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close this folderRealistic approaches to world hunger
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Realistic approaches to world hunger: Public health measures

Stephen C. Joseph
Special Co-ordinator, Child Health and Survival, UNICEF, United Nations, New York

In addressing the topic "Realistic Approaches to World Hunger," I will begin with a brief assessment of "hunger," or rather estimates of world-wide malnutrition as it currently exists, attempt some perspective regarding the major determinants that will influence the prevalence of malnutrition over the next 15 to 20 years, and then outline a series of actions to mitigate the situation, actions that I believe are within the grasp of the world community. I choose the word "mitigate" quite deliberately. In attempting this perspective of realism I do not believe that we will see an end to high-prevalence, endemic malnutrition in the foreseeable future, certainly not by the end of this century. Somewhat to the contrary, I believe that we must mount major efforts so that we do not see an increase in both chronic and acute malnutrition, especially in Africa and parts of South Asia.

The global estimates of malnutrition among the most vulnerable groups, children under five years of age and women, are numbers so large as to be more numbing than sobering:

- About 40 per cent of all children under five in developing countries, some 125 million children, are stunted from chronic protein-energy malnutrition.

- About 12 per cent, some 40 million children, are wasted from acute protein-energy malnutrition.

- Over 20 per cent of all infants born in developing countries, some 17 million annually, are low-birth-weight infants, most of whom reflect inadequate maternal nutrition and health.

- Half of all women of child-bearing age in developing countries, some 220 million, have nutritional anaemias.

- Little is known in detail about the prevalence and consequences of chronic undernutrition of women and mothers in developing countries, but the prevalence of mild to moderate malnutrition among these women may be nearly as high as among their infants. As argued in a US National Academy of Sciences report of 1983, research into the epidemiology, effects, and means of combating malnutrition among these women and mothers ought to have a very high priority on our international research agenda.

Related synergistically to these figures are the estimates of prevalence of infectious diseases, for it is the vicious combinations of repeated infections (Particularly gastrointestinal, respiratory, and, especially in Africa, malarial) that exacerbate, and are in turn exacerbated by, malnutrition. I will discuss this in more detail later.

Without question, the common root cause of malnutrition is poverty: poverty associated with inequity in land tenure and rural credit; poverty associated with urban unemployment; poverty associated with rural isolation; poverty associated with denial of economic and educational opportunities for women; poverty associated with ignorance and lack of education regarding optimal use of available food resources. {However, we should be careful about too easily "blaming the victims" for their lack of education. It is not often the rich or the powerful who are hungry).

While acute crop failures or massive natural or man-made disasters can spread hunger and malnutrition widely across class and income lines, the problem of endemic hunger and malnutrition, which most concerns us here, is one inextricably linked to the seamless web of rural and urban poverty in the Third World. Thus, in any examination of the prospects for reducing endemic malnutrition, we must ask, "What are the prospects for reducing endemic poverty?"

Especially when we leave the somewhat artificial global scale and move down through regions, countries, and the communities where people actually live, the prospects for reducing poverty seem decidedly mixed. Some areas and countries of Asia and South and Central America have shown significant progress, even though there are major discrepancies and large pockets of poverty within most of these countries. Along with increased purchasing power or alternative forms of equity, major advances in agricultural production, and improved transportation and communications systems, nutritional status has improved significantly in recent decades in a number of these countries. Examples include South Korea, Taiwan, Thailand, Sri Lanka, Costa Rica, Cuba, and of course China.

In the decade 1970-1980, per capita food production in the developing countries rose approximately 0.5 per cent, as it had in the preceding decade. But this figure was an amalgam of a 0.9 per cent rise in middle-income countries (in many cases accompanied by somewhat improved distribution within countries) and a negative trend, a decrease of 0 3 per cent in low-income countries. In Africa, low agricultural productivity and high rates of population growth yielded a per capita decrease in food production of more than 1 per cent. The vast masses of South Asia, including many millions of landless labourers, saw no per capita food production increase in the last decade, and, l suspect, very little or no actual per capita consumption increase, certainly not among the poorest, such as the landless laborers of Bangladesh and the urban masses in Karachi or Calcutta.

Surely there are reasonable prospects for second- and even third-generation "Green Revolutions" to increase agricultural production possibilities on a large scale. But before we view new varieties of genetically engineered food crops as a panacea for world hunger, we had best, this time, cast a careful eye on the equity and distribution possibilities, and the effects on the rural agricultural labour force and the urban poor.

