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Realistic approaches to world hunger: Policy considerations

Nevin S. Scrimshaw
Institute Professor, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA

By World Bank estimates there are at least 800 million persons in developing countries whose dietary energy intake limits their physical activity (1), and by WHO estimates an additional 300 million children whose growth and development are retarded and who are at risk of increased morbidity and mortality (2). It is common for those concerned with agricultural research to suggest that the application of even existing knowledge to the production of greater amounts of food will eliminate food shortages and thereby hunger. Those responsible for food aid seem to believe that the answer to the chronic hunger of the lower income populations of developing countries is to supply food.

A realistic approach to world hunger requires first a realistic appraisal of its causes. No approach based on increasing the availability of food alone will be more than marginally effective. While important to relieve genuine food emergencies associated with the effects of war, civil disturbances, and natural disasters, food aid may be counterproductive when used as a substitute for national efforts to improve food production and distribution.

Poor people are hungry or malnourished either because they are not able to obtain sufficient food of the right kind or because they are not sufficiently knowledgeable as to the nature and importance of an adequate diet. If malnutrition is to be corrected, it must ultimately be through measures affecting these two factors. There are of course a variety of social, economic, and demographic determinants that function as intervening variables. The multiplicity of these ensures that no single programme or intervention will by itself eliminate hunger and malnutrition. To do this requires concurrently an adequate food supply, sufficient means for those in need to acquire it, appropriate intra-household distribution and utilization of food resources, and, because of their adverse effects on nutritional status, prevention of those infectious diseases that can be controlled.

This paper will try to identify feasible, cost-effective measures that will help to achieve these goals. Those interventions associated with nutrition and health activities, with food and agricultural measures, and with political and social actions will be considered in turn. First, however, the nature of the nutrition problems to be overcome should be clearly identified.

Nature of the Nutrition Problems to Be Addressed

Although the causes are multiple and complex, the final nutritional consequences are easy to identify and, from a public health point of view, limited in number. They are as follows.

Protein-Calorie Malnutrition in Young Children

Among the lower-income populations of developing countries, children tend to be born at a low birth weight and with reduced nutrient reserves because their mothers are poorly nourished. Nearly all are breast-fed and do well during the first few months, but by four to six months of age breast milk is no longer sufficient and growth begins to falter. Concurrently, resistance to infection is reduced by malnutrition and the child is increasingly exposed to diarrhoeal and other infectious diseases that further worsen nutritional status. If timely and appropriate complementary feeding is not introduced, morbidity and mortality are high. Failure to correct this early malnutrition can have permanently adverse consequences for both physical and mental development. As judged by early growth failure, nearly two-thirds of the children in many developing country populations suffer some degree of protein-calorie malnutrition.

In some populations, particularly in urban areas, the need of the mother to work, imitation of the more affluent, misguided advice from health workers, and commercial promotion of bottle-feeding have reduced the duration and even frequency of breast-feeding, with highly adverse health consequences. When breast-feeding is abandoned early and the food given is grossly inadequate, the result is nutritional marasmus, a form of slow starvation. Another complication when the supplementary food is mainly carbohydrate and infection is superimposed is kwashiorkor.

Chronic Energy Deficiency

The significance of the low per capita caloric intake of most developing country populations has only recently been fully appreciated. In order to survive, individuals in such populations must reduce their discretionary activities, including those important to family welfare and community development, and/or the energy expended on work. For children, reduced physical activity means less of the stimulation necessary for normal cognitive development.

Iron Deficiency

It is now recognized that iron deficiency is the most widespread nutrient deficiency in the world, affecting about two-thirds of the populations of most developing countries, with about one-third of these manifesting iron deficiency anaemia. Because there are functionally important iron-dependent compounds in the reticuloendothelial system, brain, and muscle, the consequences are reduced resistance to infection, increased morbidity and mortality, impairment of some cognitive functions, reduced physical capacity, and diminished work performance.

Iodine Deficiency Diseases (IDD)

Iodine deficiency, manifested by thyroid enlargement or endemic goitre, is still widespread in many countries. While it is responsible for only a small number of cases of cretinism, characterized by dwarfism and feeblemindedness, it causes lesser amounts of damage, including deaf-mutism and various degrees of mental impairment, in a much larger number of persons.

