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Hunger, Health and Society
Nutrition interventions and the process of
Impact of socio-economic level on infant feeding patterns in iraq
The extent of bottle-feeding in bahrain
Nutrition interventions and the process of economic development
David E. Sahn
Senior Associate, Community Systems Foundation, Ann Arbor, Michigan, USA, and Research Fellow, MIT/ Harvard
International Food and Nutrition Program, Cambridge, Massachusetts, USA
Nevin S. Scrimshaw
Institute Professor, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA, and Director, Sub-programme on Food, Nutrition, and Poverty, The United Nations University
During the past few years an awareness has developed that economic development and the nutritional status of populations are inextricably linked. Nutritional adequacy, as it affects the quality of human capital, influences economic performance. Conversely, the extent and form of economic development conditions the nutritional status of the population. This recognition has stimulated an array of nutrition intervention schemes that have been planned and implemented in almost every country in the world. Most of these efforts have involved public expenditures or the use of foreign assistance resources in direct service programmes, without either addressing or affecting the economic determinants of malnutrition. Some efforts, however, have involved active intervention in market prices and other policy variables that directly affect the process of economic development. This paper will address relevant aspects of the relationship between nutrition and economic development. Its purpose is to indicate not only the salient points of interaction, but also to present an overall framework in which planners and policy-makers can work together to attain both nutritional and development objectives.
THE EFFECT OF NUTRITION ON ECONOMIC DEVELOPMENT
The 1960s witnessed nutrition becoming a concern of development economists as efforts to reduce malnourishment were being justified as an investment, rather than a consumption expenditure. The conceptual basis for these efforts had its origins in Shultz's work on the economic returns of "investment in human capital" (1). It has been subsequently argued that reducing malnutrition is a necessary, albeit insufficient, condition for development. The types of outcomes that represent the supposed economic returns of efforts to assure nutritional adequacy are the improved performance of workers, the protection of infants and children from cognitive impairment, the reduction of fertility and population growth as a consequence of lower age-specific mortality rates, and a reduction in expenditures for primary health care and nutrition interventions (2).
The evidence is persuasive that improving physical and mental capabilities and the quality of health is an appropriate complement to investments in physical capital and technological innovation. Nevertheless, criticisms have been leveled against employing such arguments as a justification for nutrition programmes. Specifically, the direct link between the deleterious impacts of malnourishment and retarded economic development are weak. To illustrate, Hakim and Solimano (3) argue that it is only an article of faith that the improved capacity of an individual will be translated into increased productivity. If the economic and social organization does not allow utilization of the improved potential of individuals, it will have little economic impact. Moreover, savings in costs of health care resulting from better nutrition are only applicable in countries where a serious commitment is made to the provision of health services for the poor - a scenario absent in many nations. Similary, because declining mortality rates are only one of many determinants of fertility, birth rates will not necessarily fall in the face of higher survival rates that may result from nutrition interventions.
The most persuasive criticisms of the contention that nutrition interventions lead to economic growth and increased productivity is the weakness of the empirical evidence to date. The often referred to cases of Sri Lanka and Kerala, India, are illustrations of governments that have invested heavily in nutrition and human capital, but whose economic performance is less than impressive. Nevertheless, the same arguments can be advanced for general education, and yet it is considered to be a precondition for development.
The skepticism about the direct economic benefits of improving human capital is not to suggest that there are no functional consequences of malnutrition. For example, even the mild protein-calorie malnutrition that characterize the majority of preschool children in developing countries interferes with growth and development and reduces immunity to infections. More severe deficiencies in young children lead to the diseases of kwashiorkor and marasmus that have high fatality rates and are associated with adverse effects on learning and behaviour. Nutritional anaemias caused mainly by iron deficiency are widespread among all age groups. The functional consequences of iron deficiency include reduced physical capacity and performance, increased susceptibility to infection, altered performance on some cognitive tests, and even impairment in body temperature regulation.
