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Hunger and society
Implications for women and their work of
introducing nutritional considerations into agricultural and
rural development projects
"Projects" versus "Movements"
Systematic consideration of health and nutrition in agricultural and rural development programmes and projects
Implementation of a conceptual scheme for improving the nutritional status of the rural poor in Thailand
Perspectives on infant feeding: decision-making and ecology
Implications for women and their work of
introducing nutritional considerations
into agricultural and rural development projects
Marie Angélique Savané
African Institute for Economic Development and Planning (IDEP), Dakar, Senegal President, Association of African Women for Research and Development
During recent years a number of agencies and research workers have conducted studies on the roles of women in society. These studies had become necessary because of the ever more evident decline in the status of women with respect to both working conditions and socio-cultural life. This "invisibility" of women-their exclusion from decision-making power-was the basis for the declaration of 1975 as International Women's Year. During the World Conference held that year and the World Food Conference held the previous year in Rome, stress was laid on the leading role played by women in food production and in the nutrition of the family. Following the recommendations of these two conferences, studies have been carried out that enable us to comprehend more fully the dynamics of the role of women in these two sectors.
Although some actions have also been taken in this connection, the research and actions conducted have seldom resolved the problem. Their sectorial and reductionist approach has prevented the real underlying causes of the unequal distribution of food resources from being revealed. The solutions-agricultural or rural development projects-have often ignored the role of women in the production and processing of food. Nutritional programmes have been superimposed on the already overcharged daily routine of women, thus leading inevitably to failure.
These problems will be the subject of this report, in an endeavour to show the implications for women and their work of introducing nutritional considerations into agricultural and rural development projects.
THE ROLE OF WOMEN IN NUTRITION
The role of women in nutrition is conditioned by their status in the reproduction process (1). They carry and give birth to children, nurse them, care for them, and prepare them for their adult life. The nutritional aspect of the question starts at conception and follows the various stages of procreation.
During pregnancy, it is the woman who transfers to the foetus the nutrients necessary for its survival and development. The health of the pregnant woman is therefore of decisive importance during this period.
Jelliffe underlines "the vital interdependence between the nutritional health of the mother, foetus and infant." For him, "An inadequate diet for women, especially in pregnancy and lactation, has not only direct nutritional importance for the foetus, but can lead to 'maternal depletion', often cumulative with each reproduction cycle. The result is an increased maternal and perinatal mortality and morbidity of great importance to the whole family, including previous young children still so dependent on the mother's care and attention, especially in feeding" (2).
During the first months of life, mother's milk is an infant's natural food, except in cases where the mother, for some reason or other, is unable to breast-feed.
After weaning and the introduction of solid foods, the role of the mother is even greater. It is she who has to produce or purchase the food that the young child needs, and also choose and prepare this food. This crucial period in the growth of the child requires great attention and knowledge on the part of the mother. The existence of food taboos and prohibitions is not a major obstacle to the success of weaning because, as Sai states, "It is not at all clear the extent of the adverse influences of [taboos] on overall nutrition. Most of the foods tabooed are in short supply anyway or can be sold for cash, which will be used to buy a staple benefiting the whole family more" 13, pp. 77-99.
The inability of the great majority of third-world women to buy protein-rich, industrially manufactured food gives greater value to home-prepared weaning foods. This illustrates the even greater importance of the role of women in children's nutrition in societies that cannot have access to foods produced by industry.
Women also have a major responsibility in feeding the adult members of the family. It is they who produce and process the elements necessary to feed the family. It is they who choose the menu and decide on the amount of food required and how it is distributed among the different members of the family.
WOMEN AND FOOD PRODUCTION
In several parts of the world, it is the adult women who do most of the work required to feed the family. This work includes not only the production of food but also its transformation into something that can be eaten. The processed products may be sold or exchanged, thus making it possible to balance the family's diet through the acquisition or purchase of ingredients that the family itself does not produce.
