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close this book4th Report on the World Nutrition Situation - Nutrition throughout the Life Cycle (ACC/SCN, 2000, 138 p.)
View the document(introduction...)
View the document4.1 The Relevance of Nutrition for Development
View the document4.2 The Implications of Some Global Phenomena for Nutrition
View the document4.3 The Ascent of Human Rights in Development
View the documentSummary


Few people - whether or not they are nutrition professionals - would dispute the fact that malnutrition constrains people’s ability to fulfill their potential. Hungry and undernourished people have less energy to undertake work, are less able to attend school, and once in school are less able to concentrate and learn. Diet-related chronic diseases take highly experienced individuals out of the work force and take resources away from primary health services. That improved nutritional status will lead to an improved ability to secure rewarding and sustainable livelihoods is a common sense proposition.

How important is malnutrition to economic growth? Researchers have derived conservative estimates of the forgone gross domestic product (GDP) as a result of iron deficiency alone in childhood and iron, iodine, and protein-energy malnutrition in adults.1 For Pakistan the annual losses are over 5% of GDP. For Bangladesh, the cost of iron deficiency in children alone is nearly 2% of GDP. Nutrition and food security also promote economic growth by reducing the potential for conflict.2 Chapter 5 shows that the resources required for relief activities are large and growing. Understandably these activities retain the first call on resources - resources that could otherwise be allocated to longer-term development activities. The designers and implementers of relief programmes are very aware of the importance of building development into relief activities. In general, the need for future relief flows can be reduced by improving nutrition today. Reduced relief flows will increase the availability of funds for longer-term development. Improvements in nutrition can thus serve as a crucial spur to overall economic growth.

If the contributions of nutrition to economic development are underrated, so too are the reverse contributions - both positive and negative. Economic and demographic events such as globalization, HIV/AIDS, and urbanization have large and far-reaching impacts on human development - such as the capability to be well nourished and healthy, to undertake healthy reproduction, and to be educated and knowledgeable - and they must be taken into account in developing nutrition strategies.

The emergence of human development as a guiding principle for overall development reflects a growing dissatisfaction with an exclusive reliance on economic growth as a means to development. The focus on human capabilities has opened the door for more normative arguments, including a human rights - based approach to development. In his launch of the United Nations reform, Secretary General Kofi Annan stated that all major UN activities should be undertaken through a human rights perspective. Many UN agencies, particularly the UNDP, UNFPA, UNHCR, and UNICEF, began operationalizing a “human rights approach” to development. The debate about whether or not the UN should base its work on human rights was over. The challenge now is how to develop human rights - based strategies.

This chapter discusses these themes in more detail. First, it describes some recent developments that highlight the contributions of improved nutrition to the overall development process. Recent studies, for example, confirm the strong relationship between infant nutrition, cognition, and school enrollment - linkages exploited by the early childhood initiatives of the past five years. The chapter then considers some of the policy implications of new research on the links between foetal undernutrition and diet-related chronic diseases in adults. This section of the chapter closes with a discussion of the resurgence of interest in participatory development approaches and the contributions that community-based nutrition initiatives might make to overall development.

Second, the chapter describes some major socioeconomic and demographic events together with their implications for nutrition policy and programming. The chapter considers the implications of the freer movement of financial resources, food, and information (three aspects of globalization) for food and nutrition policy. The chapter then discusses the implications of rapid urbanization and of HIV/AIDS for food and nutrition policy. Finally, the chapter describes the emergence of the human rights perspective. The ascent of the human rights agenda in an era of globalization is more than a coincidence. Human rights principles will play a crucial role in the type of globalization that emerges over the next ten years.

4.1 The Relevance of Nutrition for Development

Three emerging bodies of work highlight the nature of the link between nutrition and human development: (1) nutrition, cognition, and school enrollment, (2) foetal nutrition and adult chronic disease, and (3) the importance of community-based approaches to development and the leadership of the nutrition community in this regard.

Nutrition, Cognition, and School Enrollment

Recent studies from the nutrition and economics literatures reaffirm the importance of nutrition for the cognitive achievement and school enrollment of children. In addition, study after study demonstrates that women’s educational attainment is a key factor in preventing infant undernutrition3 and that overall educational attainment is the key factor in escaping poverty.4

Recent nutrition studies confirm the strength of these relationships. Strong associations are found between the stunting of Filipino children under age 2 and their cognitive ability test scores between ages 8 and 11.5 There is a strong link between sub-optimal neonatal nutrition and cognitive function, particularly in males.6 In Jamaica stunting was strongly associated with developmental levels in 1- and 2-year-olds.7 Nutritional supplementation and stimulation of stunted children between 9 and 24 months of age have independent and additive effects on the development of the children at the age of 7 - 8 years.8

The economics literature offers compelling evidence of the importance of nutrition for development. At the mean of a nationally representative sample from Ghana, a 10% increase in stunting causes a 3.5% increase in age of first enrollment at school.9 For Pakistan, an improvement of 0.25 in Z-score height-for-age will lead, on average, to an increase in subsequent school enrollment rates of 2% for boys and 10% for girls. This increases to 5% and 16%, respectively, when diarrhoea rates are reduced by half.10 Another recent study yields smaller impacts on child schooling performance, but the link is still statistically significant.11

Given that these findings come from both experimental design and observational data and from both the nutrition and economics literatures, and that stringent statistical and econometric techniques have been used to generate them, they present a convincing and scientific basis for early childhood interventions.