Other significant nutritional deficiencies in developing countries include avitaminosis-A that, if prolonged, may lead to blindness, and iodine deficiency that is responsible for endemic goitre. The latter is extremely widespread, and in pregnant women can cause feeblemindedness, deafmutism, and sometimes cretinism in their offspring. The most significant mechanism whereby malnutrition, even when relatively mild, increases morbidity and mortality is its synergistic interaction with infection. Conversely, episodes of infection, even when mild, have and adverse impact on nutritional status through reduced nutrient intake because of anorexia and the withdrawal of solid food, less intestinal absorption, metabolic losses in urine, and internal diversion of nutrients as part of the immune response.
Too often, malnutrition is viewed as homogeneous rather than a continuum of different levels of severity, displaying a variety of physiological, biochemical, and behavioural manifestations. The thresholds at which the deleterious biological effects of different forms of malnutrition are manifest is an area for continuing study. The prevalence and significance of nutritional deficiencies require the establishment of systems of nutritional surveillance, interventions to counter the more serious nutritional problems, and evaluations of their effectiveness
There can be no doubt that malnutrition is the cause of much suffering for the afflicted individuals, and causes a range of adverse functional consequences. Measuring the economic implications of such negative outcomes, however, presents numerous methodological problems. For example, in the case of malnourished mothers and children, it may be a generation before "returns on invest meet" to reduce malnutrition are realized.
Such difficulties in demonstrating economic benefits of ten serve as an excuse for inaction. Unless governments and policy-makers are motivated to reduce hunger on humanitarian grounds, the debate over long-term economic returns will only serve to detract from the immediacy of the problem It seems evident, furthermore, that malnutrition is just one among several syndromes characteristic of underdevelopment and poverty. Its reduction, along with a constellation of improvements in the socioeconomic environment, are necessary to allow individuals to develop their potential to the fullest. This implies that a dynamic and effective overall development strategy is a prerequisite to making productive use of human resources.
NUTRITIONAL IMPROVEMENT IN THE COURSE OF ECONOMIC DEVELOPMENT
The need for and feasibility of nutrition interventions to reduce hunger and malnutrition are functions of a country's development strategy and its success in meeting social and economic goals. The extent of malnourishment is largely determined by governmental choices for the provision of social services and by the priority accorded to equitable patterns of growth. It has become clear that, with few exceptions, developing countries will not resolve their hunger problems through their current patterns of development (4). It is important to recognize the basis for this conclusion and the reasons for possible exceptions.
First, we must recognize that during the past decade the average growth in per capita GNP in developing countries has commonly been less than 1 per cent annually. It is all but certain that many nations will not be able to realize the necessary aggregate economic growth, even with an improving income distribution that is needed to eliminate hunger. Compounding the problem is the empirical evidence that in the course of economic development, there has usually been an increased skewing of income (5). Even in those countries that have successfully raised per capita income, the welfare of individuals in the lower deciles of income distribution has deteriorated (a, 7). The nutrition problems in Northeast Brazil illustrate how, despite an impressive performance of the economy in the aggregate, poverty and hunger remain endemic in a large segment of the population.
A few poor countries appear to have been relatively effective in limiting the magnitude of malnourishment. It is interesting to note that such "success" stories cut across political and economic ideologies. To illustrate, most dramatic have been countries such as China and Cuba, that have adhered strictly to a communist paradigm of economic development. As described by Field (8), malnutrition in these countries is not addressed explicity; rather it is eradicated in conjunction with "... the wholesale transformation of society and the economy engineered by the state." Similarly, Winikoff (9) argues that these countries have not reduced malnourishment through nutrition policies and programmes per se. Rather, improvement has resulted from the distributional reforms that were undertaken in conjunction with major social and economic change.
Fig 1. Model the determinants of Nutritional Status
A second model that demands attention has variously been described as the basic human needs or equityoriented strategy to economic development. The fundamental tenets of this people-centered approach is to place priority on a macro-policy set concerned less with growth in the aggregate, and more with the assurance of access to education, food, health care, and so forth. This emphasis on social development at the expense of growth in GNP is perhaps best embodied in the cases of Sri Lanka and Kerala, India (10).
As with the communist paradigm, in neither country is there an explicit nutrition policy, although both have public food distribution systems and help small farmers through support prices. However, what distinguishes Sri Lanka and Kerala is the "... general governmental political commitment to the poor majority..." (10).