In Africa these tasks represent 40 per cent of the work necessary to feed the family (4). Such work includes digging or ploughing, sowing, planting, hoeing and weeding, and also protecting the crops against pests. Women help with the harvest and transport the produce from the fields to the village. In forested areas, the women grow root vegetables and condiments. In savanna countries, they help to grow millet and have their own vegetable plots (5). They also handle certain food crops such as rice and maize. In addition to these production activities, there is the gathering of leaves and seeds. In some coastal zones the women engage in fishing for small species of fish or for shellfish. Part of the catch is dried or smoked. It provides a considerable addition to the diet of cereals and roots (6). Fishing activities may be seasonal, i.e., carried out during the dry season, but sometimes they keep women occupied for the whole year, depending on the area and on the returns obtained. In traditional agricultural societies, women are responsible for the small livestock and poultry. They feed them bran and household waste and care for them. Women sometimes own small livestock that they use both for everyday consumption and also as gifts during ceremonies, as sacrifices in rituals, or as a means of exchange in the markets.
Among nomadic peoples rearing cattle and sheep, women, in addition to domestic tasks, devote themselves to the livestock. They handle the milk and milk products (curds, butter, etc.). The surplus is sold or exchanged for millet or maize grown by settled peoples (7).
After being harvested, food products need considerable processing before they can be eaten or marketed. The processing and preparation of food is the responsibility almost exclusively of the women. They also engage in a whole range of food-conservation activities. They build storehouses for the grain and dried vegetables and make all kinds of receptacles (8).
Pounding and milling of the grain, the preparation of yams, bananas, and platains, the extraction of palm oil, and the drying or pickling of fish are activities that require a lot of time. Boserup refers to a study carried out in the Congo showing that the preparation of tapioca ant maize takes four times longer than all the agricultural work required to grow these products (9, p.164).
It must be remembered that the processing of food continues throughout the year, even if the time devoted to it decreases slightly during the rainy season, when there is most work to be done in the fields. The importance of the role of women in the production and processing of food is undeniable. Yet, depending on the ecosystem and on the amount of labour required, they also help in the growing of cash crops for export without receiving any pay for this work.
All these activities prolong the working day for women, who also have to cope with all the domestic chores (cooking, fetching water and wood, washing, caring for the children, cleaning the house, etc.).
These tasks entail much outlay of energy by women and affect the physical and psychological health both of women themselves and of the young children and even the whole family .
THE IMPACT OF AGRICULTURAL AND RURAL DEVELOPMENT PROJECTS ON WOMEN
In traditional agricultural societies, women, recognized as food producers, were afforded specific social and economic rights as well as duties (10). But the old methods of production have been overturned by the integration of these societies into the international division of labour. The development strategies devised for this purpose, both during the colonial period and later, have changed the patterns of production and introduced new crops and new cultivation techniques. This has also had repercussions on the division of labour by sex and age, on the land ownership system, on the causes and types of migration, etc. Women have been particularly affected by the changes that have occurred.
In agriculture, the development of cash crops has changed the division of labour by sex (11). The men have specialized increasingly in commercial agriculture, while the women have continued to grow the food, although taking an active part in producing income from the family field.
The mechanization of certain agricultural tasks and technical innovations often prolong women's working day and make the work heavier (12). In many cases, although these innovations increase women's participation in the family workforce, they do not result in any rise in their incomes (9).
This new division of labour between the sexes has had repercussions even on food habits. Thus, according to the study conducted by Bukh in Ghana, it seems that, as the men have become involved in growing cacao, they have had to stop producing yams because both crops have to be harvested at the same time. The women consequently have had to take over the food crops, but it has been necessary, because of the scanty resources available to them, to replace yams with cassava, which requires less labour and yields more per hour of work. This arrangement, although it has certain advantages with regard to output, has resulted in a drop in the quality of the diet, since cassava has a lower nutritive value than yams (11).
In general, the introduction of cash crops has been effected at the expense of food crops, thus creating an ever-growing dependence of the developing countries on the industrialized countries for food (13).
In Asia and Latin America, agrarian reform, by taking into account only laws on land ownership, has completely overlooked women's usage rights. In certain large agricultural projects the government agents have quite simply ignored the inheritance systems that granted land to women. Moreover, access to co-operatives, credit, training, and organization has been denied to women as a result of traditional cultural forces and economic necessity.