Policy Implications of the Link between Foetal Undernutrition and Adult Chronic Disease

Evidence on the links between foetal undernutrition and chronic disease in adulthood has been discussed in Chapter 1. The implications of these links for formulating development policies are only now being thought through. Three points are noteworthy. First, an investment in avoiding foetal undernutrition becomes an even better investment because it not only improves maternal and infant nutrition but also slows down or prevents the onset of chronic diseases in later life. Of course, preventing these effects is intrinsically valuable, as emphasized by the human rights approach. In addition, prevention will have a significant impact on economic productivity - an impact that has not been captured in conventional estimates of the economic returns to improved nutrition.

Second, increasing health expenditures - whether private or public - to modify behaviour and prevent undernutrition throughout the life cycle may well diminish or at least postpone health expenditures to later in life. This postponement will better allow ageing populations to lead productive adult lives, thus enabling them to better insure themselves - formally or informally - against health shocks. Third, if the allocation of public health resources is to be guided by the global burden of disease metrics such as disability-adjusted life years lost (DALYs), then the new findings will lead to an enormous increase in the rationale for investing in adolescent, maternal, foetal, and infant nutrition, simply because foetal undernutrition is a leading cause of such major components of the global burden of disease as cardiovascular disease, hypertension, and obesity.

Decentralization and the Empowerment of Communities

Many institutions throughout the world are rapidly decentralizing the allocation of public resources - whether health and nutrition or otherwise. In principle, moving authority and accountability closer to the intended beneficiaries of an initiative - poor communities, for example - is likely to strengthen the incentives to use public funds more effectively and to facilitate the generation of complementary private funds. In practice, however, mechanisms to ensure sufficient local capacity and accountability have to be present as well. Communities also have embedded power structures, and in the absence of transparency and accountability mechanisms, local groups can misallocate funds. Moreover, if local communities are to compete for central funds, the better-equipped, more-cohesive, and less-excluded communities will capture them. Communities that are unable to organize proposals or are less likely to be noticed by central authorities will lose out.

The nutrition community has taken leadership in this area. Community-based nutrition programming has long been considered a vital component of the fight against malnutrition.12 Can these community-based efforts serve as a way of empowering communities to participate in other development activities? The body of quantitative empirical research on how community participation affects the performance of development projects is small but growing. The two studies that use data from a large number of projects and have paid most attention to the econometrics issues find that community participation leads to improved project performance.13, 14 Further, community-based lending schemes have higher repayment rates if their membership has higher indicators of social cohesion.15 In addition, there is a rapidly growing body of work linking membership in social and economic groups to accelerated upward income mobility.16

Ideally, data on a large number of nutrition projects will become available so that similar analyses can be undertaken. Can nutrition programs empower communities beyond their immediate concerns? And can community-based nutrition initiatives foster an increasing adherence to human rights by a wide range of actors? These questions remain to be answered, but the signs are promising. Several community nutrition projects have served to stimulate other decentralized development activities. In Sri Lanka, for example, the nutrition component of a World Bank - supported poverty alleviation project used participatory approaches to enhance nutrition awareness and improve feeding practices. The project used nutrition as an entry point to poverty alleviation, by combining it with community infrastructure development, savings, credit, and micro-enterprise development in a phased manner. In a setting characterized by top-down development planning, the project demonstrated that community ownership could accelerate positive change.17

4.2 The Implications of Some Global Phenomena for Nutrition

The globalization of financial markets in the absence of appropriate oversight and governance has led to financial crisis, which in East Asia has turned into a human resource crisis. We highlight these relationships and their implications for public policy with a case study of Indonesia - the country that has been hardest hit by the Asian crisis in terms of investments in children. Increasing trade liberalization is generally thought to spur overall economic growth. But the increasing openness of developing-country markets to food combined with the failure of developed countries to reciprocate may well produce a situation that denies developing countries access to high-income markets for their exports. In addition, different standards of food safety between importers and exporters may lead to concerns about the safety of imported food. As food safety concerns heighten, the use of food safety as a trade barrier against exports from developing countries may become a more pressing concern. We also consider the implications of the decreasing costs of information flows, including how the new information and communication technologies can be best used to help accelerate reductions in malnutrition. The freer flow of capital and people across national boundaries has been mirrored by an increasing migration from rural to urban areas, and the implications of this increased rate of migration are discussed in this section of the chapter as well.

