essen-
tial to improving understanding of the metabolic
derangements responsible for the severe protein
wasting of uncontrolled diabetes, sepsis, and
anxiety. depression. and hostility. All results of
trauma. and for an understanding of the ammonia-
the mood-assessment test were normal (Table 3).
tion of keto-acids and the metabolism of urea.
The subject was generally cooperative with the at-
both of which are thought to occur in hibernation
tending staff throughout the study and was deter-
and may add to our knowledge concerning the
mined to endure the fast. even when the physi-
management of uremia.
cians recommended against it.
Although serum albumin remained normal
throughout the fast. serum transferrin declined
from 240 mg/dL at the beginning of the fast to 175
DISCUSSION
mg/dL at the end of the fast. The total iron-binding
The subject achieved a weight loss of 19 kg (27
capacity, likewise. declined from 379 µ/mL on day
percent of his body weight) during the "water
13 to 272 µ/mL at the end of the fast. The total
only" part of the fast (through day 48). Six days
lymphocyte count also dropped from 3.068 at the
later (4 days nothing by mouth. 2 days water only).
beginning of the fast to 1.770 on day 41. These
the subject lost an additional 1.6 kg. Thus. after 54
results reflect a depletion of visceral protein; this
days of going completely without food and only
is also observed in the delayed hypersensitivity
drinking water. the subject had lost 20.6 kg (29.4
skin tests performed on the subject. Three out of
percent of his body weight). Similar results were
five skin tests were positive on admission, and
obtained by Benedict in 1912 during a 31-day fast.
complete anergy developed by day 49 (of the total
The subject in this study lost 21.3 percent of his
fast). Nevertheless. the subject showed no signs of
weight.'
infection throughout the fast.
The patient's body fat decreased from 18 to 4
The fall in hemoglobin from 15.5 g to 10 g is
percent (the limits of detection and/or measure-
greater than would be expected in fasting. Usually
ment with the range of skinfold calipers and Pol-
fasting subjects demonstrate a mild normocytic
lack's nomogram) throughout the fast, although
normochromic anemia." The 5.5-g drop may be
the most rapid fat loss occurred within the first 30
iatrogenic as a result of the amounts of blood taken
days. Body protein declined 29 percent during the
from the subject biweekly throughout the study.
fast. The literature states that a 30 to 50 percent
Evidence of vitamin deficiencies sometimes
loss of lean body mass. ie, protein. is incompatible
seen in fasting studies beyond 30 days was not
with life.
present in this study. The decline in metabolic
Changes in body fat in fasting subjects have re-
rate. however, would diminish the need for some of
cently been suggested to be associated with a
the vitamins, particularly those whose requirements
prognosis or probability of death. According to the
are linked to caloric intake. eg. B-complex. Since the
report by Marliss" concerning the ten Irish hunger
subject had access to vitamins during the fast. the
1164
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL 75. NO. 12. 1983
CHANGES IN PROLONGED FASTING
possibility of vitamin ingestion cannot be ruled out:
and represent an attempt by the body to retard
however, it seems extremely unlikely because of the
metabolic processes and thus conserve energy and
subject's commitment to the experiment.
preserve vital organ systems and their functions.
Thyrotropin-releasing hormone from the hypo-
Insulin levels were reported to be consistently
thalamus and elsewhere in the body decreases
low (too low to measure) throughout the fast. It is
progressively as fasting advances. The subject's
believed that low levels of insulin do not modulate
TRH was significantly decreased by the first week
glucose, since glucose turnover studies indicate
of fasting. with the rate of decrease accelerating
that most of the glucose produced is probably uti-
between days 32 and 42. It is assumed that this is
lized by tissues not sensitive to insulin, eg, the
the principal mechanism of the body to lower met-
brain. 16.17 Therefore, the role of insulin during fast-
abolic rate. conserve fuel stores. and prolong vital
ing appears to regulate the inflow of glucose into
organ function. However, only 5 percent of the
the blood. In addition, it may be indirectly re-
circulating thyrotropin-releasing hormone (TRH)
sponsible for the release of free fatty acids from
can be identified as coming from the pituitary por-
adipose tissue and in triggering the metabolism of
tal circulation. The source of the rest is not
amino acids from proteins and subsequent gluco-
known. Does it possibly come from elsewhere in
neogenesis. 17 B-hydroxybutyrate levels rose to a
the brain or from the periphery? In the absence of
peak on day 24 (of the water-only fast), and were
evidence to the contrary. one can assume that
returning toward normal on day 49, when next
there is. however. a relationship between blood
measured.
levels and brain levels.'
