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2012-02-23 07:12:57
Why do so many people in poor countries eat so badly and what can be done about
it?
Feb 18th 2012 | ROME AND S O PAULO | from the print edition
IN ELDORADO, one of S o Paulo s poorest and most misleadingly named favelas,
some eight-year-old boys are playing football on a patch of ground once better
known for drug gangs and hunger. Although they look the picture of health, they
are not. After the match they gather around a sack of bananas beside the pitch.
At school, the kids get a full meal every day, explains Jonathan Hannay, the
secretary-general of Children at Risk Foundation, a local charity. But in the
holidays they come to us without breakfast or lunch so we give them bananas.
They are filling, cheap, and they stimulate the brain. Malnutrition used to be
pervasive and invisible in Eldorado. Now there is less of it and, equally
important, it is no longer hidden. It has become more visible so people are
doing something about it.
If Eldorado s slum children today eat better, it is partly thanks to Jos
Graziano da Silva. He ran Brazil s Fome Zero (zero hunger) campaign, a policy
that has helped to cut hunger by more than a third in Latin America s largest
country. Now Mr Graziano wants to apply the lessons he has learned more widely:
he recently took over as head of the United Nations Food and Agriculture
Organisation (FAO). And he stands a better chance of success than his
predecessors. His appointment coincides with a shift in the world s approach to
fighting hunger.
Governments around the world are paying increasing attention to nutrition. In
2010 donors, charities and companies drew up a how-to policy guide called SUN
(which stands for scale up nutrition). Britain s Department for International
Development and other aid agencies are devoting more of their money to
nutritional projects. The World Bank has nailed its colours to the mast with a
book called Repositioning Nutrition as Central to Development . Save the
Children, an international charity, talks about galvanising political
leadership behind the effort. Underlying all this is a change in thinking
about how best to improve nutrition, with less stress on providing extra
calories and food and more on improving nutrition by supplying micro-nutrients
such as iron and vitamins.
A damning record
In the 1960s and 1970s, ending hunger and malnutrition seemed relatively
simple: you grew more crops. If the harvest failed, rich countries sent food
aid. But the Ethiopian famine of 1984 undermined this approach. Here was a
disaster of biblical proportions in a country where food was available. It was
a reminder of what an Indian economist, Amartya Sen, had long taught: what
really matters with food is not the overall supply, but individual access.
So in the 1990s and early 2000s the emphasis switched to helping people obtain
food. This meant reducing poverty and making agricultural markets more
efficient. Between 1990 and 2005 the number of people living on less than $1 a
day in poor countries (at 2005 purchasing-power parity) fell by a third to
879m, or from 24.9% of the total population to 18.6%.
Yet the food-price spike of 2007-08 showed that this approach also had
limitations. Prices of many staple crops doubled in a year; millions went
hungry. The world remains bad at fighting hunger. Experts argue about exactly
how many people are affected, but the number has probably held flat at just
below 1 billion since 1990.
Even where there is enough food, people do not seem healthier. On top of 1
billion without enough calories, another 1 billion are malnourished in the
sense that they lack micro-nutrients (this is often called hidden hunger ).
And a further 1 billion are malnourished in the sense that they eat too much
and are obese. It is a damning record: out of the world population of 7
billion, 3 billion eat too little, too unhealthily, or too much.
Malnutrition is attracting attention now because the damage it does has only
recently begun to sink in. The misery of lacking calories bloated bellies,
wasted limbs, the lethargy of famine is easy to spot. So are the disastrous
effects of obesity. By contrast, the ravages of inadequate nutrition are
veiled, but no less dreadful.
More than 160m children in developing countries suffer from a lack of vitamin
A; 1m die because they have weak immune systems and 500,000 go blind each year.
Iron deficiency causes anaemia, which affects almost half of poor-country
children and over 500m women, killing more than 60,000 of them each year in
pregnancy. Iodine deficiency easily cured by adding the stuff to salt causes
18m babies each year to be born with mental impairments.
Malnutrition is associated with over a third of children s deaths and is the
single most important risk factor in many diseases (see chart). A third of all
children in the world are underweight or stunted (too short for their age), the
classic symptoms of malnourishment.
The damage malnutrition does in the first 1,000 days of life is also
irreversible. According to research published in The Lancet, a medical journal,
malnourished children are less likely (all things being equal) to go to school,
less likely to stay there, and more likely to struggle academically. They earn
less than their better-fed peers over their lifetimes, marry poorer spouses and
die earlier.
Paradoxically, malnutrition can also cause obesity later in life. In the womb
and during the first couple of years, the body adjusts to a poor diet by
squirrelling away whatever it can as fat (an energy reserve). It never loses
its acquired metabolism. This explains the astronomical obesity rates in
countries that have switched from poor to middle-income status. In Mexico, for
instance, obesity was almost unknown in 1980. Now 30% of Mexican adults are
clinically obese and 70% are overweight. These are among the highest rates in
the world, almost as bad as in America. India has an obesity epidemic in
cities, as people eat more processed food and adopt more sedentary lifestyles.
And with obesity will come new diseases such as diabetes and heart disease as
if India did not have enough diseases to worry about.