Globalization of Financial Resources and the East Asian Crisis: Implications for Nutrition

The East Asian financial crisis, which began in July 1997, is a reminder of how unreliable the past can be as a guide to future events. In one year (1997 - 98), per capita growth rates in East Asia fell sharply. The worst hit was Indonesia, where per capita growth declined from 3.3% to -14.8% (Figure 4.1).

FIGURE 4.1: Growth rate of GDP per capita in South-East Asian countries, 1993-2000

Source: 18.


The crisis occurred as a result of many complex factors. First, and largely in retrospect, the economic outlook of the region had been worsening since the mid-1990s. The increasing strength of the dollar, to which the currencies in the region were linked, made East Asian exports less competitive. Japan, a major consumer of exports from the region, experienced slow growth, and China was becoming an increasingly powerful export competitor. Second, the opening up of East Asian financial systems led to a massive flow of private capital into the region. Given the low interest rates in the industrialized countries and the recent good economic performance in East Asia, foreigners began investing heavily in the region. The inflow of private capital accelerated because of assurances - implicit and explicit - from the region’s governments that they would underwrite or guarantee repayments. On the other side of the coin, East Asian companies could now borrow from sources overseas. Because currencies were linked with the dollar, repayments from East Asian companies would be more predictable and involve lower risk. This easier access to less risky credit led to investment in riskier and lower-performing projects. Third, the region’s financial systems did not respond to the need for greater supervision and oversight in a more deregulated environment.

The trigger event was Thailand’s large and rapidly growing current account deficit (exports minus imports minus interest payments on foreign debt) in 1996-97. This deficit led foreign investors to sell their assets in the region, redeeming them for dollars at the dollar-linked exchange rate. Investors did this because they feared that regional governments would run out of foreign currency to maintain a linked exchange rate and be forced to depreciate the currency. When depreciation occurs, the holdings of foreign investors lose value and, fearing further depreciation, investors sell more assets, leading to a self-fulfilling cycle of currency depreciation. This asset sell-off and the accompanying depreciation can and did spread to other countries via fear, trade, and financial markets. The depreciation and the massive outflow of private capital led to company bankruptcies and sharp price increases for imported goods. The stock markets of the region also declined because of a loss of investor confidence, with an accompanying loss in wealth, and hence in local demand. Increases in unemployment followed as did declines in the real wages of the employed due to inflation.18-21

The effects of the crisis on indicators such as nutrition and educational attainment will play out well beyond the upturn in GDP per capita. How has the crisis affected poverty, education, and nutrition? Moreover, what does the crisis mean for improving public policy to minimize the impacts of future shocks and crises? A case study of Indonesia sheds light on these two questions.


We choose Indonesia as a case study for two reasons. First, its economy was worst hit in the region - a situation exacerbated by the 1997 drought and massive forest fires in Sumatra and Kalimantan. For example, at the micro level, data from the Indonesian Family Life Surveys (IFLS)22 show that the proportion of individuals living below the poverty line has nearly doubled, from 11% to 19%. This is an enormous increase - equivalent to an additional 20 million people falling below the poverty line between 1997 and 1998. Second, the best data on the crisis and analysis of its impacts are to be found for Indonesia. Appendix 11 summarizes some of the studies available for Indonesia, and Box 4.1 summarizes some of their key findings.

A general point that emerges from the Indonesian case study - and one that has been observed in other countries in the region - is that the crisis had widespread, but not universal, effects. For example, some regions within the country were hit much harder than others. Moreover, the middle-income groups were more affected than the poorest in absolute terms, but because the poor have to make more difficult choices, they may suffer more permanent effects than the middle class. But the data show that me most severely affected were a heterogeneous group - poor and non-poor, consumers and producers, rural and urban, and from many different areas. While a significant per cent of the chronically poor were hit hardest by the crisis, a large number of non-poor households were also significantly affected.

Several nutritional implications for public policy in the region emerge from the Indonesian case study:

· Indicators of diet diversity and micronutrient status should be considered leading or early indicators for monitoring the impact of crises on nutrition status.

· Targetting the chronically poor is not the same as targetting crisis relief. Areas with the largest drops in welfare may hot be the poorest.

· While the impact of a crisis is widespread, it may not be universal - there is scope for geographic targetting of assistance.

· Public expenditures in social sectors need to be protected during crises, because households rely increasingly on public (as opposed to private) services during hard times.