At this point, I must at least mention the effects of continued high rates of population growth on the food production-food consumption-malnutrition equation. The world is on its way to a population of some 6,000 million in the year 2000, from 2,500 million in 1950 and some 4,500 million today. The projected world population by the year 2100 is 11,000 million. If we disaggregate these figures, some 5,000 million of the 6,000 million global inhabitants of the year 2000 will be in the developing countries, and over 2,000 million of these in the low-income developing countries [excluding another 1,000 million in China).

Looked at in other ways, Bangladesh, which had an area population of 40 million in 1950, has more than 90 million today and will have a population of over 150 million in the year 2000. Kenya, with a current annual population growth rate of almost 3.5 per cent, and a current population of 17 million, would have an ultimate steady-state population of 54 million even if-and this seems a rather unlikely "if"-replacement-level fertility is achieved in the year 2000. What are the prospects for increased equity and distribution in countries such as Bangladesh and Kenya under these conditions of population pressure?

The urban areas of developing countries, even in Africa, are now beginning to account for a greater share of population growth than the rural areas. Governments, for their own survival, have to feed these urban populations, and have often done so to date by agricultural and food-pricing policies that decrease incentives for the rural small-holder What will the equity and employment patterns be in the 20 or so Third World cities that will each have populations of more than 10 million inhabitants by the year 2000, and the scores of other cities of more than a million population?

I will end this rather gloomy assessment concerning medium-term future prospects for easing world hunger via improved equity, and thus via decreasing poverty, by sketching two other factors.

The first has to do with disasters and food crisis situations. It is true that the world community, and the internal infrastructure of many countries, have evolved monitoring and response capabilities so that food disasters, especially those based on crop failures, are less likely to occur, and can be better contained and dealt with when they do occur. But disasters, both natural and man-made, will continue to arise, especially in Africa-as witness the current acute food crisis in a score of countries in western and southern Africa and in the Horn. Furthermore, these crises are likely to occur in the very countries least able to cope with them and most difficult to reach with effective and absorbable external assistance. Moreover, these crises are increasingly likely to be not only "natural" in origin and course, but to be mired in local and international economic, political, and military struggles. Though my major topic relates to endemic and long-term themes, any "realistic" approach to world hunger must make allowance for the sure-to-arise disaster and food crisis food situations. Again, these will be an especially important feature of the African hunger context over the coming years.

Up to this point, I have hardly mentioned bilateral or multilateral external assistance, food aid, economic development assistance, and the like. I am sure that, over the next 20 years, more effective means of external assistance will be devised-whether food transfers, monetization of food aid, or other forms of food entitlement. These will, no doubt, be useful in combating world hunger. But on the major question, the use of external bilateral and multilateral instruments to build a global economic order of significantly greater equity (within as well as among countries), l am rather pessimistic, at least as far into the next 15 to 20 years as I can see. A realistic approach to world hunger will use external assistance creatively for what progress it can offer, but will need to place its major emphasis somewhere else.

It is on this "somewhere else" that I will spend the rest of this presentation. In contrast to the pessimistic tone of the foregoing assessment, l believe that there are two major trends under way, the accentuation of which gives us the possibility of mitigating, but not eliminating, the worst effects of endemic malnutrition.

Both of these trends are more about people, families, and communities than they are about governments, international organizations, and institutions. Both are really more about ideas than about things, though they rely on things and institutions for their actualization. These two trends are closely interrelated. I have in mind, of course, the global trend towards increased economic and social mobility of women and the global prospects for rapid and major reduction of infant and early childhood mortality. In my view, the existing and accelerating changes in the roles and status of women, a trend taking place on a global basis but at varying rates in different societies, offer one of the most direct and powerful approaches to improved child health and to improved child nutrition.

Virtually every study that has examined variables associated with improvements in child health, and (not coincidentally) with reductions in high fertility rates, has found female literacy to be at or near the top of the list of associated factors Female literacy is itself a surrogate for a host of other social and economic variables that together can powerfully influence the quality of nurturing available to the dependent infant and young child.

It is important to stress that improvements in the social and educational status of women are, by themselves, only partial measures. Attention to increased economic opportunity, especially in the modern sector, forms the other vital part. Greater control over personal and household finances is as important in societies where women have traditionally had cloistered roles as it is in those societies such as in much of sub-Saharan Africa where women have major responsibilities as primary agricultural producers In the latter setting, working with local women's farm cooperatives and making improved credit and relevant agricultural extension support available can have significant direct and indirect benefits for the health and nutritional status of the entire family, and most importantly the woman and her children.

