|Food and Nutrition Bulletin Volume 03, Number 3, 1981 (UNU, 1981, 64 p.)|
|Hunger and society|
Fred T. Sai
Inter-regional Co-ordinator for Africa and Europe, World Hunger Programme, The United Nations University
One major dilemma in social and economic development is how to overcome the gulf in wealth between the developed and the developing countries and the in some ways even greater disparity among groups within the developing nations. In some areas poverty is so extreme as to make it impossible to conceive how those affected can have any higher aspirations than day-to-day existence against terrible odds. Such abject poverty is accompanied by many ills that help to maintain the status of poverty or even worsen it. Among the more glaring ills are poor health, poor nutrition, poor housing, poor environmental sanitation, and a generally low degree of security in life. The intractable problem of individual and community poverty, particularly as found in many rural areas of Africa, Asia, and Latin America, is both an impediment to the development of those areas and also a challenge to organized development efforts.
In the past, development projects and programmes meant to benefit nations and groups have mainly addressed economic issues. Many have been income-generating, while others have been geared to increased production; specific attention to what was happening to the rural poor was often lacking, and there were no explicit social goals.
Even where programmes and projects have been addressed to the rural areas, they have not confronted health and nutrition in a systematic way. Even specific health and nutrition projects may be so narrowly based and so ill-suited to the social and cultural realities as to have no lasting benefit for the rural poor. Many health projects have omitted any provison for nutrition. Food aid projects, ostensibly addressing an aspect of the nutritional problem, may aggravate it by their effect on production and the fragile rural economy. An over-enthusiastic concern for one nutrient (for example, protein or calories) may so distort the patterns of food production and consumption as to lead to a lowering in nutritional status rather than an improvement. It is necessary therefore to take a comprehensive approach to the analysis of programmes and projects meant to assist the rural poor.
From the point of view of the individual and for the rural poor as a whole, the objective of development as stated in the 1970 Development Strategy may still be our guide:
The ultimate objective of development must be to bring about sustained improvement in the well-being of the individual and bestow benefits on all. If undue privileges, extremes of wealth and social injustice persist, then development fails in its essential purpose. It is essential to bring about a more editable distribution of income and wealth for promoting both social justice and efficiency of production, to raise substantially the level of employment, to achieve a greater degree of income security, to expand and improve facilities for education, health, nutrition, housing and social welfare, and to safeguard the environment. Thus qualitative and structural changes in the society must go hand in with rapid economic growth, and existing disparities- regional, sectoral and social -should be substantially reduced. These objectives are both determining factors and end results of development; they should therefore be viewed as integrated parts of the same dynamic process and would require a unified approach.*
Even small-scale development projects and programmes meant to benefit the poor should be examined in relation to a set of objectives that take the above into account. It would be anti-development if a programme were to help a section of the poor to obtain a hold on the means of production and rapidly become wealthy at the expense of their neighbours. It is in this light, too, that one should examine such programmes and projects for their likely influence on, and contribution to, health and nutrition.
Nutrition is the basis of good health, and good health also contributes to the maintenance of good nutrition. It is therefore necessary to look at health and nutritional issues as an interrelated whole. For a complete and comprehensive analysis, the two must be taken jointly. The following are some of the social, health, and nutrition considerations that should be included in agricultural projects.
The health and nutritional status of any population is related intimately to some basic demographic variables. Thus it is essential to examine what influence a programme will have on major demographic factors. What will the programme and project do to the growth rate and the spatial distribution of the population, and how will these affect demand and supply of foods and of the health services generally? A programme that creates centres of industrialization and urbanization may draw in the more active of the rural poor and depress agricultural output of the areas it is meant to help. On the other hand, with prior consideration for requirements, steps could be taken to form an interdependent series of projects within the programme to ensure increased production of food for the poor rural sector. It is important to realize that many organized agricultural programmes and projects concentrate on the male and alienate females from their traditional roles in agriculture. Resettlement schemes have been known to be so ill-conceived that they result in women losing their livelihood. This can also happen in efforts to make food crop production an organized, profitable business. Capitalization and financial constraints may transfer production to males exclusively.