BOX 4.1

Impacts of the Asian Crisis in Indonesia

· Diet quality and diversity have declined. Analyses from Helen Keller International (HKI) reveal that Indonesians are consuming fewer dairy and meat products.23 IFLS studies show the per cent of the budget allocated to food staples increasing and the per cent going to nonstaples decreasing.22, 24

· In terms of micronutrient status, the HKI work shows increased child and maternal anaemia and night blindness in rural Central Java. The IFLS analysis shows an opposite pattern: declines in low haemoglobin rates, although this is the average change for all individuals over the age of one. Both the HKI and IFLS studies show declines in the per cent of children receiving vitamin A supplements prior to the survey rounds.

· In terms of adult anthropometry, the HKI studies show an increased prevalence of low maternal BMI, and the IFLS study shows an increased prevalence of low BMI for all adults.

· In children, the crisis did not have universal effects. Some regions were harder hit than others. For example, the HKI data from Central Java for 1995-99 show increases in wasting and underweight in children under 5. The IFLS data show declines in wasting and stunting rates for children aged 5 - 9. For children aged 7-12, the IFLS data show decreases in school enrollment for both boys and girls. For the same age group, the 100-Village Survey shows the reverse pattern.

· The IFLS data show that households are devoting a decreasing share of their shrinking budgets to education and health care.

Improved safety net mechanisms are needed to mitigate the effects of future crises. For the Indonesia case study, the IFLS study reports that in the months before the 1998 survey, 9.6% of households received assistance from the government or nongovernmental organizations (NGOs) in the form of cash, food, or non-food, and 22.9% of households were able to purchase food in subsidized markets. These coverage rates are reasonably high, although they can only be evaluated in response to the location of need. But the average value of the transfer was only 1% of average monthly household expenditures.

Globalization of Trade: Food Quality and Safety

The globalization of food trade refers to the process of improving access to food markets throughout the world by reducing and ultimately removing barriers to trade. During the Uruguay Round of multilateral trade negotiations, which started in 1986 and lasted eight years, the international community attempted for the first time to introduce rules regarding the liberalization of trade in agricultural products. The Marrakesh Agreement, which marked the close of the Uruguay Round negotiations, established the World Trade Organization (WTO) with the mandate to establish the global rules of trade between nations. Countries that join the WTO commit themselves to respect the series of agreements that were achieved during the Uruguay Round. To date 134 countries have joined the WTO and a further 31 countries have applied for membership.

The World Trade Organization organized a summit in Seattle in December 1999 to launch a new round of trade negotiations following up on the Uruguay Round. Efforts to launch a new round at this meeting were unsuccessful and have been suspended with a view to restarting the talks in Geneva in 2000.25


The value of international food trade in 1997 stood at US$458 billion and continues to show steady growth. The high level of international trade in food is prompted by a number of factors. Consumers are demanding a greater variety of foods fitting a range of preferences and lifestyles. Likewise, the food industry is supplying more options. Foods are now produced, handled, processed, and packaged using a variety of novel techniques, and “new” foods are entering the international food market. These innovations have created new challenges to food safety. Reports of new pathogens and new associations of food to pathogens have been linked to the innovations in handling, processing, and presenting foods.


The international food market is of great importance to industrialized and developing countries alike. Growth of food exports not only provides much-needed foreign exchange but also generates employment within the agricultural and agro-industrial sectors. Food exporters who fail to ensure that the quality and safety requirements of importing countries are respected can face serious economic repercussions. Detention, rejection, and destruction of food consignments have obvious negative cost implications for food exporters. It is in the economic and national interest of food-exporting countries to reliably supply safe products of acceptable quality.

Poor food safety control in international trade also has important public health implications. Food-borne illness has been linked to internationally traded food.26 Diarrhoeal diseases are the second leading infectious cause of death worldwide for children under age five27 and are projected to remain so until 2020 if current trends in resource allocation persist.28 The large volume of food traded internationally presents a major challenge to public health authorities. Countries must develop and implement adequate food control measures to ensure that food entering and leaving the country is safe.


Having decided to embark upon the path towards a globalized food market, governments must deal with several issues related to the regulation of the international food trade in order to protect their citizens. Consumers must be protected from food-borne hazards and fraudulent practices in the food trade. Just as important, governments must ensure the quality and safety of food supplies without introducing unnecessary barriers to trade. These issues were discussed during the Uruguay Round and are dealt with in the WTO Agreements on the Application of Sanitary and Phytosanitary Measures (SPS Agreement) and Technical Barriers to Trade (TBT Agreement).

The SPS Agreement is intended to set rules that prevent food safety measures from being used as non-tariff barriers to trade. The agreement emphasizes the use of risk assessment in determining the appropriate level of protection with respect to human, animal, or plant life and health in a territory and the use of scientific principles and evidence in establishing and evaluating SPS measures. It also calls for WTO members to regulate food safety based on the standards, guidelines, and recommendations set forth by the Codex Alimentarius Commission regarding food additives, veterinary drug and pesticide residues, contaminants, methods of analysis and sampling, and hygienic practice (see Box 4.2).