Leuenkephalin levels remained within normal
Inactive thyroid hormone. reverse T, (an iso-
limits. for the most part. during the fast, with a
mer of T3). was produced by the subject. peaking
general trend of increase from 17.2 pg/mL on day 7
at day 20 and declining subsequently.
to 37.6 pg/mL on day 49. Leuenkephalins are en-
Other studies have shown that fasting. malnutri-
dogenous opiates that are found primarily in the
tion. and anorexia nervosa are associated with low
limbic system. gastrointestinal tract, and gonads.
serum T₃ levels in man. This reduction in serum
They have been known to stimulate food intake
T3 appears to be due to decreased peripheral con-
upon intraventricular administration to mice. 19 In
version of T. to T₃ rather than to a diminution in
the authors' study, there was no correlation be-
thyroid secretion. Thus. there is little or no de-
tween the subject's moods or feelings, as noted
crease in total serum T. concentration in fast-
from comments written in the progress notes. and
ing. 10.11 A routine thyroid profile (T₃ uptake. T..
leuenkephalin values. Leuenkephalin values were
and Ti) was normal in the subject on two
reported to be at their lowest on day 9, when the
occasions.
subject appeared to be euphoric, and conversely,
Serum concentrations of reverse T3 have been
at their highest on day 41. when he was lethargic.
found by others to increase during caloric depri-
A rise in the subject's norepinephrine level on
vation. 13-15 Since peripheral metabolism of T. is
days 15 and 42 was observed; however, no
the major source of reverse T.1." it has been sug-
changes in pulse. blood pressure. or respiratory
gested that during caloric deprivation. there is a
rate were associated with this rise. The subject
shift in the metabolism of T. away from production
meditated every morning. It is not known whether
of T3. toward reverse T3.
the high levels of norepinephrine observed on the
The subject's basal metabolic rate (BMR)
days in question bore any relationship to gluco-
dropped progressively during the first 34 days: its
genesis or to the subject's meditation practices.
lowest point was 45 on day 54 of the water-only
Throughout the fast, no significant changes
fast. Because the BMR is. at best, a crude meas-
were observed in terms of depression, hostility. or
urement, influenced by stress, climate. mood. ex-
affect in the subject. No signs of thought disturb-
citement. or infection. some of the values obtained
ances or of difficulties in maintaining good reality
were erratic and showed moderate fluctuations
contact were noted. In the opinion of the two psy-
from one week to the next. The basal oxygen con-
chologists and the psychiatrist in charge. these
sumption. which correlates well with heat produc-
results were unusual for an individual who was
tion. was lowest on days 34 and 48. These changes
undergoing prolonged stress such as that expected
correlate well with the thyroid hormone changes
during a much-publicized fast.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL. 75. NO. 12. 1983
1165
CHANGES IN PROLONGED FASTING
CONCLUSIONS
analysis: Dr. Kenneth D. Burman. for reverse T3 analyses:
Dr. Ralph Snyderman, for growth hormone and
The ability of even a healthy subject to endure
B-hydroxybutyrate analysis: the nursing staff at Flint
such an extensive fast without any major medical
Goodridge Hospital: and Winnie Mpanju, MD, and Lori
Silver, MPH, research assistants.
complications, and then to successfully complete
Literature Cited
an 80-mile jog-walk, only days after ending his fast
1. Benedict FG. The relationship between body sur-
with juices and a mixture (4X) of vitamins, miner-
face and heat production, especially in prolonged fast-
als. and herbs, suggests that the body can recover
ing. Am J Physiol 1916; 41:292-308.
quickly when provided with energy substrate and
2. Cahill GF. Starvation in men. N Engl J Med 1970;
282:668-675.
does not need additional time to replete so-called
3. Felig P. Owen OE. Cahill GF Jr. Amino acid metabo-
protein reserves.
lism during prolonged starvation. J Clin Invest 1969; 48:
A normal. nonobese subject might safely fast
584-594.
