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Nutrition and health in the Americas

Nutrition and health in the Americas: Introduction
Nutrition in Central America and Panama: Comparative data and interpretations
The Costa Rican experience in improving nutrition and health care
Comparative public health: Costa Rica, Cuba, and Chile
The nutritional impact of rural modernization: Strategies for smallholder survival in Mexico
Nutrition and agricultural change in southern Honduras
Agrarian reform and small-farmer welfare: Evidence from four Mexican communities

Nutrition and health in the Americas: Introduction

Billie R. DeWalt

Most of the papers in this issue were prepared for a conference on Health and Nutrition in the Americas, sponsored by the Latin American Studies Program at the University of Kentucky in March 1986. The purpose of the conference was to bring together scholars, policy-makers in health and nutrition, and politicians to discuss topics relating to health and nutrition in Latin America. As with most such gatherings, large amounts of information were presented, considerable debate and disagreement were generated, and a few important ideas came to the fore and stood out as themes. Some of these themes can serve as points on which further debate might be focused.

A general point that emerges is the diversity of disciplines and institutions involved in research and action concerning health and nutrition in Latin America. In addition to nutritionists and physicians, social scientists, agricultural scientists, and basic scientists must be involved in the effort. Collaboration must also be encouraged among such institutions as the National Institute Nutrition and the Ecodevelopment Centre in Mexico and US and Mexican universities (see the paper by Suárez et al.) and consortia of universities such as in the International Sorghum/ Millet Program (see the paper by DeWalt et al.). An important role is also taken by the Institute of Nutrition of Central America and Panama (INCAP) and the Pan-American Health Organization, which help to train investigators and administrators, and coordinate and disseminate results from ministries and institutions within specific countries. Collaboration and co-ordination are especially important in circumstances such as that mentioned in the paper by Valverde, Delgado, and Noguera where there were 65 group feeding programmes operating in the Central American countries during 1984-1985, most supported by contributions from various external donor agencies.

As research proceeds on the social and biological epidemiology of nutrition and health, it becomes critically important to have knowledgeable political leaders who are willing to put such research to use. Daniel Oduber, a party leader and the president of Costa Rica from 1974 to 1978, placed great emphasis on improving health and nutrition in his country. He was able to devote substantial attention to these areas largely because of the consensus that the nation's resources should not be invested in building a large military apparatus. During the past four decades Costa Rica has achieved health and nutrition indicators that compare favourably with those in countries with much higher per capita incomes.

The paper by Horwitz compares three countries with the best health and nutrition indicators in Latin America-Cuba, Chile, and Costa Rica. Horwitz attributes the emphasis on improving peoples' physical well-being to a national ethos that all individuals are entitled to good health and adequate nutrition. The commitments of these countries to improving health and nutrition do not seem to have varied with political fluctuations or diverse ideologies.

The successes of the three countries contrast markedly with the situation in most of Central America and Mexico. Honduras is the second poorest country in the Western Hemisphere. The poor health and nutritional conditions that exist there are characteristic of large areas of Central America. The work of Valverde and his colleagues at INCAP was designed to help those countries develop appropriate methods for understanding where poor health conditions exist, the nature of the problems, and how best to address them. The paper by DeWalt and DeWalt demonstrates how farming-systems research and nutrition systems research can be integrated to target agricultural research efforts to the most needy parts of the population. As the papers by Valverde et al. and Oduber note, however, conditions are not likely to improve until the wars and civil strife that presently characterize that region are ended.

Several of the articles in this issue point out the necessity of providing individuals with resources so that they can afford to improve their own health and nutrition. The two articles about Mexico address this effort directly. The paper by DeWalt et al. reports that agrarian reform in four communities in different ecological regions of the country is an effective way of improving health and nutrition indicators if individuals are provided with sufficient resources to make farming a viable activity. Greater access to land, credit, and other resources is also of critical importance. According to Suarez et al., peasants who have the alternative of returning to a subsistence economy have fared better in facing Mexico's economic crisis than persons without the same access to land. Both articles indicate that Mexico's health and nutrition indicators have not improved as substantially as those of other, poorer countries. When wealth is extremely unequally distributed, even generally populist governments such as have existed in Mexico have difficulty providing the needed subsidies, health-care facilities, and welfare programmes to keep the populace healthy and well fed.

Because they focus heavily on Central America and Mexico, these articles touch on only some of the health and nutrition problems in Latin America. They do demonstrate, nevertheless, the kind of knowledge coming to light that can help policy-makers to understand better and plan for alleviating the poor conditions that afflict substantial numbers of their citizens.

Acknowledgements

The conference on Health and Nutrition in the Americas was made possible by a grant from the Ashland Oil Corporation, which provided the funding for the Ashland Oil Visiting Professorship, designed to bring distinguished individuals in the fields of business, the sciences, humanities, government, or the professions to the University of Kentucky. Lic. Daniel Oduber was the Ashland Oil Visiting Professor in 19851986. Kenneth Coleman, former director of the Latin American Studies Center, Donald Sands, Vice Chancellor for Academic Affairs, and Kay Ruiz of the International Programs Office were the individuals most responsible for organizing the conference.

This volume is most respectfully dedicated to the memory of Dr. Victor Valverde. His untimely death shortly after he participated in this conference is a great loss to his professional colleagues as well as to his family. We will miss him.

Nutrition in Central America and Panama: Comparative data and interpretations

Victor Valverde, Hernán Delgado, and Arnulfo Noguera Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala

Background

Food and nutrition-problems and solutions

Most public health and nutrition experts now accept that the undernutrition that affects children in developing nations results from a combination of complex social and biological factors. These factors may lead to low availability of adequate foods to meet energy and nutrient requirements and/or to poor use of foods consumed because of the overwhelming toll of infections to which most children and other family members are exposed in poor areas of developing countries [1]

Adequate amounts of food may be obtained from items available in a community and/or through purchasing power (depending on income and prices). If sufficient demand exists in a community, markets are likely to be able to offer enough commodities through local production and/or imports. Thus, the low availability of foods to families in rural areas of developing nations is generally related to lack of purchasing power rather than to insufficient supply.