The TBT Agreement is designed to ensure that technical regulations and standards do not create unnecessary obstacles to trade. This agreement covers a large number of measures that seek to protect consumers from economic fraud and deception. Codex Alimentarius provisions concerning quality and compositional requirements, labeling, and methods of analysis are relevant to the TBT Agreement.

Two critical concepts reflected throughout the agreements are “harmonization” and “transparency.” The importance of harmonization is clear. When potential trading partners apply different standards of food quality and safety, trade becomes complicated if not impossible. Transparency is essential for assuring the integrity of the agreements and building a solid foundation for a globalized food market.

BOX 4.2

Codex Alimentarius:
A Mechanism for Ensuring the Quality and Safety of the World’s Food Supply

The Joint FAO/WHO Food Standards Programme and the Codex Alimentarius Commission (CAC) were established in 1962 in response to worldwide recognition of the need to ensure the quality and safety of the world’s food supply, given growth trends in international trade. Today there are 165 member countries in the Commission: a strong basis for achieving global consensus on issues related to food quality and safety.

The objectives of the programme are to protect the health of consumers and to ensure fair practices in food trade; to promote coordination of all food standards work undertaken by national governments and international governmental and nongovernmental organizations; to determine priorities and initiate and guide the preparation of draft standards with the aid of appropriate organizations; to finalize standards; and, after acceptance by governments, to publish them in a Codex Alimentarius (Latin for “food code”) as either regional or worldwide standards.

The role of Codex Alimentarius in facilitating international trade has been strengthened through the recognition given in WTO agreements to Codex standards, guidelines, and recommendations as benchmarks for quality and safety of food in international trade. The CAC’s elaboration of their standards, guidelines, and recommendations reflects their rigorous use of science and scientific evidence.

In undertaking its work on the establishment of standards for foods and limits for ingredients, food additives, pesticide and veterinary drug residues, and various contaminants in food, the CAC is regularly provided with independent scientific advice from the Joint FAO/WHO Expert Committee on Food Additives, called “JECFA,” and the Joint FAO/WHO Meeting on Pesticide Residues. The CAC also frequently draws on the advice of other bodies, such as the International Commission on Microbiological Specifications for Food, and panels of experts that are convened on a temporary basis to address specific issues relevant to its deliberations.

Exporters’ capacity to ensure that their products meet internationally accepted standards of quality and safety consistent with provisions of the SPS and TBT Agreements is a prerequisite to participation in the globalized market. Compliance with regulatory requirements, however, is not the only consideration. Globalization of trade means free and open competition, and food exporters must obtain the trust and confidence of importers if they are to maintain or expand market share. They can only do this through consistent assurance of their product quality and safety and careful attention to the specific demands of markets of interest to them.

To ensure food quality and safety, countries must establish appropriate food legislation and implement food control programmes to enforce compliance with legislation. The standards, guidelines, and recommendations adopted by the Codex Alimentarius provide the basis for national food regulations and controls and are recognized by the WTO Agreements as a basis for international harmonization of food quality and safety measures.

There will be trade-offs however. Exporting countries may not have the monitoring and enforcement capacity to improve food safety to importer standards. In countries such as Ghana where the poor purchase a high proportion of their food from street vendors, excessive regulation may lead to the closure of such vendors, and this could have a detrimental impact on the nutritional status of the poor.29 As proposed by WHO, such regulations should address only the essential safety requirements.30 On the positive side, a food regulatory system is a necessary prerequisite for the establishment of national food fortification programs, which have large nutritional benefits.

Another dimension of food trade liberalization is the decline in overall grain stocks and decrease in the availability of food aid globally. This decline may lead to greater food price volatility, particularly in thinly traded grains such as rice. Rather than arguing for more food aid per se, this potential volatility calls for more attention to appropriate safety net measures in countries dependent on food imports.

The Globalization of Information and Communications

Knowledge about how to treat such a simple ailment as diarrhea has existed for centuries - but millions of children continue to die from it because their parents do not know how to save them.

- World Development & Report 1998/99, p. 1.

The last decade has seen an unprecedented decline in the cost of transferring information. Transmitting information electronically today costs 1/100th what it did in the mid-1980s,31 thanks to a revolution in information and communications technology - personal computers, microchips, optical fibres, satellite communications, and the like - that has connected hundreds of millions of people to each other and to enormous amounts of information via the Internet.32 Three hundred thousand users join the Internet each week, and while access to this information is far from global, some developing countries are catching up: uptake in several developing countries is now exceeding those of some industrialized countries.