Meaningful income-generating activities and literacy would seem to be among the most powerful levers for social change, and doubly so when combined. A major problem does arise here, especially in urban areas in the Third World, where women are moving increasingly into the cash economy and yet living in poverty in unsanitary environments and in settings of high risks of infectious disease. How, in these settings, can women increase their social and economic mobility while continuing to provide critical protection and nurturing functions for their children? This is particularly so where traditional extended family structures are no longer available. This dilemma, difficult enough for the working mother in an affluent country, is often of life and death significance in Third World settings. Beyond the comments that I will make later concerning public policy support for working mothers, I have few detailed solutions to offer on this point, which seems to be one of the most pressing problems in social development.

Women's health and nutrition and children's health and nutrition in the Third World are very closely related. Mothers could significantly improve their own nutritional status and that of their children, even without a major increase in the total amounts of food available in most communities or most countries, if they had three factors: (al improved literacy rates, (b) increased income-generating and income-controlling capacity, and (c) increased confidence in their own abilities to deal with external events and processes. The third factor is, of course, highly dependent on the first two. I shall return to this important factor of confidence at the end of this paper, as I suspect it may be the most important of all.

What can we do to assist this trend of increased social and economic mobility of women? In addition to adherence to the concept, I would suggest four lines of action for international and local organizations:

The first is to fill in the many blanks in our knowledge. For example, how are decisions made at the household level in a given society-decisions that affect the health and nutritional status of those most at risk? What are the positive and negative beliefs and practices that determine the quality of nurturing? If we understood better, society by society, the factors that cause some families to function effectively with regard to health and nutrition, often in spite of quite limited resources, we would understand better how to avert and to redress the situation where families, and particularly mothers, are unable to maintain adequate family health and nutrition.

Second is to provide direct programme support to activities designed to improve the economic and social status of women, giving special emphasis to combined efforts that might offer synergistic benefits.

Third is to explore all avenues of public policy that bear on the question. For example, it does little good to exhort working mothers to breast-feed, even if family and health advisers are supportive, if employment and maternity leave legislation, availability of child care, adequate transportation for mother and child, and other similar factors all work against the ability of the mother who has made the choice to actually carry it out.

Fourth, national and international agencies should attempt to increase the number of women in positions of professional, managerial, and political responsibility at all levels from local to global.

I turn now to the issue of infant and early childhood infectious disease mortality and morbidity and its relationship to malnutrition. In the practice of paediatrics and public health in a developing country, the first thing to do is let go of one of the basic precepts taught in the Western medical curriculum: the one that seeks a single, unifying diagnosis for all of a patient's symptoms. Patients, especially children, in the Third World have multiple, repeated illness of diverse aetiologies, and chief among them are the repeated infections that grind down a child's nutritional status in the first two years of life.

A typical child in a developing country may well have five or more significant bouts of diarrhoea per year, often beginning at about six months of age (earlier if the infant is not breast-fed), and a similar number of significant respiratory infections, not including the major threats of whooping cough (its incidence is difficult to define, but case fatality rates probably approach 2 per cent), and measles (with a virtually 100 per cent incidence in unimmunized children, and a case fatality rate that may be as high as 5 per cent and has even been over 20 per cent in local studies of epidemics and in acute malnutrition settings).

The above list of obstacles to survival does not include neonatal tetanus, which accounts for 1 to 1.5 million deaths per year in developing countries, nor the ravages of malaria - another 1 to 2 million early childhood deaths annually, especially, but not exclusively, among African children.

The most important feature of this pattern-particularly the diarrhoea and respiratory infections-is that the infections occur in relentless repetition in the first two years of life, most often in children whose protein and energy intakes are inadequate or barely adequate for normal growth, and most often during the period when children are nutritionally most vulnerable. The infections create a further nutritional drain, and the downward spiral of nutritional status leaves the child less able to defend against the next round of infection.

Thus, while we say that 15 to 20 million children under five years of age die each year in developing countries and estimate that five million of them die "from" diarrhoea and a roughly equivalent number "from" respiratory infections, the majority of these children actually succumb to a progression of infection and malnutrition that is synergistic, cumulative, and in many cases entirely preventable.

My own most vivid memory of this was an 11-month-old boy who was a measles patient on my hospital ward in Cameroon. Apart from his measles, he appeared to be in reasonable shape, the usual low haemoglobin, chronic malaria, and intestinal parasites excepted. He survived his measles pneumonia, and we discharged him. Less than three weeks later he was back, with full-blown kwashiorkor and a week's history of diarrhoea. He did not survive that second hospitalization. What did he die of? Measles? Diarrhoea? Malnutrition?