A third model is exemplified by the notable performance of a few countries, e.g., South Korea, Taiwan, Hong Kong, and Singapore, that have successfully reduced malnourishment. These nations have followed a neoclassical economic growth strategy. They exploited comparative advantage, emphasizing domestic savings and foreign exchange accumulation to spur investment. The outward looking export promotion strategy of these small nations is based on a macro-policy set (e.g., currency devaluation, free capital markets) that fostered rapid growth in labour. intensive manufactures (11).
The above discussion of successful development strategies is not to suggest that one approach is superior or should be adopted elsewhere. For example, many would criticize the communist paradigm because of the costs in human liberties. There is also increasing skepticism as to the accuracy of information concerning how well communist policies and the social transformation accelerate an escape from poverty (12).
As for adhering to the people-oriented approach, it may also entail a high price in terms of long-term economic growth and vitality. This is perhaps best illustrated by Sri Lanka's indebtedness and poor financial standing, which recently required severe successive cutbacks in its public food distribution system (13).
Or finally, the replicability of an export promotion strategy on a worldwide scale is suspect. Reasons for skepticism include the changing global environment of increased protectionism and the special social and political traditions characteristic of the homogeneous and relatively small Asian nations.
Despite these qualifications, it is apparent that some countries have been more successful than others in reducing malnutrition A common thread that ties them all together, regardless of whether it be a centrally planned economy or a capitalistic market system, has been the ability to provide the poor with access to resources. Poverty is addressed directly as the main constraint to inadequate nutrition. So, while hunger does not appear to be a problem with an easy and rapid solution, despair is not the appropriate response. There are a number of viable programme and policy options that must be considered within the political and economic framework of individual countries.
MODEL OF THE DETERMINANTS OF NUTRITIONAL STATUS
The political economy perspective in the previous section provides a framework for considering how nutrition and economic development are linked. The specifics of the relationship are presented in a simplified model of the determinants of nutritional status in Figure 1. Nutrition is seen as the end-point of a series of socio-cultural and economic determinants. A multiplicity of processes and variables interact in concert to govern the nutrients available to the individual and the requirements for them.
This model illuminates the three sub-systems that impact upon nutritional well-being:
1. Intra-household Distribution and Utilization of family food resources that condition who receives what quantities of nutrients.
2. Effective Demand, which depicts those decision variables that affect the supply of nutrients available to the household unit.
3. Food Supply, which controls the aggregate quantity and quality of nutrients in a country or region.
While this model could be discussed at length, it is designed to provide a framework to assist in conceptualizing the aetiology of malnutrition. Any intervention that affects the variables depicted in Figure 1 can influence nutritional status. Indeed, programmes and policies covering a wide range of activities and decision variables must be considered in terms of their nutritional impact, whether or not this is their stated purpose.
One may wish to think of interventions as a continuum according to how directly they address the malnourishment problem. For example, such a continuum would be distinguished at one end by interventions such as nutrition rehabilitation in a hospital's malnutrition ward; at the other extreme are macro-economic policies, such as setting foreign exchange rates and interest rates.
While the specifics of interventions will be discussed in greater detail below, it is emphasized that manipulating some of the policy or decision variables depicted in Figure 1 will have a more direct and traceable impact upon nutritional status than others. The more proximal an intervention to the model's dependent variable, nutritional status, the fewer variables along the system whereby losses to non-nutritional benefits may occur.
To illustrate, if the individual's food intake is augmented directly, nutritional status will be improved commensurately, although metabolic losses caused by parasites and other infectious disease may blunt the impact. At the other extreme, nutritional status is less directly linked to increasing domestic food production. Numerous points of leakage, ranging from post-harvest transport and processing losses, exports, and intrafamilial distribution, make intervention at more distal variables more difficult to realte to nutritional improvement, especially in the short term. Paradoxically, it is precisely those more distal factors that are usually considered the more structural and fundamental causes of malnutrition.
TRADITIONAL NON-MARKET INTERVENTIONS
Efforts to improve nutritional status have traditional been focused on bringing about micro-level behavioural and dietary changes. The emphasis has been on improving individual food intake and utilization. The point of departure for planning and implementing programmes has traditionally viewed the household endowment and ability to attain resources as a fixed variable, around which interventions must be designed to improve nutritional status. Little attention is thereby placed on augmenting effective demand or the household's command of goods and services. The direct nutrition interventions discussed in this section emerged in response to broad-based nutrition problems. They were essentially designed to operate as adjuncts to the development process, and by implication were not intended to result in significant alterations of macro-policy. Three types of intervention can be cited as examples.