4. Owen OE. Felig P. Morgan AP. et al. Liver and kid-
for as long as the Bible states that Jesus did, "forty
ney metabolism during prolonged starvation. J Clin Invest
days and forty nights." An experienced faster.
1969; 48:574-583.
such as the subject (normal. nonobese, and in
5. Blackburn GL. Bistrain BR. Maini BS. et al. Nutri-
tional and metabolic assessment of the hospitalized pa-
good health). can fast for a longer time, following
tient. J Parent Enteral Nutr 1977; 1(1):11-22.
``internal cues" that tell him when to quit. He
6. Marliss EB. Hunger strikers may have died of fat. not
cannot. however, go beyond 55 to 60 days without
protein. loss. JAMA 1981: 246:1878-1879.
running the very great risk of running out of fat.
7. Leiter LA, Marliss DB. Survival during fasting may
depend on fat as well as protein stores. JAMA 1982; 248:
The authors agree with Marliss that in the ab-
2306-2307.
sence of stress. infection. and trauma, the critical
8. Benedict FG. A study of prolonged fasting, publica-
tion 203. Washington, DC: Carnegie Institute. 1915.
life-threatening metabolic event in a prolonged
9. Mallik TK. Wilber JF. Pegues J. Measurements of
water-only fast is running out of body fat. Brain
thyrotropin-releasing hormone-like material in human pe-
death is apt to occur before protein deficiency im-
ripheral blood by affinity chromatography and radioim-
pairs the function of the diaphragm. setting the
munoassay. J Clin Endocrinol Metab 1982: 54:1194-1198.
10. Portnay GI, O'Brian JT. Bush J. et al. The effect of
stage for a hypostatic pneumonia. Of course. a
starvation on the concentration and binding of thyroxine
cardiac arrhythmia. leading to ventricular tachy-
and triiodothyronine in serum and on response to thyroid
cardia, can theoretically. and occasionally does.
releasing hormone. J Clin Endocrinol Metab 1974; 39:191-
197.
result in death at any time.20
11. Chopra IJ. Smith SR. Circulating thyroid hormones
Since this study was done on only one subject,
and thyrotropin in adult patients with protein calorie mai-
the authors cannot generalize about the results ob-
nutrition. J Clin Endocrinol Metab 1975: 40:221-227.
12. Moshang Jr. Parks JS. Baker L. et al. Low serum T3
tained. Future similar studies involving more than
in patients with anorexia nervosa. J Clin Endocrinol Metab
one volunteer would be useful.
1975; 40:470-473.
In situations in which fasting has been utilized
13. Vagenakis AG. Burger A. Portnay GI. et al. Diversion
of peripheral thyroxine metabolism from activating to inac-
appropriately. such as in treating obesity. bene-
tivating pathways during complete fasting. J Clin Endocri-
ficial therapeutic results have been shown. This
nol 1975; 4:191-194.
therapeutic approach will probably gain more ac-
14. Chopra IJ. Chopra U. Smith SR, et al. Reciprocal
changes in serum concentration of reverse T3 in systemic
ceptance as more studies are done to show how
illness. J Clin Endocrinol 1975; 41:1043-1049.
fasting affects the physiological and biochemical
15. Burger AG. Berger M, Wimpfheimer K. Danforth E.
status both in normal and in diseased human sub-
Interrelationship between energy metabolism and thyroid
hormone metabolism during starvation in the rat. Acta En-
jects. Making fasting safer. using various nutrients
docrinol 1980; 93:322-331.
to maintain a weight-losing subject in relatively
16. Sokolef L. Metabolism of the CNS in vivo. in Field J
good nutritional status, and exploring how the risk
(ed): Handbook of Physiology. Baltimore: Waverly, 1959. pp
18-43.
of cardiac arrhythmia can be minimized or elimi-
17. Schrinberg P. Observations on cerebral carbohy-
nated are important areas for research prior to rec-
drate metabolism in man. Ann Intern Med 1965: 62:367-371.