The new information technology provides several opportunities for accelerating the reduction of malnutrition. First, a vast amount of food and nutrition information and data is already available to anyone with access to the Internet. Appendix 12 provides examples from the UN system and elsewhere. Such information can be fairly easily accessed to (1) find out about new nutrition initiatives, (2) determine the latest thinking on existing nutrition problems, (3) obtain best practices, and (4) map food production and undernutrition by country and region within country.33 Second, the Internet provides a forum for debate on issues that require discussion (recent examples include the NGONUT forum - see section 5.5 and Appendix 12). Third, the wide availability of information makes organization based on the centralized control of information much harder to sustain. For example, many believe that improved access to information will foster democracy and the decentralization of decision-making.34, 35 The nutrition community has long recognized the benefits of decentralized decision-making at the community level, as well as the importance of democracy for avoiding undernutrition.36 Fourth, easier access to information makes it easier to hold institutions and other duty bearers accountable for their actions. When human deprivation becomes more visible, as does the performance of the institutions that are charged with eliminating it, the pressures to improve performance increase. This is an important component of respect for human rights, a subject discussed in section 4.3.

Improved access to information can, however, have negative effects on efforts to eliminate malnutrition. First, because the generators of much of the new information reside primarily in industrialized countries, there is a real danger that proprietary concerns will restrict public access to that information. Second, information is frequently incorrect - either through error or by design. Misleading information - from advertising or poor training - about breastfeeding or HIV prevention, for example, could prove fatal37 Third, information generation reflects the perspective of the person generating it. If information is generated solely by people who do not experience poverty and malnutrition themselves, it will lack balance. The new information technology affords an opportunity for the poor and malnourished to have a voice in policy-making and programme design.

How can the nutrition community accentuate the potentially positive aspects of the information and communications revolution and minimize the potentially negative ones? A number of mechanisms exist. For example, public institutions can share as much nutrition data and information as possible via the Internet and other mechanisms. They can undertake quality control of that information via peer review and open and transparent debate. They can subject themselves to accountability mechanisms such as external reviews of processes and impact, and they can make the rationales for their decisions more transparent. Finally, they can serve as active partners with private organizations to ensure that private data and information resources generate positive benefits for the poor and malnourished.

The Increasing Urbanization of Poverty and Malnutrition

Urbanization is progressing at a rapid pace. Over the period 2000-25, the rural population of the developing world is projected to increase from 2.95 billion to 3.03 billion. Over the same period the urban population of the developing world is projected to double, from 2.02 billion to 4.03 billion.38 In Asia and Latin America most of the growth in population in the next 20 years will be in urban areas (see Figure 4.2). The most recent data indicate that urban areas are responsible for an increasing share of national undernutrition (see Table 4.1). This shift is important because it is unlikely that the constraints to better nutrition will be the same in urban and rural areas.

FIGURE 4.2: Projected urban and rural population by developing-country region, 2000 and 2025

Source: 38.

TABLE 4.1: Changes in the numbers of underweight children in urban areas, available countries and time periods

Absolute number of urban underweight children increasing

Absolute number of urban underweight children decreasing

Share of urban underweight children increasing

Bangladesh, 1985-96
China, 1992-96
Egypt, 1990-95
Honduras, 1987-93
Madagascar, 1992-95
Malawi, 1992-95
Nigeria, 1990-93
Philippines, 1987-93
Uganda, 1988-95

Brazil, 1989-96
Mauritania, 1990-96

Share of urban underweight children decreasing

Tanzania 1991-96

Bangladesh, 1989-96
Peru, 1991-96
Zambia, 1992-97

Source: 39.

A number of phenomena that are unique to or exacerbated by urban living, and the circumstances that bring individuals to urban areas in the first place, produce these urban-rural differences. These phenomena include

1. a greater dependence on cash income for food and non-food purchases (and hence a greater reliance on foods grown by someone else),

2. possibly weaker informal safety nets (due to smaller family size and less sense of community),

3. greater participation of women in the formal labour force and its consequences for child care, in that there will tend to be fewer opportunities for women to undertake income-generating activities that are compatible with child care,

4. lifestyle changes, particularly those related to higher-fat diets and lower levels of physical activity, and given the evidence implicating foetal undernutrition as an additional risk factor for diet-related chronic disease in adults as discussed in Chapter 1, policy-makers will feel added pressure to find solutions to urban under-and overnutrition,40, 41

5. greater availability of public services such as water, electricity, sewage, and health, but questionable access for poor slum dwellers, and

6. governance by a new, possibly nonexistent, set of property rights, that may deter government and NGOs from working in such communities.