Mother and child feeding programmes are designed to fill the nutrient gap between what is consumed at home and what is needed to maintain adequate nutritional status. A supplementary food is distributed either at an on-site feeding centre, usually at a health care facility, or provided as a take-home ration. The food ration is not designed to augment the family's food or financial resources. Rather, the intent is to circumvent household-level food shortages and alter decisions on intra-familial allocation and utilization of limited resources. Mother and child feeding programmes are also designed to improve nutritional status indirectly by acting as an incentive for participation in other health and educational activities. Food may serve to motivate individuals to seek immunizations, pre-natal care, well-baby care, and other health services. Similarly, it can provide a captive audience for the delivery of nutrition education.
Development of human capital, as well as humanitarian efforts, represent the underpinnings of this type of programming. Mother and child feeding also finds supporters who point out the highly targeted nature of such interventions. In theory, resources can be targeted not only to the poorest of the poor households, but to individual family members in greatest need. Nevertheless, these efforts have been plagued by numerous difficulties that have eroded enthusiasm for them.
Nutrition education programmes are based on the assumtion that changes in knowledge, attitudes, and behaviour of malnourished individuals will reduce the hunger problem. Although educational efforts involve the presentation of facts and information, success is contingent upon increasing awareness of the importance of changing behaviour and motivation to do so.
Activities and messages cover a wide range, At one end of the spectrum is individualized instruction, whereby a health worker interacts one-to-one with mother or child. Monitoring health and development through the use of growth charts and the proper use of oral rehydration solutions are the types of messages conveyed. At the other end are campaigns designed to discourage a food taboo (e.g., not feeding a child with diarrhoea), or to promote a feeding habit (e.g., encourage breast-feeding).
Pronounced among the criticisms have been the inability to substantiate nutritional change attributable to programmes, the limited coverage of the malnourished population, and the relatively ineffectual screening and targeting criteria that have been employed. The formidable administrative burden and logistical problems associated with these interventions have also constrained potential impact. Most serious, however, is that when there is a significant calorie gap at the household level attributable to poverty, targeted feeding programmes fail to address the main constraint to adequate nutrition-lack of purchasing power. The size of the income effect (i.e., the value of the food ration to the recipient) has generally not been large enough to have a significant impact on household food availability, and thus the dietary intake of the targeted individual. Simply stated, when one accounts for the substitution of the food ration for normal food expenditures, and the expected sharing among siblings and other family members, them leakages severely detract form the potential impact of supplementary feeding programmes (14, 15).
Of special interest in the context of economic development is the potential deleterious effects of increasing commercial advertising by changing the nature of the food supply toward more costly, processed, and less familiar foodstuffs. An extreme example of such a problem is the promotion of infant formula to replace breast-feeding. Lack of money to purchase adequate quantities, coupled with inappropriate use, has resulted in more infant malnutrition. Less pronounced examples include the Us of costly snack foods and soft drinks at the expense of adequate nutriture. Therefore, the problems inherent in, and the role for nutrition education, increase commensurately with changing habits and practices that accompany economic development.
Finally, the appropriateness and effectiveness of nutrition education efforts are conditioned by a number of factors. Most important is a determination of the degree to which poverty and other limiting environmental factors overwhelm any conceivable benefits of changing knowledge and behaviour. Conversely, the fact that nutrition education provides long-term benefits by changing attitudes and behaviour commends it as a developmentally sound intervention.
Fortification programmes involve enriching a food(s) with a nutrient(s) deficient in the dietary of the population. Examples include the Us of iodine in salt, vitamin A in sugar or monosodium glutamate, thiamine in rim, vitamin D in milk, and iron salt in bread. The appropriateness of these non-targeted efforts is contingent upon the population's consuming the carrier food in sufficient quantity, and on acceptable organoleptic and storage properties of the fortified food. The need for the food to go through a central processing procedure and the cost inherent in that process also determine the viability of this type of intervention.