One recent study in the Gambia described a measles epidemic with a case-fatality rate of about 5 per cent. But in the nine months following "recovery" from their measles, another 10 per cent of the children died, compared to a death rate of only 1 per cent among children who had not had measles.

There are a series of relatively low-cost, mass-scale health measures that not only can prevent most of these deaths, but also have a major impact on malnutrition-both directly and indirectly. Immunization can prevent death, disability, and nutritional drain from measles and whooping cough, as well as avert death and disability from tetanus, diphtheria, polio, and tuberculosis. Immunization protection against these six diseases for all children (and, in the case of tetanus, their mothers) would cost about US$3-5 per child, with the cost of the vaccines themselves being less than US$1.

Oral rehydration to combat the dehydration of diarrhoea, whether through a pre-packaged sugar-salt solution or by a "home brew" that mothers can be taught to make using commonly available materials, is appropriate and adequate therapy for 80 to 90 per cent of cases of diarrhoea and also can intervene in the downward spiral of infection and malnutrition. It costs less than 25 cents to treat an episode of infant diarrhoea with the packaged mix.

Breast-feeding, safe and nutritious weaning practices, and growth monitoring as an early-warning system that alerts mothers and health workers to growth faltering have obvious direct potential for improving the nutritional status of children, in addition to the anti-infective and child-spacing properties of breast-feeding. A growth chart that the mother can keep at home, and that will serve as a health record for the child for five years, costs less than 10 cents. Safe and nutritious weaning foods can be produced locally out of materials available in the village.

These relatively simple, appropriate technologies exist, and UNICEF is doing its best, along with WHO and many others, to spread their application. We estimate that, if very broadly applied throughout the developing world, these measures could save up to one-half of the annual infant and early childhood deaths. In addition, they would have a very major impact on the nutritional status of those children who survived-an impact quite possibly greater than that currently achieved by those more direct nutrition and food transfer mechanisms now within our power.

But these technologies, by themselves, are not likely to reach and affect the hundreds of millions of children in need. Primary health care infrastructures need to be expanded, or brought into being in those many areas where they do not now exist, to help carry and spread these efforts. Reliance on the health system-even a more relevant health system-will not, in the foreseeable future, be able to do the job. It is clear that we must use all available channels, well beyond the traditional reach of the government service organizations, if these efforts to improve child survival and nutritional status are to have anywhere near maximum possible effect.

The keys to developing and utilizing these multiple channels are two: mass communications and social mobilization. Through the use of traditional and contemporary forms of local communication and mass media, parents can become active in using or seeking the kinds of measures discussed above. Social mobilization at the community, national, and even international level can increase awareness of available services, improve the relevance and quality of those services, and advocate their extension and further development. Perhaps not least, social mobilization has a confidence-building effect.

Through the application of these low-cost relevant technologies by emphasizing mass communications and social mobilization, especially if combined with efforts to improve female literacy and to enhance family planning demand and supply, we at UNICEF believe that a major reduction in infant and early childhood mortality and morbidity-directly linked to nutritional status-should be rapidly brought about. The confidence gained by parents in seeing their children survive and thrive as a result of their efforts is likely to be the most persuasive incentive for, and in many societies a necessary prerequisite to, widespread choices for family planning and reduction of fertility rates.

How does this all sum up? My emphasis has been on those things that depend very much on what people can do for themselves. There is no doubt that world hunger is a fundamentally structural issue with deep roots in the international political and economic orders. Of course, attention to restructuring these orders, and attention to large-scale questions of food assistance, increased agricultural production, and economic development is required if we are to see an end to endemic hunger and malnutrition.

This paper is not an attempt at a technological "quick fix." Quite to the contrary, the approach is really centred on ideas, on the empowerment of people to believe that they actually can do better by and for themselves and their children. This comes back to the confidence factor mentioned earlier. This is, perhaps, the factor currently most lacking on all sides of the development equation. Some may say, "You cannot eat confidence," and that is undoubtedly true. My response is that both local and global structural changes are unlikely to be brought into being without there first being that elusive confidence quotient. What I have tried to describe are ways that people can see that they can alter the nutritional and survival prospects of their children, by their own efforts, using relatively simple means that could actually be at their own disposal with, as they say, "a little help from their friends."