These trends and phenomena pose several questions that need answering if urban malnutrition is to be effectively addressed in the next decade. First and most basic, we need better measures of trends in urban under - and overnutrition. Are the trends in Table 4.1 seen in other countries and in other time periods? Second, how different are the constraints to good nutrition in urban and rural areas, and how generalizable are those differences? Third, what are the opportunities for and challenges to developing successful programmes and policies in urban areas? For example, how does the community-based approach have to be modified in urban areas if it is very difficult to identify a cohesive community? And are governments and NGOs even willing to commit to marginal urban areas that are highly transient but highly vulnerable? Fourth, for the delivery of services to poor communities, urban malnutrition poses new problems owing to highly mobile populations. Greater distances to travel between home and work, and rising rates of violence and other crime, make outreach increasingly difficult.

HIV/AIDS and Nutrition

Today, one in every 100 adults in the most sexually active age group (15 - 49) is living with HIV. The vast majority (89%) live in Sub-Saharan Africa and the developing countries of Asia. Africa alone contains 87% of all the world’s children living with HIV. However, the largest increases in HIV prevalence are found in Asia.42 By 2000, worldwide, the disability-adjusted life years (DALYs) attributable to diarrhoea and to HIV/AIDS will be almost identical. Nevertheless, by 2020, projections indicate that HIV/AIDS will be only the tenth leading contributor to DALYs in the developing world, behind ischaemic heart disease (first), tuberculosis (fourth), and lower respiratory infections (sixth).28

What makes this infection particularly relevant for the nutrition community? First, 90% of HIV infection in children is due to transmission of the virus from mother to child during pregnancy, delivery, or perhaps breastfeeding. Thus the nutrition community - led by WHO, UNICEF, and UNAIDS - has had to develop best practices to help educate and counsel women on how best to feed infants in the context of HIV.43 Further research and thinking need to be undertaken with regard to these best practices as they evolve. In particular, how can adequate breastmilk substitutes be provided to HIV-positive mothers who choose to use them? How can provision of substitutes avoid “spillover,” that is, unnecessary use by HIV-negative mothers and those of unknown status?44

Second, there is some evidence to suggest that improved nutrition may play a role in preventing the transmission and progression of the disease, although this link remains inconclusive and much more basic research is needed.43 Third, there is evidence that the orphaning of children that accompanies the adult mortality due to HIV/AIDS leads to stunting of children - regardless of the wealth of the adopting household - and decreases in school enrollment and attendance as children are pulled out of education as part of the household coping strategy.45 Finally, there is clear evidence that the nutrition situation in a significant proportion of Sub-Saharan Africa - the region hardest hit by HIV/AIDS - is deteriorating (see Chapter 1). The challenge to the nutrition community is to work with local organizations to identify mechanisms that enable households to cope with HIV/AIDS while maintaining investments in nutrition and education.

4.3 The Ascent of Human Rights in Development

Development has to do with people, but the precise role of people in development has been debated in philosophy and social and political science for several hundred years. After World War II, with the establishment of the United Nations and the adoption of the UN Human Rights Declaration, the idea that the main objective of development should be human well being became more acceptable.

According to both capitalist and socialist perspectives, the key to such development was thought to be essentially faster economic growth, with the assumption that the economic growth would automatically result in human development in the short run. There is now a consensus that, although economic growth is crucial for sustainable improvements in human welfare, it is not a sufficient condition. Moreover, there is agreement that development is not solely economic growth or human development - it is both.37 One objective is not a simple function of the other. The two are related in a complex manner.

Human development expresses itself in human capabilities. In the 1996 Human Development Report, UNDP defines the three most important human capabilities as (1) the capability to be well nourished and healthy, (2) the capability for healthy reproduction, and (3) the capability to be educated and knowledgeable.46 In a broader sense human development can be seen as enlarging people’s choices (see Box 4.3).

BOX 4.3

New Approaches to Measuring Poverty and Development

There are a number of approaches to defining and measuring poverty. The traditional model is based on assessing household income or total consumption in relation to a poverty line, which in turn is related to the ability to purchase a basket of foods that meets a given energy consumption level. More recent approaches assess poverty in asocial deprivation context - a formulation closely related to the concept of human rights. The social deprivation approach takes at least three forms: (1) a human poverty approach, (2) a social exclusion approach, and (3) a participatory approach. UNDP’s human poverty approach argues that “because income is not the sum total of human lives, a lack of it cannot be the sum total of human deprivation” (p. 25).37 The human poverty approach focuses on a lack of access to education, income, and longevity. It is closely related to the social exclusion and participatory approaches. The social exclusion approach focuses on the lack of resources required to participate in activities and enjoy living standards that are customary or widely accepted in a society. The participatory approach looks for local definitions and perceptions of poverty and often serves to broaden the social exclusion approach by identifying exclusion concepts that have evolved in the community in question.47

Broader definitions and measures of poverty have also become common currency in the World Bank over the past decade. Nevertheless, indicators of income poverty remain dominant in poverty assessments, and until recently the focus of country assistance strategies was still squarely on improving economic growth rates and per capita incomes. A recent assessment of World Bank performance in support of poverty reduction commits the bank to the set of targets embodied in the International Development Goals, developed in partnership with developing countries, the Organization for Economic Cooperation and Development, and UN agencies.35 One indicator for the goal of reducing extreme poverty by half is preschool underweight. Improving nutritional status is of course also an important factor in achieving some of the other goals, such as reducing infant and child mortality. Although there are issues regarding the interpretation and application of the IDGs, the broad consensus around these goals and indicators is significant and creates an opportunity to ensure greater attention to nutrition in poverty assessments and strategies.