18. Cahill GF. Hormone fuel interrelationships during
ommending prolonged fasting without qualification.
fasting. J Clin Invest 1966; 45:1751-1769.
19. Grandison L. Guidotti A. Stimulation of food intake
Acknowledgments
by muscimol and beta endorphin. Neuropharmacology
1977: 16:533-536.
The authors acknowledge the assistance of the follow-
ing. without whose help this research would not have been
20. Lantigua RA, Streck WF, Lockwood DH, Jacobs LS.
possible: Mr. Dick Gregory, for volunteering: Mr. AI Chap-
Cardiac arrhythmias associated with a liquid protein diet
man and Mr. John Levy. for financial support: Dr. Candace
for the treatment of obesity. N Engl J Med 1980; 303:735-
Pert, for leuenkephalin analysis: Dr. Jack Wilber. for TRH
738.
1166
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL. 75. NO. 12. 1963
20
rte*s LISSE othar mart
The Provisional Military Government of Socialist Ethiopis
MC
No
> & n 109 Frūcnt
FORM
ADDIS ababa UNIVERSITY
Date
+A
}
11-08-44
*M96P
ADOIS ABABA, ETHIOPIA
Tel.
Cable Address
tshn
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in
AAUNIV
7.9.9.
IX
21205
1176
P.O.Box
May 28, 1985
Mr. Dick Gregory
Tower Hill Farm
Independence Rd.
P.O. Box 3266
Plymouth, MA 02361
Dear Dick,
: have at long last written the results of the small study on the use
of a modified Dick Gregory 4X Nutritional Formula :a severely malhourished
children. I sincerely apologize for the long delay.
As stated in the report, the modified formula was successfully used to
rehabilitate the 3 children with kwashiorkor as gauged by clinical and
objective laboratory tests. I am tempted to reduce the volume of milk and
see :: the efficacy is still maintained. I intend to do that in a few
patients.
The next phase will be to embark on a larger comparative trial. For
this I will need a room in the hospital to accommodate 4 patients and a 24
hour nursing coverage. As agreed I will utilize the money that you kindly
donated.
One of the interesting side effects of the study was the 'accidental'
discovery by a few friends of the other use of your Bahamian slimsafe diet.
A friend who chanced to read the brochure in my home begged to have a :in
to try it on. You recall that you brought a few of the Bahamian slimsafe
tins at your first visit. He tried it and lost weight: He was amazed a:
how the drink quenched his appetite, maintained his energy and resulted in
significant weight loss. This news spread around and I now have a large
clientele o: obese and otherwise unfigurly bodied characters whom I hade
from!! So it appears that your wonder mixture has hit 2 birds with one
stone!!
I hope this letter finds you before you leave for Ethiopia. My
daughter plans to leave the U.S. on 6 June 1985 and arrive here on the
8th June.
Warmest regards to you and your family, and greetings to Dr. David Allen.
Yours sincerely,
Jam
Demissie Habte
DIETARY REHABILITATION OF CHILDREN WITH KWASHIORKOR USING A MODIFIED
DICK GREGORY 4xx NUTRITIONAL FORMULA
(Seleshi Lulseged, M.D. and Demissie Habte, M.D.,
Ethio-Swedish Children's Hospital)
May 1985
INTRODUCTION
Ewashiorkar is endemic amongst pre-school children to Ethiopia, but
the magnitude of the problem has scaled new heights following the drought
that has affected a large portion of the country. Dietary management has
traditionally been based on milk or other foods fortified with ailk. The
cost o: such treatment is generally outside the reach of most rural and
urban/periurban slum communities, and indeed may be considerable to
governments during large outbreaks of famine.
Dick Gregory's nutritional formula is based on cheap natural foods
containing enerzy, protein, all vitamines, minerals and trace elements.
The formula does not contain food from animal sources (Appendix I).
The formula can be produced at an exceedingly low cost. This fact
persuaded us to try a modified Dick's formula on a few children with
kwashiorkor on a pre-pilot basis.