Vitamin Deficiencies

The only vitamin deficiency that is still of major public health importance is avitaminosis-A. In some developing countries it is responsible for dryness of the conjunctive (xerophthalmia), softening of the cornea (keratomalacia), and blindness. Fortunately, the classic vitamin deficiency diseases of beriberi, pellagra, and scurvy have virtually disappeared, and anaemia due to folic acid deficiency is of minor significance compared with that caused by iron deficiency.

Food and Agricultural Measures

In general, food is available to meet effective demand, i.e., the food that someone will pay for. Apart from disasters, food shortages occur when there are no funds to pay for more food if it is produced or when prices are so naturally or artificially depressed by government policies that producing more food is not profitable. Poor price policies can negate the benefits of land reform.

Agricultural research and extension help by making it possible to produce food more efficiently. They can help the economic status of farmers who accept improved agricultural technologies, but they cannot overcome the problem of lack of purchasing power of the remainder of the population. This will require measures that are beyond the role of the agricultural sector per se, ones that will improve land distribution and tenure, reduce social inequities, and alleviate poverty. They will be discussed below.

Nutritional and Health Measures

WHO and UNICEF have identified a package of activities that are affordable and of demonstrated effectiveness in preventing most malnutrition and its consequences in young children. These include the use of growth charts and measures to control infection.

Growth Charts

The best way of detecting when breast milk must be complemented by other foods and when the weaning diet is inadequate is periodic weighing of the young child and use of a growth chart. Experience has shown that even illiterate mothers can understand the significance of an increase or decrease in weight from one weighing to the next. If falloff in growth is detected early, only minor adjustment in the distribution of the family diet is needed to halt it and prevent its consequences. Weighing programmes conducted within the home or village should be the cornerstone of any programme to reduce childhood malnutrition. They are worthless, however, if not accompanied by their effective use to indicate to the mother when the child must be given more or better food or brought to the health centre because of infection. This requires the capacity to carry nutrition and health education directly to mothers.

Control of Infection

Infections worsen nutritional status by causing reduced nutrient intake and absorption and increasing both external and internal metabolic losses. Conversely, even moderate degrees of malnutrition reduce resistance to infection. The interaction is mutually reinforcing and is responsible not only for most clinic malnutrition but also for most of the excessive infant and preschool mortality in developing countries, whether ascribed to nutritional or to infectious disease. There are a number of specific measures that, by reducing infectious disease, will reduce malnutrition.

Since the most common infection among young children is diarrhoeal disease, the promotion of ample water supplies and measures to improve environmental and personal hygiene become measures to combat malnutrition. So is immunization against the common communicable diseases of childhood, diphtheria, tetanus, whooping cough, measles, and poliomyelitis.

Measures to Increase Social Equity

It is increasingly evident that the key to improved nutritional and health status of populations is greater social equity that leads to greater ability to obtain food. This may be achieved in a number of ways:

Access to Agricultural Land and Services

A family that has access to land can grow all or part of its own food. As populations increase, plots may become too small to divide further. The result is an increase in landless labourers and migration to urban areas. The former may mean only seasonal employment and the latter chronic underemployment, with the result in either case, undernutrition.

In some developing countries the land tenure system is so inequitable as to guarantee a permanent underprivileged and undernourished class. With 2 per cent of the population controlling 80 per cent of the agricultural land, El Salvador has had the largest proportion of landless agricultural labourers of any country in the world, and yet the forces dominating successive governments have been totally resistant to any kind of land reform, including the most recent US-backed land reform effort that is stalled with little progress. The situation is little better in neighbouring Guatemala. Yet other countries, such as Egypt, Peru, and Taiwan and, much earlier, Mexico, have managed to carry out far-reaching programmes to increase small farm holdings and limit the size of large farms. It is generally agreed that elimination of rural poverty and hunger will require overcoming the extreme inequities in land distribution that characterize many developing countries.

Increased Income for Food Purchases

For those without land, government actions are required that will improve their purchasing power, such as minimum wage laws and price controls targeted to the poor. Other measures, such as import and export policies and industrial development policies, can have a profound effect on local employment prospects and income available for food purchases.

Entitlements

The concept is that everyone is entitled to food and shelter, and those who are too poor to achieve this should be helped. The two principal ways of doing so are food subsidies and income supplements. In Egypt subsidized bread is a major factor in preventing severe undernutrition. Subsidies are of value if they can be targeted to those who are most needy. Fair-price shops in the Asian subcontinent have been moderately successful in doing this. Food stamps, as income supplements, can be effective if the logistic and administrative problems can be overcome, although this is a large "if" for most developing countries.