The reduction of debilitating deficiency diseases such as xerophthalmia, iron deficiency anaemia, and so forth, as discussed earlier, also has significant functional consequences. Apart from this, however, the direct linkage with the process of economic development is generally non-existent. Furthermore, in many cases the people are not even aware that a given intervention has taken place.
Besides the three interventions described above, there is considerable experience with other traditional efforts, such as integrated health and nutrition programmer, hygiene and sanitation services, formulated food programmes, or nutrition rehabilitation centres. Discussion in detail of these interventions, and a critical evaluation of such efforts, is the subject of a number of reviews ( 14, 16, 17). However, suffice it to say that these interventions have met with generally limited and variable success. In most cases they have fallen short of the aspirations of those who promoted the concepts. This is not to suggest that they have been ill conceived. Rather, the less than enthusiastic assessment is due to: the methodological difficulty of attributing success to programmer that operate within a larger and complex food system; the limited expendable resources for such efforts; the growing realization that only limited effectiveness can be expected in the face of a hostile and unrelenting social and economic environment, plus the problems of reaching the periphery with centrally planned programmer.
Them interventions are often viewed as highly visible efforts and therefore politically attractive. They avoid manipulation of major policy instruments and circumvent the need for bold decisions. They involve no meaningful redistribution of wealth. As Chafkin (18) remarks: "Such interventions retrofit nutrition programs into a development strategy often biased against the poor." They can be expanded and contracted without affecting anyone but the indigent. Whatever finances are available can be programmed easily, politicians can shake hands, work with highly regarded private voluntary organizations; encourage community-level volunteerism, and the like, all of which are risk-free and expedient.
Some others (8, 19) have gone so far as to suggest that programme efforts discussed above may, in fact, do positive harm to those they are designed to assist. By acting as palliatives, it is argued, direct nutrition expenditures serve to reinforce the existing economic and political structures. Programmes can thereby serve to maintain inegalitarian regimes, rather than foster the requisite social change.
While such harsh criticism deserve serious attention, it is more useful to consider traditional interventions as a legitimate bridging mechanism. That is, in the shor-term feeding programmes and the like can successfully insulate the most vulnerable segments of the population from unconscionable suffering that may accompany underdevelopment. However, such problems must inevitably find long-term resolution in structural change and reform. It is stressed, therefore, that targeted, non-market interventions must be accompanied by government policies and an international climate designed to bring about growth with equity, thereby making stop-gap measures obsolete. If this is not the case, costly programmer will be required indefinitely, as has been the case in many countries.
Finally, it is necessary to make explicit the budgetary linkage between the types of nutrition programmes discussed above and the process of economic development. Fiscal and monetary policy conditions the expendable resources of the government. Government priorities then dictate how much of the budget is allocated to health and nutrition-related programmes.
While this paper is not the place to explore the budget process in detail, three significant points deserved emphasis First, health and nutrition expenditures are characteristically accorded a low priority by most governments. Second, expenditures on health are usually strongly biased toward curative rather than preventive measures. Hospitals and sophisticated medical care are the recipients of most government outlays. Only limited domestic resources are usually made available for health promotion and disease prevention.
Third, there are large sums of foreign assistance available specifically for health and nutrition programmes. Bilateral and multilateral aid agencies have given priority to these types of expenditures. For example, the vast majority of feeding programmes are supported by external food aid, and a significant portion of promotional and preventive health care is contingent upon external support.
As relatively more developed countries, such as Brazil, receive less and less of grants-in-aid, governments will be faced with the hard choice of eliminating traditional externally financed nutrition programmes or continuing them with scarce domestic resources. If the former option is chosen, there will inevitably be negative political repercussions, while if programmes are maintained, the fiscal cost will be a heavy economic burden. Unfortunately, the only solution to this dilemma is for governments to pursue actively a development strategy that mitigates the need for feeding programmes and other stopgap measures over the long term. This further emphasizes the need to move simultaneously on three fronts of (a) immediately effective but limited and specifically targeted relief-oriented programmes; (b) social change and structural reform of the food and agricultural system, in particular, and national and international economy in general; and (c) self-sustaining improvement in nutritional and health practices at the home and village level.
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