DICK GREGORY MODIFIED NUTRITIONAL FORMULA
The constituents of the modified aixture is shown below.
Dick's 4.x Nutritional Formula -
90 gns
Vegetable
- 100 ml
Cane sugar
- 13 go
Whole cow's milk
- 200 nl
Water
- to make 1000 al
Approximate energy per 100 al of
mixture (cals)
- 140 3.
Approximate protein per 100 al
of mixture (gm)
-
3
- 2 -
Preparation of the Mixture: All ingredients were first dissolved
in a small amount of water. While stirring more water was added to make
the required volume. On standing there was a tendency for the oil to
float but a homogenuous consistency could be restored readily with
shaking. The mixture has a muddy brownish colour and had no strong
odour.
PATIENTS & METHODS
Three patients, who met the criteria for the diagnosis o:
kwashiorkor or marasmic kwashiorkor according to the welcome classifica-
tion, were enrolled in the study as they became available 12 the out-
patient department. One patient had kwashiorkor with pneumonia and
anemis (Table I).
Detailed medical, dietary and social history was taken and a
complete physical examination performed on admission. Subsequently
complete blood count, urine and stool analysis, total serum protein
were determined and a chest X-ray taken.
All patients were admitted to the regular infant ward and
observed closely with daily weights and total serum protein and
hemoglobin concentrations every other day. Other investigations
were done as indicated and antibiotics and other supportive medica-
tions were offered.
Patients were initially provided with 120 Cals and 4 gms of protien
per 3g body weight. Naso-gastric tube feeding was initiated in all
patients on admission and maintained as necessary. Patients were weaned
to regular diet for age before discharge.
- 3 -
A separate group of patients without gastro-enterological disorders
were fed on the formula to test acceptability and tolerance.
RESULTS
Acceptability & Tolerance: All the 3 children with kwashiorkor
were reluctant to drink the mixture voluntarily even after significant
clinical improvement had ensued and appetite had returned to normal.
By contrast a group of children without malnutrition and gastro-
enterological problems readily drank the mixture and appeared to enjoy
it.
The formula was tolerated by all. Vomiting was not a common
feature.
Clinical & Biochemical Response: Clinical improvement with pro-
gressive well-being as manifested by euphoria, interest in the surround-
ing and attentiveness was observed to occur rapidly in the 2 patients, and
less so in the other patient whose course was mirredby an episode o:
diarrhea (? nosocomial ). All were successfully rehabilitated and dis-
charged in satisfactory condition.
Table 2 summarizes some of the parameters used to gauge outcome
(Table 2).
DISCUSSION
The findings in this pre-pilot study provide confidence to initiate
a larger study comparing modified Dick's formula with formulas used
traditionally in the hospital. The composition of the Mixture may also
require change to reduce the energy and protein content to match the
standard hospital diet. However in the patients studied, Dick's modified
mixture was clearly efficacious in reversing clinical and biochemical
- 4 -
abnormalities of kwashiorkor. The poor acceptability by the malnurished
children may partly be due to colour and taste. A larger trial is now
in order to confirm this positive finding.
TABLE 1
Admission Clinical Data of Children with Severe Malnutrition
Patient Code
A
B
C
Age (mos)
12
15
24
Diagnosis
Marasmic
Marasmic
Ewashiorkor
kwashiorkor
kwashiorkor
Weight (gm)
5,100
6,400
8,000
Total serum protein
3.5
4.6
5.4
gm/lml
TABLE 2
Summary of Clinical Response of Children with Malnutrition
Given Modified Dick's Formula
Patient Code
A
B
U
Total hospital stay (day)
16
17
15
No. of days to attain
minimum weight
4
9
7
Rate of weight gain, gm/day=
45
42
430
Rate of rise of serum protein,
gm/days=
0.2
0.2
0.2
"Calculated from minimum wgt and discharge wgt.