SOCIAL AND CULTURAL STRUCTURES AND VALUES
In rural areas, and especially among agrarian societies, work and general styles of living are intricately mixed. Social structures are woven around work and other activities. Family types and relationships, the distribution of foods, eating patterns and habits-including consumption of prepared foods within and among families-are all dictated by complex cultural and social practices that may have existed for generations. These same structures control health practices and health decision-making. Some of these practices help group cohesiveness and may ensure reasonable management of food resources as well as the general health of the group as a whole.
The influence of any development programme on social and cultural structures, particularly those that relate to health, food, and nutrition must be carefully assessed. If women are given work outside the home, who tends to the household garden, prepares the family meals, and cares for the young? In particular, how will this affect the pregnant women, lactation, and breast-feeding, without which infant survival among the poor cannot be guaranteed A programme that incorporates women should therefore make adequate provision to minimise conflict between economics and their social and biological roles.
Even a project helping men to improve their income and providing food for them at their place of work may affect family food consumption in a negative way. Well-fed fathers may partially neglect their family responsibilities. In many rural areas of Africa, the consumption of alcoholic liquor is largely social. However, with modernization come beer bars. Even in rural areas money-earning heads of households have been known to spend disproportionate amounts on alcohol to the detriment of their families.
In general, those earning good incomes are better able to look after their health and obtain health services than are the poor. Peasant populations increasingly need cash income. The feeling that peasant populations fed reasonably well on their own produce can have little use for money as far as food supply is concerned is of only limited validity. Income-however slight the modernization that has taken place among the poor-is of considerable importance to food intake as indeed it is in tiding them over shortages caused by adverse climatic conditions. Some studies undertaken in Ghana indicate that rural populations may need to purchase between 25 and 50 per cent of their foods. The foods usually purchased are the more expensive and nutritious components in the diet.
Even the rural poor now have some need for basic cash expenditures that become increasingly burdensome- education and clothing of children, fuel and transportation. Any increase in income will therefore play a major role in the nutritional status of the rural poor. Projects that help to generate income need to be accompanied by continuous education in household budgeting and in the requirements for good nutrition. Below a certain income level, food may enjoy high priority, but, when income reaches a point at which certain symbols of modernity can be acquired, these may be purchased at the expense of the food budget.
FOOD PRODUCTION AND DISTRIBUTION
Peasant societies generally mix their crops in such a fashion as to make nutritional and even economic sense, especially if enough land is available. Such problems as exist relate to land tenure, to the increasing partitioning of land under population pressures, or to the adherence to customs that were valuable in days long past.
A rough assessment of nutritional adequacy or inadequacy of a peasant group can be made on the basis of a study of the cropping patterns, the types and characteristics of foods produced, and land distribution.
Any project or programme to benefit the rural poor should be looked at from the point of view of its impact on cropping patterns, on food production and distribution, and, therefore, on nutrition. For example, insistence on monoculture has been detrimental in some situations, or cereal varieties have been introduced that populations would not use because the taste or other characteristics of these varieties made them ill-suited to traditional preparations.
Recently the introduction of cassava to help fill the calorie gap and to provide a surplus for export has been advocated. This may make economic sense, but there are many caveats. How will the introduction of this crop, which is relatively easy to grow and to store, affect the production of the more nutritious cereals? How and in what proportions will it enter the diet-in particular the diet of infants and pre-school children? Finally, will there be enough education about its use to avoid both acute and chronic toxicity? How will the cultivation of the "lazy farmer's crop" affect social organizations?
Another area of major concern should be the nutritional role of food items such as fruits and vegetables that are gathered in the wild. Will the project or programme destroy these to any great extent? If it does, then provision will have to be made for deliberate cultivation of substitutes and the population must be taught how to use them.