Is It Realistic to Believe That Hunger Can Be Eliminated from Developing Countries by the Year 2000?

It is realistic to state that hunger can be eliminated by the year 2000 but not that it will be eliminated. There is ample evidence that it can be done. Some developing countries in extremely unfavourable situations have made notable progress in applying the needed measures and in eliminating hunger and malnutrition as public health problems.

China, with a cultivatable land area no greater than that of India, has managed successfully to feed a population nearly half again as large and extend health services to them. Taiwan, Korea, and Singapore are doing well; and a number of other countries, such as Indonesia, Malaysia, Thailand, Colombia, and Peru, are making good, if somewhat uneven, progress. Egypt, India, Pakistan, Bangladesh, Tanzania, Sri Lanka, and the Philippines, despite recent setbacks in several of these countries, are fully capable of achieving the Alma Ata goals for primary health care, including the elimination of hunger and malnutrition by the year 2000.

Recognition should be given to the success of both Cuba and Costa Rica in correcting long-standing inequities and achieving enviable nutritional and health records. Data for the latter are given in table 1. In the early 1950s infant and preschool mortalities were high in Costa Rica, the degree of growth retardation of preschool children was the same as in the highlands of Guatemala, and both kwashiorkor and marasmus were hyperendemic. As recently as 1966, 14 per cent of the preschool children experienced second- and third- degree malnutrition by the Gomez classification. By 1982 it was less than 5 per cent, and both infant morbidity and mortality in one- to four-year-old children had dropped to the same range as in Europe and North America, with avitaminosis-A and endemic goitre eliminated as public health problems. Yet this occurred with economic resources proportionately less than in the other Central American countries where infant and preschool mortality rates have remained high and even increased. Land tenure inequities remain a problem, but the consequences are mitigated by the other social policies.

The difference in every one of these examples was political commitment, a government that, regardless of its ideological base, cared about its people and gave a high budget priority to education and health, particularly that of mothers and young children. It was government policies that targeted goods and services including health, nutrition, housing, environmental sanitation, education, and welfare activities, to the most deprived population groups. The provision of such social services became part of a dynamic process of redistribution of national income. These policies also encouraged the small farmer with agricultural extension, credits, and access to the necessary inputs of seed, fertilizer, and pesticides. With political will dramatic changes can be brought about in only a few years.

It is noteworthy that Chile and Cuba, with governments that are now poles apart, both have excellent systems of primary health care and good vital statistics. Nicaragua is placing the same emphasis on social services as Costa Rica despite the differences in form of government. China can be considered the political opposite of Taiwan and Singapore, yet with comparable health records. Turning from the successes to the failures, we find a similar diversity of political systems, with one common characteristic - protection of the status quo for the elite or the vigorous pursuit of becoming a new elite, i.e., the acquisition of economic and social privilege without regard for the welfare of the whole population. There is no question that at the present time hunger and malnutrition, poverty and social inequity, land distribution, and food availability are becoming worse in a number of countries as the direct result of the ineptness, corruption, or policies in support of an elite minority. In these countries the policies of national and multinational companies often contribute to the problems.

Many of the countries of Africa are in this sad situation as well as several in Latin America. Without a change in government policies nutrition and health in these countries will not improve and may even grow worse.

TABLE 1. Changes in Some Maternal and Infant Indicators in Costa Rica

* Pregnancy, delivery, postpartum.

What Industrialized Countries Can Do

The criterion should be only convincing and continuing evidence that their assistance will benefit the population as a whole. One way to free such US assistance from national politics and selfish interests is to offer it through international channels. WHO and UNICEF are, in general, effective agencies for improving the nutrition and health of populations with concern for national policies but not politics. The World Bank and its associated international lending agencies have the greatest leverage in persuading governments to adopt sound economic policies that will benefit their populations. The Food and Agriculture Organization and the World Food Programme are also directly concerned with alleviating food problems, and the education programmes of Unesco make a contribution.

The United Nations University is strengthening the capacity of institutions in developing countries to provide needed research, advanced training, and advisory services in food and nutrition. It does this through provision of fellowships for advanced training and supporting applied research.