**Calculated from admission and discharge values
+ Minimum wgt. aggained and subsequent weight gained modified by diarrhoea.
mucturet Atres LILIT 0+262 mart
The Provisional Military Government of Socialist Ethiopia
MC MF/326/77
No
> & n 107
3
January 12, 1985
LOW
ADDIS ABABA UNIVERSITY
Date
+A.
}
11-08-44
+1969
ADDIS ABABA, ETHIOPIA
Tel.
Cable Address
tunn
-
in
AAUNIV
7.9.9.
1X
21205
1176
P.O. Box
DEAN'S OFFICE, FACULTY OF MEDICINE
its. Dick Gregory
P.O. Boz 3256
Plymouth, Mcss. 02362
U.S.A.
Dear Yr. Gregory,
:- was = pleasure to mee: with you and discuss the possibilities of
using your food missure for distary rehabilitation of malnourrished
children in Echiopia. As you know, the search for = checo and efficacious
food for use in severely mainourished children will consinue until we find
one that has the right biologic and economic miz. Your food Tisture based
on secueds and sesame offers = very bright prospect. :- is because of
this face that : will be COOPY to collaborate with you and your scientific
staff in trying is in children with severe protein-energy malnusricion.
After = initial trial in 2-3 children, we will embark on = comparazive
trial of = diet based on your mizture (with Tilk added) with the regular
diet in use in hospital. : will send you the protocol in ine time.
Ilwas greatly impressed by your concern for the starving :- Echiopia
and is your depth of knowledge in nutrision.
: look forward to = long and fruitful collaborazion.
- fours sincerely,
Dears
Demissie School
Dean 3 Professor of
Pediatrics
/
PERMANENT MISSION OF ETHIOPIA
TO THE UNITED NATIONS
see UNITED NATIONS PLAZA
NEW YORK. N. Y. 10017
15 April 1985
Mr. Dick Gregory
39 South La Salle Street, Suite 825
Chicago, Illinois 60603
Dear Mr. Gregory,
we urgently request 100 cases of
the Dick Gregory 4x nutritional formula for
malnourished children in our Ethiopian
hospitals. We also request 100 cases of the
4x nutritional food bar, if available.
Yours sincerely,
Berhane Deressa
Deputy Commissioner
Relief and Rehabilitation Commission
of Ethiopia
(
Use of Modified 'Dick Gregory's' 's' Formula in the
Management of Kwashiorkor
(
Sileshi Lulseged, M.D.
and
Demissie Habte, M.D.
(
Introduction
Advanced protein-energy malnutrition occurs fairly commonly in children
between the age of 1 to 5 years. In Ethiopia, it is estimated that under
normal circumstances about 10% of children in this age group are affected.
Kwashiorkor and marasmic kwashiorkor constitute about half of these cases
being higher in rural areas. The most important management is provision
of energy, protein and other nutrients in a food mixture that is easily
digestible, available and acceptable. The commonest food mixture in use
employs cow's milk to which is added extra source of protein (usually
cow's milk protein concentrate), energy (vegetable oil) and other nutrients
(particularly potassium and magnesium).
Various food mixtures have been tried and all have some drawbacks
such as cost, availability, quality of nutrients, etc. In times of famine,
the number of cases with advanced protein-energy manutrition dramatically
increases and cost becomes an important factor. 'Dick-Gregory's modified
formula' (see appendix for composition) is a food mixture that possesses the
advantage that it is potentially very cheap and can therefore be available
to a much larger population groups.
In this study we report the results of dietary rehabilitation using
nodified Dick-Gregory's formula in children with kwashiorkor.
Material and Methods
Children fulfilling the Welcome' criteria for the diagnosis of
kwashiorkor and marasmic kwashiorkor were subjects of this study. Nine
patients entered the study of which 7 had other complicating medical
conditions.
On admission detailed medical, dietary and social history was taken
and a complete physical examination performed. Complete blood count,
urine and stool examinations, Mantoux skin test, chest x-ray and total
serum protein ditermination were done in all at admission. Blood sugar,
VDRL test, peripheral blood morphology, Blood Urea Nitrogen and cultures
of blood, urine and cerebrospinal fluid were done when obviated by
clinical condition of patients either at admission or during hospital
stay.
1.