This situation-i.e., the negative impact of social and economic changes on the role and status of women-has attracted the attention of a number of planners and politicians. Projects specifically for women, aimed at integrating them into development, have been launched. At the same time, a more overall approach that takes women's problems into account has been introduced into rural development projects. Although some of these projects have succeeded in their main objective-that of reducing the imbalance between men and women in access to resources-they have never succeeded in calling into question the subordination of women in these societies and changing the division of tasks between the sexes.
In fact most of the projects for women are a failure. The reasons for this are manifold (14), but the main one is the total lack of understanding of women's place in a rural economy in the process of change. Peasant women, individually, within the family unit of production, take part in the same way as others in social production (5).
WOMEN, NUTRITION, AND RURAL DEVELOPMENT
The preceding sections have tried, within the limits of this report, to show the importance of the role of women in food production and nutrition. We have also underlined the constraints under which women labour in trying to adapt themselves to fluctuations in the social and economic order, in order to fulfil their role in society and in the family. These readjustments cause imbalances in their rights, their working conditions, their incomes, and even their health and food habits. The main aim of the nutrition and health education programmes proposed for women has been to teach them how to balance their diet, use the resources available, and manage the household budget.
As a whole, these programmes have not been a great success. The conventional approach adopted has failed in both content and form to influence the women. The use of inappropriate techniques and teaching material and references to resources not available locally are all factors that tell against these programmes (14). But the main cause of failure lies in the fact that women have never been considered full-fledged producers. Thus, account has never been taken of the fact that in certain regions, particularly in Africa, they are the main suppliers of the family's food and that women have so much work to do that conventional training courses are not possible. Any measure aimed at ensuring food self-sufficiency must take these facts into account. But most of the agricultural or rural development projects have been geared toward men, totally ignoring the work of the women (5;9; 11).
The only efforts directed toward women, based on the western model, have concerned home economics and have been aimed at making peasant women into good houswives and nutritionists. These programmes have reduced the causes of nutritional problems to ignorance, taboos, the inability of the women to manage their budget, etc. The food deficit and its causes and the unequal distribution of resources at the international, national, and regional levels among and within peasant households are questions that have been ignored by these programmes. This explains the absence of dynamism in these projects and their relative failure, particularly when they do not form an integral part of a programme aimed at overall change within the community.
The introduction of nutritional considerations into agricultural and rural development projects can have a decisive impact on women and their work, but the effects will only be of real benefit if nutrition is just one aspect of a vast programme aimed at meeting the specific needs of each member of the community (women, men, children, the aged).
Rethinking Rural Development
Meeting the nutritional requirements of each member of the community means changing the structures of production, the method of assigning the land, production techniques, the division of labour between the sexes, and the distribution of resources and incomes. For women this new orientation will have to take into account their roles in both reproduction and production, defining the relationship between the two, their influence on the course and outcome of pregnancy and breast-feeding, and women's energy requirements during these periods, bearing in mind seasonal variations, food taboos, and prohibitions.
Taking into account the specific food requirements of women also means admitting that fatigue caused by the multiple stresses to which women are subjected should no longer be considered as "natural" but seen as the result of an excessive physical and psychological burden. This implies the need to lighten both the productive and the reproductive tasks of women, at both an individual and a collective level, through appropriate technologies and social structures (15).
Meeting the nutritional requirements of each member of the community means reassessing the rightful contribution of each member in the production and processing of food. This includes acknowledging the right of women to work under better conditions in order to achieve levels of productivity capable of satisfying each person's needs. Here the problem of women's access to land ownership, particularly in areas where there is heavy migration by men, is of great importance.
In addition, the possibility of having credit facilities, of being members of production or marketing co-operatives, and of receiving appropriate technical training are all factors that would enable women to fulfil satisfactorily their functions as providers of the family's food. The lightening of domestic chores and a more equitable distribution of work within the family-as well as a solution to the problem of accessibility to potable water-are indispensable complements to such a policy.
Providing Functional Nutritional Education
Meeting the food requirements of each member of the family means giving the women who decide on the menu the knowledge that will enable them to improve the daily diet. This education must take into consideration existing food practices and reappraise them in the light of the objectives to be obtained. Food taboos and prohibitions should be a subject of particular attention.
Programmes must use local resources as far as possible and be adapted to the daily routine of women and to the traditional forms of community and family organization. They should be conceived as a research-participation programme in which women's consciousness is raised so that they become the agents of their own change (16). Particular emphasis should be placed on the importance of breast-feeding, arranging for work to be organized in such a way as to free women to carry out this essential task successfully.