A comprehensive government strategy to tackle food and nutrition problems should include health and environmental sanitation programmes geared to improving the use of consumed foods. These programmes can include primary health care activities, introduction of potable water, hygienic disposal of excrete and garbage, control of domestic animals, and adequate housing. All of these may substantially reduce the frequency and severity of prevailing infections. Therefore health programmes, by themselves, are likely to produce important improvements in child survival and better growth patterns [2], indicating improved nutritional status.

The prevailing low levels of income in rural areas of Central America result from the low cash-generating capacity of labourers (lack of employment and/or low wages) and the insufficient production of foods by subsistence farmers. Such situations preclude these persons from fulfilling their own and their families' energy and nutrient needs. Some of the strategies available to and exercised by governments of developing nations to improve the purchasing power of undernourished persons include generating labour opportunities for deprived areas, providing subsidized low-price shops, periodically revising and improving minimum wages, and providing supplementary feeding and other types of food distribution.

Analysis of food and nutrition conditions

Appropriate indicators to measure food and nutrition conditions have been the subject of various publications and controversies among nutritionists [3-6]. We have adopted the approach presented in table 1.

As can be seen, food balance sheets (column 1 ) are useful tools for measuring the national availability of foods (column 2), which is the result of all or some of the indicators listed in column 3. The indicators presented in column 3 should facilitate the identification of intervention programmes necessary to improve the particular problems.

Adequate or inadequate national availability of foods does not necessarily reflect the nutritional status of children in a given region, community, or family, however.

TABLE 1. The value of various data. instruments, and indicators in the analysis of food and nutrition situations

Source: Ref. 7.

In addition, the presence of a child with a low weight-for-age relationship may be the result of all or only one of the conditions listed in column 2. Thus table 1 confirms that the nature of and the solutions to food and nutrition problems are complex. The indicators measuring these problems and solutions should be carefully identified, classified, interpreted, and presented to political and technical decision-makers in order to ensure effective allocation of social government funds in developing nations.

Food and nutrition in Central Amarica and Panama

The information summarized in this section is derived from reports compiled in other papers prepared by the authors [8, 9]. It is important to point out that marked differences exist in the quality of data and in collection methods, and in the sample sizes and number of data sources. Therefore, the comparisons made on the food and nutrition conditions in different countries and those related to changes within countries over time should be interpreted cautiously. Differences between or within countries derived from these data sources should not be submitted to statistical tests of significance.

Factors predisposing to malnutrition

Low purchasing power

As mentioned previously, food and nutrition problems are in part due to low purchasing power. Table 2 summarizes, by country, information on the proportion of families whose income in 1979-1980 did not permit them to purchase the required amount of foods. In Costa Rica, the country with the least poverty in the Latin American isthmus, about one fourth of families are living in extreme poverty or in conditions that make it impossible to satisfy their basic needs. in Guatemala, Honduras, and El Salvador more than two-thirds of families do not generate enough income to satisfy their potential food needs.

TABLE 2. Families in different categories of poverty in Central America and Panama (%), 1979-1980

Source: Ref.9.

Limited access to health and nutrition services

A large segment of the population residing in Central America and Panama has a serious problem of access to health, nutrition, and other basic services. The mortality rates for infants (under one year old) and for children one to four years old are used here to reflect the access to and coverage of the health services in the six countries.

Tables 3 and 4 present figures, derived from official statistical reports, on changes in the mortality of infants and one- to four-year-olds from 1970 to 1977-1981. Table 5 shows the latest infant and child mortality figures reported by the countries in their National Child Survival and Development strategies [11]. The latter are more accurate (with less underestimation) than those in tables 3 and 4. Even if no changes occurred in the reporting system in the period under comparison, however, as is the case with the official statistics, they still are useful data for determining the extent of changes in mortality over periods of time.

As shown in these tables, Costa Rica and Panama have the lowest mortality figures. Guatemala has some of the highest infant and child mortality rates in Latin America. Tables 3 and 4 show important reductions in mortality during the 1970s in all the countries, even though in Costa Rica and Panama the figures were already low early in the decade. These changes reflect government efforts in the last 20 years to expand the coverage of health services to traditionally neglected areas. The infant mortality rates reported for 1982-1984 (table 5) ranged from 19 per 1,000 in Costa Rica to 102 per 1,000 in Honduras. The mortality of children one to four years old varied from 0.8 per 1,000 in Costa Rica to 15.5 per 1,000 in Guatemala. These figures reflect marked differences in the extent to which government policies in each country are geared to provide health and environmental sanitation services to the most deprived populations.

National availability of energy and proteins

Table 6 presents information from food balance sheets prepared in the late 1960s or early 1970s and in the late 1970s or early 1980s on the national availability of energy and proteins. For the more recent period, Panama (1979) and Costa Rica (1982) showed adequate mean availability of energy and proteins for their entire populations. In Honduras, Guatemala, and El Salvador, however, energy availability was below the mean energy requirement of 2,250 calories. No recent information from food balance sheets is available for Nicaragua.

TABLE 3. Infant mortality in Central America and Panama, 1970 and 1977-1981

Source: Ret.10.

TABLE 4. Mortality for children 1-4 years of age in Central America and Panama, 1970 and 1977-1981

Source: Ref.1 0.

TABLE 5. Mortality of infants (0-1 year) and pre-school children (1-4 years) in Central America and Panama (deaths per 1,000)

Source: Ref. 11.

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