FOOD CONSUMPTION AND NUTRIENT INTAKE
A programme or project may affect the type, quality, and quantity of foods entering the home and thereby affect the composition of diets and the nutrient intake of the population. The classic example of a rise in beriberi with the introduction of dry milling of rice in East Asia is a constant reminder of possible pitfalls. For some reason, with increasing modernization, green vegetables disappear from many diets. If other sources of vitamin A are expensive or unobtainable, vitamin A deficiency may increase among a population that, on the surface, should be doing well. Changes in the method and frequency of feeding children may aggravate protein/calorie malnutrition. Many rural communities, especially poor ones, are generally on the border level with regard to intake of iron, and deficiencies can therefore be created relatively easily. Iron deficiency due to poor nutrition is fairly frequent among pregnant and nursing women of such communities as well as in very young children, and it is desirable to include monitoring of this particular deficiency in any nutritional surveillance. In parts of Africa, folic acid deficiency is fairly common and is aggravated by the presence of malaria. Here again, pregnant women are particularly vulnerable. Therefore, when changes take place in the supply and availability of food, it will be necessary to ensure that foods rich in folic acid are made available to especially vulnerable groups. Among the B group of vitamins, thiamine and riboflavin deficiency may create similar problems. Particular attention needs to be paid to the thiamine intake of rice-eating communities. Among many rural poor, the intake of riboflavin is marginal, and under any kind of stress, such as pregnancy and lactation, deficiencies may occur. Signs and symptoms of these deficiencies can also be observed relatively simply.
THE NUTRITIONAL STATUS OF THE POPULATION
It would perhaps be unnecessary to require that a comprehensive study of the nutritional status of the population be undertaken before mounting a project or programme or reorienting agriculture generally. Instead, a nutritional profile based on knowledge of some of the above issues and a few major criteria discussed below should provide a reasonable basis for assessing the present status of the population to be affected by the project and the likely impact of the project on it, as well as potential nutritional problems to be encountered within a programme. The profile would also provide a basis for monitoring any changes that take place during and subsequent to the implementation of the project. The assessment of nutritional status is a complex undertaking if comprehensively done; it is time-consuming and expensive. However, among many rural poor populations, a nutritional profile can be developed using a few indicators-with little extra investment from the programme or project-that will provide the basis for assessment of the project's nutritional impact and potential problems.
OTHER HEALTH CONSIDERATIONS
For many rural communities, agricultural practices are intimately related to health and disease patterns. The housing of agriculture labour forces and the location of villages in relation to water supplies and resources are issues of importance when planning agricultural programmes. Water management in relation to environmental sanitation and the role of health services should be carefully considered.
Water and Environmental Sanitation
Water management is a very important consideration for agriculture as well as for general health and nutrition in any agricultural programmes, therefore, the effects on the sources of water available to the population should be carefully studied. Apart from possible decreases in quantity, the even more important factor of biological and chemical pollution of water should be kept in view. Irrigation projects have been notorious for aggravating health hazards such as helminthic infestations (e.g., bilharzia and hookworm).
By changing the ecological balance, dams and irrigation projects may also increase the breeding of some disease vectors-the black fly (Simulium) and some species of mosquitoes are a case in point. The Volta Lake in Ghana has become a major source of schistosomiasis and of simulium, both of them nuisances and sources of ill health.
The provision of facilities and services for health care in the community is an important consideration in any agricultural or rural development programme. There is no need to set up complex services that the people will not use. It is more important to help them create their own participatory health care system. The People's Republic of China has perhaps the best integrated health care system for agricultural communities in its Commune Health Care programmes. No one is more than a few minutes away from first-level care. Immunizations, antenatal care, and all basic public health measures are readily accessible at minimal cost.
It is important to make people responsible for their own health and nutrition education and service programmes. In this respect, the community's own structures, adapted if necessary, assume major responsibility in the programmes.