The role of women in food production is decisive for the family's nutritional status. Any development programme aimed at meeting people's nutritional requirements must take this into account in planning activities and allocating resources. But success will be achieved only if there is the political will to call into question the pre-existing production relations. The "invisibility" of women and their confinement to the domestic sphere of social production is not due solely to ignorance. It is based on the underlying nature of a class system in which one class estranges the others and takes advantage of the social and cultural oppression of women to profit from their status as unpaid workers.
Thus any strategy aimed at creating conditions for a better redistribution of resources and incomes that will enable each member of the community to meet her or his basic requirements, particularly with regard to food, must have as its starting point a far-reaching structural change.
1. Lourdes Beneria, Production, Reproduction end the Sexual
Division of Labour, ILO Working Paper, WEP, 10 WF2 (ILO,
2. D.B. Jelliffe, "Nutrition in Early Childhood," in World Review of Nutrition and Dietetics (1973).
3. F.T. Sai, "The Problems of Food and Nutrition of West Africa," in World Review of Nutrition and Dietetics, vol. 10 (1969).
4. Economic Commission for Africa, The Changing Contemporary Role of Woman in African Development, (Addis Ababa, 1974).
5. M.A. Savané, L'insertion des femmes dans la problématique du dévéloppement Afrique (IDEP, Dakar, 1977).
6. Economic and Social Council, Etude complémentaire sur le rôle et la place de la femme sénégalaise dans le dévéloppement (Dakar,1979).
7. M. Dupire, in Femmes d'Afrique noire (D. Pauline et Cie, the Hague, 1960).
8. Economic Commission for Africa, The Role of Women in Population Dynamics Belated to Food and Agricultural and Rural Development in Africa (Addis Ababa, 1976).
9. E. Boserup, Women's Bole in Economic Development (St. Martin's Press, New York, 1970).
10. O.A. Pala, La Femme africaine dans le dévéloppement rural: Orientations et Priorités, Cahier OLC no. 12 (1976).
11. T. Bukh, The Village Woman in Ghana (Copenhagen, Centre for Development Research, 1978).
12. Food and Agriculture Organization, Report of the Commission on the Status of Women, 25th session (FAO, Rome, 1970).
13. F.M. Lappe and J. Collins, Food First: Beyond the Myth of Scarcity (Ballantine Books, New York, 1977).
14. Afard, Où en est Animation féminine en Afrique? (IFAD dossiers, Nyon, Switzerland, 1979).
15. UNICEF, "Technologies villageoises" en Afrique de l'ouest et du centre, en faveur de la femme et de l'enfant (UNICEF and ENDA, 1979).
16. Food and Agriculture Organization, Women in Food Production, Food Handling end Nutrition (FAO, Rome, 1979).
"Projects" versus "Movements"
Discussion of "interventions" should distinguish between projects and movements. Ideally, projects are of limited duration-they have a starting point and a termination date. Projects are planned in advance and may or may not be open to adjustment while under way. Projects are usually dependent on resources from outside the project area-material as well as human resources. Problems as well as solutions are usually defined by well-meaning outsiders, not by those with the problems.
Ideally, movements are first and foremost characterized by control over actions by those who have the problem. The ideals) behind a movement may well come from "outside" the movement itself, but the ideas take time to grow and mature and become adjusted to the local reality. Those with the problem formulate their views about problems, priorities, and solutions. There is no fixed plan available a long time in advance, although good movements need both planning and analysis; movement leaders first have to use intuition to feel their way forward. Intuition is an important tool for understanding the exceedingly complex situation of which problems taken up by a movement are usually a part. This requires an intimate knowledge of both the problems and their causes. Movement leaders need to understand not only what is said and expressed openly but also what is behind the words and under the surface.
Movements take their own time, and have no defined time frame. Their starting point may be difficult to perceive, and so may their end. Either they die out, or they are suppressed (as is often the case), or they grow and lead to social change. The latter may be the most important aspect of movements as against projects: the much greater potential of movements for social change.
Systematic consideration of health and nutrition in agricultural and rural development programmes and projects
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.
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