A number of other effective activities of the UN system are beyond the scope of this discussion. Currently, some of the best assistance in agricultural research and its application is coming from the international agricultural research institutes organized under the Consultative Group for International Agricultural Research. These are located in the Philippines, India, Peru, Syria, Nigeria, Ethiopia, Kenya, Mexico, and Colombia. Each institute specializes in a different combination of crops and ecological conditions. The Institute for Food Policy Research in Washington, D.C., is also part of this system. The Asian Vegetable Research and Development Center in Taiwan contributes in a similar manner.

For health, the Institute for Diarrhoeal Disease Research in Bangladesh is an international institution making important contributions, as is the Institute of Nutrition of Central America and Panama (INCAP) in Guatemala.

There are also a number of non-governmental organizations that are making important contributions. Through their demonstration projects that place emphasis on community participation and community development, they often have an influence on government policy and the thinking of government officials out of proportion to the modest scope of their projects and resources. Oxfam and the Save-the-Children Fund are two that have focused effectively on self-help activities and health. So have some of the activities of the Catholic Relief Services, the Friends Service Committee, and the Unitarian Service Committee.

The largest part of US government assistance over the years has been provided as food aid. The original Food for Peace Program had as its primary purpose the disposal of troublesome food surpluses in a way that was politically attractive within the United States. Only gradually has the altruistic component of US food aid received genuine, as distinguished from rhetorical, attention. This came about as food surpluses decreased and decisions to continue food aid required a different rationale. During much of the period the largest proportion of food aid has been allotted on the basis of "strategic considerations" rather than need.

The problem with food aid is not only that it tends to be shaped to the political and economic interests of the donor country, but also that the foreign exchange support it generates is all too often used for inequitable urban-based development strategies and for the purchase of armaments. The long-term result is a deleterious impact on the nutrition of the poor.

The availability of massive amounts of subsidized grain from the United States in the 1960s enabled India to neglect its rural sector in favour of heavy industry and urban development. When relationships between India and the United States changed and India began to pay attention to its rural sector, its subsequent ability to meet its food needs and to establish adequate reserves within only a few years seemed miraculous. Bangladesh, dismissed as a "basket case" in the 1960s and early 1970s, achieved remarkable progress in domestic food production with a change in government policy in the late 1970s. The conclusion is that food aid should be limited to genuine short-term emergencies, to improvement of agricultural infrastructure and production, and to strengthening health services for mothers and young children.

Apart from temporary relief of populations suffering from natural or man-made disasters, the objective of all assistance for overcoming hunger and malnutrition should be to improve both the degree of self-sufficiency of a country in food production and the equity of its food distribution. We have seen an evolution in concepts because so much of development assistance has not achieved the expected benefits for the lower socio-economic groups of developing countries.

It became evident that the benefits of economic development will not "trickle down" to the masses sufficiently to prevent growing hardship and unrest. Hope was then placed on measures to create a so-called "new economic and social order." it became the position of the majority of developing countries that massive transfers of resources from the industrialized countries to the developing ones must take place along with major economic concessions. There seems little merit in debating this issue here because it is simply not going to occur on a scale sufficient to change the nature of developing country problems. Instead, it is increasingly recognized that the countries must help themselves through people-oriented development.

As indicated above, it is the countries that are prepared to undertake such development that can be helped and that should receive generous support from the United States and other industrialized countries and the international system. Governments unwilling or unable to make a commitment of this kind should not be given external financial support. However, such countries should not be written off. They can still be helped on a project-by-project basis, particularly with those projects that are at the community level. In fact, such assistance can often provide examples and improve the climate for needed changes in government policies. In this kind of assistance, the international and voluntary agencies can be highly effective and deserve strong support.

Conclusion

It is realistic to contemplate the elimination of hunger and malnutrition if and when governments adopt social, economic, agricultural, educational, and health policies that have enabled countries with a wide range of political systems to achieve this goal in a surprisingly short time. It can be anticipated that an increasing number of countries will adopt this course so that both the proportion and absolute number of hungry and malnourished people will be reduced by the end of the century. The encouragement and assistance that international, bilateral, and voluntary agencies can provide will make a critical difference.

REFERENCES

1. S. Reutlinger and H. Alderman, "The Prevalence of Calorie-Deficient Diets in Developing Countries," World Bank Staff Working Paper No. 374, (World Bank, Washington, D.C., 1980).

2. "Infant and Young Child Nutrition," report by the Director General of WHO to the World Health Assembly (Document WHA36/1983/7, 15 March 1983).

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