(
Table 1 - Admission clinical data of patients
(with mean values and range)
(
Total Number
9
Age (months)
19.2(12-30)
Sex distribution
Male
3
Female
6
Type of malnutrition
Kwashiorkor
6
Marasmic-kwashiorkor
3
(
Serum protein (gm/dl)
4.9(3.5-6.5)
Hematocrit(%)
29(25-36)
Number with evidence of
(
infection at admission
7
Patients were observed closely. Daily weight and total serum
protein and hematocrit were determined everyother day. Investiga-
tions were repeated and antibiotic and supportive therapy provided
whenever indicated.
The feeding mixture was prepared as described in table 2.
Table 2: Dick's formula preparation (modified)
*Dick's formula
Amount
Cal
Protein
(Scoop, each 22.4 gm)
3
270
33
Vegetable oil (ml)
100
900
-
Table sugar (gm)
15
30
-
Whole cow's milk (ml)
200
140
6
Water (ml)
700
-
-
1000ml
1300
39
All ingredients were mixed and thoroughly stirred. On standing there
was a tendency for the oil to float but a homogeneous consistency could be
restored readily with shaking.
Patients were initially provided with 100 cal, 3.9 grams of protein
and 70ml of water per kg of ideal weight for age and increased in
accordance with their tolerance.
Results
Acceptability
Nasogastric tube feeding was instituted because of anorexia or
refusal to take feeds in seven patients. Patients were noted to take
it from cup or bottle a few days before discharge or before shift to
"regular" diet had to be arranged.
"Contains adequate amount of electrolytes, trace elements and
vitamins according to information from producer.
Clinical and biochemical response
One patient expired a weak after trial was started. This was a
1 9/12 old child admitted for kwashiorkor and septic features and
sepsis seemed to have responded to therapy. As evidenced by assess-
ment a day prior to her death edema had started resolving and protein
had increased from 4.5 to 4.8 grams%.
Clinical improvement with progressive well being was generally
noted. Three patients showed uncomplicated clinical course and
progressive and dramatic biochemical improvement. On<patient, despite
good response, developed generalized muscular twitchings which were
emperically but successful treated with calcium and magnesium. The
rest of the patients' course was complicated with either diarrhoea
(infections) or nosocermial systemic infections despite which rise in
total serum protein documented except in one where both weight and
rise in serum protein failed to occur.
Table 3 - Summary of treatment on surviving
patients (means values and ranges)
*Total hospital stay(days)
27.1(15-49)
+Number of days to attain
minimum weight
7.6(6-10)
#Rate of weight gain while
on formula(gm/d)
42.3(0-80)
©Rate of rise of serum
protein (gm/d)
0.12(0.05-0.17)
*Acmission to discharge though most patients had protracted stay because
of their serious illnesses.
+Admission weight and nadir weight used for calculation.
#Nadir weiht to discontinuation of formula used for calculation.
©Calculated from readings at admission and either initial peak reading
or reading at discontinuation of formula.
Discussion
One of the means of testing the nutritional quality of a food
mixture is to see the extent to which it succeeds in reversing the
clinical and biochemical disorders of children with kwashiorkor.
The success in dietary rehabilitation is related to the quality of
food consumed.
Nodified Dick Gregory's formula was able to reverse the clinical
and biochemical disorders in all the ninechildren with kwashiorkor/
marasmic kwashiorkor despite the fact that the majority has
complicating associated findings such as infections. Infection is
recognized to increase the energy and protein requirements in a child.
Although it is difficult to compare the performance of different
diets, it appears that this mixture is as good as the standard kwash
mixture used made up of cow's milk, calcium caseinate and oil.
However, one will have to study a larger longer number of cases to draw
definitive conclusions.
Anorexia is a common features of children with severe kwashiorkor,
and nasogastric tube feeding is a standard practice in hospitalized
patients to ensure adequate intake. All our patients required nasogastric tub
feeding.
The results of this pilot study indicate that modified Dick-Gregory's
formula has a place for use in management of children with kwashiorkor.
Its low cost is ought to enable its widespread use thus ensuring adequate
coverage of children with kwashiorkor.