ASSESSMENT OF HEALTH IMPACT
Programmes meant to benefit rural populations can be assessed through a few indicators that have been proved to be good pointers to any changes in social health and nutritional status.
Infant Mortality Rates general health status of a population. A good rural development or agricultural programme that takes care of people will lead to a lowering of these rates.
Selected Disease Morbidity and Mortality
To monitor the impact of an agricultural programme on the population, it may be useful to identify those diseases whose incidence and prevalence can be influenced by alterations in agricultural practices and methods of settlement. These include infectious and communicable diseases and helminthic infestations.
Specific impact on women may be monitored through their pregnancy performance and the problems that arise, including what happens to their infants.
ASSESSMENT OF IMPACT ON NUTRITION
To assess nutritional impact, some or all of the following indicators can be recommended:
Age-Specific Mortality Rates
Studies of death rates of infants and young children give a relatively useful indication of the nutritional problems within a community. In their work on mortality among infants and children in Latin America, Puffer and Serano found that 5 per cent of all deaths in children under five years of age were due to malnutrition. In 55 per cent malnutrition was a major associated cause of death.* If malnutrition has some contribution to make to two thirds of deaths in these age groups, then the rates and changes in the rates over a period of time can be used as an indicator for changes in nutritional status.
Low Birth Weight and Prematurity
It has now been shown that the proportion of "low-birthweight babies" as well as prematurely is high among malnourished populations. A serial analysis of these indicators over time should give some idea of the impact of a project on the nutrition of at least women in the fertile age groups.
Mortality Registration from Specific Nutritional Diseases
Most countries have mortality registration. However, only in a very few developing countries can one place any confidence in the returns. The people who make the diagnoses are often not well trained, and efforts at analysing these returns are rather perfunctory. A great deal of information, however, can be obtained from such registration if training and supervision are improved and registration of major symptoms is encouraged. In the case of nutritional diseases, registration by both actual disease and deficiency symptoms can be performed, and these will give indirect evidence of the extent of the nutrition problem. This evidence has to be considered indirect because of the restrictions in the basis for diagnosis and the training of personnel. Where properly trained personnel are available to collect evidence of mortality from nutritional disease, then such evidence should be taken as direct evidence. Changes in these death rates with time are a significant indicator of what is happening within the population.
Direct Indicators of Nutritional Status
Incidence and prevalence of signs and symptoms of nutritional deficiency and their change over time should be noted. The incidence of marasmus and kwashiorkor, the most severe forms of protein/calorie malnutrition, should always be noted, because changes in the incidence of these diseases can be indicative either of deterioration in the health and nutritional status of the population as a whole or of changes in feeding practices of children. The incidence and prevalence of keratomalacia and xerophthalmia are used to assess the adequacy or inadequacy of vitamin A, Cheilosis, angular stomatitis, and changes in the tongue signify a deficiency of a member of the vitamin B group. These are seen most often in pregnant and nursing women and in young children and school children.
Growth and Development Studies
Growth studies of children from birth to five years old as well as annual cross-sectional height, weight, and arm circumference measurements in school children are good indicators of their nutritional status as well as of what is happening in the community as a whole.
In attempting to present an approach to a systematic consideration of health and nutrition in development programmes and projects aimed at the poor, one is acutely aware of the complexity of the subject. There is also the fact that-with some very few outstanding exceptions-no such work has been undertaken in any systematic way. Guidelines are badly needed to help both the ordinary programme planner and his health and nutrition advisors, if there are any. Considerations of nutrition must enter into programmes and projects at the pre-planning stage and be made evident in all subsequent phases.
If the guideline for food and nutrition prepared for the Food Policy Division of the FAO (unpublished internal FAO document) is found satisfactory in field trials, it will be a major step forward in efforts to analyse projects in terms of an important aspect of human development- adequate nutrition. A similar, even more comprehensive, exercise needs to be undertaken for the health field generally.