The failure of economic growth approaches on their own to build human capabilities has opened the door for more normative arguments in development. The number of global conferences, including the International Conference on Nutrition (1992), reflects such a normative basis. In all of these conferences goals were agreed upon. These goals were not primarily based on traditional economic arguments, but rather on normative arguments. They thus represented “global moral minima” that entailed commitments or promises but not obligations.

The United Nations has a normative foundation, explicitly expressed in both the UN Charter and the Universal Declaration of Human Rights. This fact, however, was not appreciated by many development scholars and practitioners, not even within the UN itself. With the end of the Cold War and the criticism of economic growth theories, a human rights approach to development could be revived as a part of UN reform, which started in 1997.

The subject of nutrition as a human right has been debated for years. At least in the case of children, adequate nutrition is enshrined as a human right in the Convention on the Rights of the Child, a convention ratified by all countries in the world except Somalia and the United States. The principle of the “best interest of the child” ensures that adequate nutrition is one of the rights of the child.

Human rights express relationships between subjects with claims or rights and objects with duties or obligations. Essentially, human rights are the relationships between claim-holders and duty-bearers.48 Bearers have a duty to respect, protect, facilitate, and fulfill the rights of the claim-holders. Claimants have valid claims. Bearers and claimants can be the international community, national and local governments, NGOs, communities, families, households, and parents.

For countries that have ratified human rights covenants and conventions, the issue is no longer one of promises, but of legal obligations. UN programmes and projects should therefore aim at building and strengthening the capacity of governments and other duty-bearers to meet their obligations. Seen from this perspective, there is no conflict between human rights and “development.” A human rights approach represents a normative approach to development.

One of the most significant paradigm shifts embodied in a human rights approach is that people who are poor are no longer seen as passive recipients of transfers, but rather as subjects of their own actions. An important purpose of development cooperation is then to improve the capabilities, including responsibility, motivation, authority, and resources, of the duty-bearer to meet nutrition-related obligations. The next major challenge for the nutrition community is to operationalize the use of rights-based principles as a guide to nutrition programming. The 1999 ACC/SCN symposium on human rights and nutrition made progress in this regard.48 Several examples of the value of rights-based approaches to nutrition programming were presented at that meeting, one of which - related to breast-feeding - is reproduced in Table 4.2.

TABLE 4.2: Breastfeeding rights: Duties and obligations at different levels of society

Duty or obligation





To understand that breastfeeding is best for both boys and girls

To assist in the promotion of breastfeeding

To constantly promote breastfeeding


To avoid buying breast-milk substitutes

To inform people about the importance of breastfeeding

To protect people against misinformation


To assist in household work during lactation

To assist in reducing the workload of lactating mothers

To provide basic mother and child health care


To ensure that the lactating mother eats well and gets sufficient rest

To provide food to poor households with lactating mothers

To ensure household food security

Source: 49.


A new wave of evidence confirms the importance of nutrition to development. In particular, recent evidence shows strong links between infant undernutrition and cognitive development. This new evidence re-emphasizes the crucial role played by nutrition in the acceleration of development, no matter how it is defined. The link between foetal undernutrition and adult chronic disease has implications for development policy, including strengthening the economic productivity rationale for investing in nutrition. The community-based approach by the nutrition community serves as a model for other sectors to emulate, re-affirming the importance of community empowerment to the overall development process.

The broad changes taking place on the global stage also have implications for the nutrition community. The freer flow of finances, food, and information presents opportunities and challenges to the nutrition community. For example, the East Asian financial crisis of 1997 and 1998 threatens to eradicate the gains in nutrition status made by a large proportion of an entire generation. The increased liberalization of food trade requires the establishment of a benchmark set of food standards. Such benchmarks exist in the Codex Alimentarius and associated agreements, which might become blueprints for effective international regulation in a global environment. Although access to information and knowledge is uneven, their scope for accelerating declines in malnutrition seems very large indeed. The rapid rate of urbanization poses new challenges to the food and nutrition community and will require new models and approaches.

Finally, the human rights paradigm has emerged as a potentially powerful way of thinking about and practicing development. Nutrition is about much more than economic productivity arguments; it is about fundamental rights. A final challenge for all the readers of this document will be to work out - and to share with others - ways in which the potential of the human rights paradigm can be further unleashed to enhance every available resource in the fight against malnutrition.