Nutrition is also attracting attention because of some puzzling failures. In a
few big countries, notably India and Egypt, malnutrition is much higher than
either economic growth or improvements in farming would suggest it should be.
India s income per head grew more than fourfold between 1990 and 2010; yet the
proportion of underweight children fell by only around a quarter. By contrast,
Bangladesh is half as rich as India and its income per head rose only threefold
during the same period; yet its share of underweight children dropped by a
third and is now below India s. Egypt s agricultural value-added per person
rose more than 20% in 1990-2007. Yet both malnutrition and obesity rose an
extremely unusual combination.
The good news is that better nutrition can be a stunningly good investment.
Fixing micro-nutrient deficiencies is cheap. Vitamin supplements cost next to
nothing and bring lifelong benefits. Every dollar spent promoting breastfeeding
in hospitals yields returns of between $5-67. And every dollar spent giving
pregnant women extra iron generates between $6-14. Nothing else in development
policy has such high returns on investment. In 2008, as part of a project
called the Copenhagen consensus, eight prize-winning economists listed the
projects they thought would do most good (they had an imaginary $75 billion to
spend). Half their proposed projects involved nutrition.
If malnutrition does so much damage and the actions against it are cheap and
effective, why is the affliction only now being taken seriously? Some countries
have successfully tackled it. Brazil cut the number of underweight people by
0.7% a year between 1986 and 1996 and reduced stunting by 1.9% a year.
Bangladesh reduced both rates by 2% a year in 1994-2005.
But in many countries the problem of hidden hunger is hidden from victims
themselves, so there is no pressure for change. If everyone in a village is
undernourished, poor nutrition becomes the norm and everyone accepts it. This
may also explain the reluctance of poor, ill-fed people to spend extra money on
food, preferring instead to buy such things as televisions or a fancy wedding.
When asked about his spending choices, an ill-fed Moroccan farmer told Abhijit
Banerjee and Esther Duflo of the Poverty Action Laboratory, a think-tank: Oh,
but television is more important than food.
Education can help change attitudes by persuading people they would benefit
from a better (if more expensive) diet. But people in rich countries consume
vast quantities of junk food knowing full well that it is bad for them. It is
unrealistic to expect consumers in poor countries to behave differently. Hence
the idea of doing good by stealth.
Just push all the buttons at once
HarvestPlus, a research group, breeds staple crops with extra nutrients and
distributes the bio-fortified seeds. It released a vitamin A-rich cassava in
Nigeria in 2011. This year it will bring vitamin A-rich maize (corn) to Zambia
and iron-rich beans and pearl millet to Rwanda and India. Companies do
something similar with processed foods: Kraft s Biskuat biscuits (sold in
Indonesia) have nine vitamins and six minerals added.
But education or fortified foods alone will not overcome the most intractable
barrier to better nutrition, which is the sheer complexity of the task. Some
problems of development are relatively straightforward. You can improve
education by building schools and paying teachers. Nutrition is not like that.
In many countries nutritional standards vary according to the season. Often
both the amount and quality of food drop alarmingly in the months before the
main harvest. Nutrition varies also within households. Mothers eat less in bad
times to leave more for their older children, which harms the suckling child.
Culture adds to the problem. In rural Bangladesh an attempt to improve
nutrition by educating young mothers backfired, because the family diet turns
out to be determined not by mothers, but by mothers-in-law.
And nutrition can also be improved in all sorts of ways, including by better
sanitation, which reduces intestinal diseases and enables people to absorb more
nutrients; by investing in smallholder farming, to increase dietary variety; by
vaccinating children against diseases; by educating women to breastfeed babies
for longer, to improve immunity. Marie Ruel, of the International Food Policy
Research Institute in Washington, DC, ticks off some of the tasks: focus on the
first 1,000 days of life (including pregnancy); scale up maternal-health
programmes and the teaching of good feeding practices; concentrate on the poor;
measure and monitor the problem.
All this implies that a successful effort to improve nutrition has to push all
the buttons at once. Brazil s Fome Zero has 90 separate programmes run by 19
ministries. It embraces everything from a conditional cash-transfer scheme,
called Bolsa Fam lia, to irrigation projects and help for smallholders. Such an
effort is hard to organise and cannot work unless politicians support it.
Malnutrition reduction needs powerful champions who know how to get things done
across government, avoid gobbledygook and finish the story, says Lawrence
Haddad, director of Britain s Institute of Development Studies.
Let them eat mangoes
Hence the importance of Mr Graziano, the FAO s new boss. Interest in improving
nutrition is growing; so is alarm at the failures of fighting malnutrition so
far. He will not find it easy to cajole more countries into a large,
broad-based effort. Governments are reluctant to change and want clear
evidence. And just as the damage from malnutrition builds up over a lifetime,
so better nutrition reveals its benefits only over many years, as well-fed
mothers pass on good health to well-fed children.
At a recent FAO conference someone was heard to remark that at the moment
nutritionists are in a position similar to environmentalists in the 1990s.
That is depressing, because it means progress will be slow; but it is
encouraging, because progress will come eventually.
from the print edition | International