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2
Famines:
The H istorica I Context
Famines get the spotlight. The television specials and the historical
controversies and the sad Irish songs are about famines. But famine is a fairly
smalJ part of the world food problem. lfthrough some magical intervention we
could end famines, we would stilJ have an enormous problem of widespread,
pervasive, and permanent undernutrition. Although most of this book is fo-
cused on this pervasive and permanent condition, this chapter discusses
famine.
In the popular press, the word famine is used to describe any newsworthy
food shortage. Here we reserve the term to refer to localized, temporary, and
severe food shortages. Famines are almost always the result of a confluence of
forces that include natural disaster and poor policy response. Of course, there
is a connection between the permanent state of widespread undernutrition and
the crisis of famine: in countries where undernutrition is a serious and com-
mon problem, it does not take much of a natural disaster to create a famine.
Brief descriptions of present and historical famines illustrate how natural
disasters and policy responses have interacted to create or exacerbate famines.
These examples also illustrate some of the ways that economists have studied
famines and policy approaches to famine.
7
8 The FactsAbout Malnutrition
200 I :2). Per capita income in Ireland in the early I 840s was only about 60 per-
cent of tbe level in Britain (Mokyr 1985).
Poverty was especially prevalent in rural areas. About two-thirds of the
Irish population depended On agriculture for their livelihoods (Kinealy
2002:18), and 40 percent of these were landless laborers (Donnelly 2001:9).
Much of the land in the Irish countryside was owned in large tracts by land-
lords. Landless laborers acquired plots of land from the landlord and in return
either worked in the landlord's fields (primarily growing grain or flax for linen
for export, Or producing butter for sale in urban areas) at paid a rent to the
landlord. A social structure that trapped Irish labor in the agricultural sector
caused labor productivity in that sector to be about half that of British agricul-
tural workers (Donnelly 200 1:9).
In this environment of poverty, a third of Irish households depended al-
most exclusively on potatoes for food (a farmer in pre-famine Ireland might
have consumed twelve Or more pounds of poratoes per day). Potatoes have a
number of advantages as a law-cost food source in Ireland: they can be grown
in relatively poor soil; they yield a high number of calories per acre; and they
are rich in protein, carbohydrates, vitamins, and minerals. A diet of potatoes
and bunermilk (a low-value by-product of producing butter) provides better
nutrition than a diet consisting primarily of wheat or maize.
Because of the potato-based diet, and despite the widespread poverty, "the
Irish poor were among the tallest, healthiest and most fertile population in Eu-
rope" (Kioealy 2002:32). (See Box 2.1 for a more general assessment of the
importance of the potato to European economic development.) The cheap and
nutritious potato diet served as a foundation for low-wage agriculture; cheap
food exported from Ireland in tum fueled the iodustrial revolution in Britain.
In addition, the low-wage labor provided a cushion protecting some landlords
from the consequences of their inefficient farming practices.
I Research by economists Nathan Nunn and Nancy Qian demonstrates the im-
portance of the potato in European development more generally: "[T]he intro-
duction oftbe potato was responsible ... for approximately one-quarter of the
growth in (European] population and urbanization between 1700 and 1900"
(2011: 593). Nunn and Qian are able to attribute causality because of geograph-
ical differences in the degree to which the potato was a suitable crop and be-
cause of differences in when the potato was introduced to different areas. (The
potato is a South American crop, unknown in Europe before Columbus's voy-
ages, and introduced Widely in Europe in the seventeenth and eighteenth cen-
turies.)
Il!:---=--~~ _
Famines: The Historical Context 9
The potato blight-s-a fungus that causes potatoes to tum black and rotten
as they grow in the ground-had appeared in small areas prior to 1845. But
the blight hit about half the crop in 1845, and destroyed nearly the entire crop
in 1846, 1848, and 1849 (the 1847 crop was partially successful). Estimates of
famine-related deaths range from 290,000 to 1,250,000 compared to Ireland's
pre-famine population of about 8 million (Johnston 2003).
Once the severity of the potato blight was understood, a tremendous
amount of attention was devoted to the appropriate "policy response": What
could or should the government do? Throughout the nineteenth century, Ire-
land was governed by Great Britain. The choices made by the British govern-
ment, and the criticisms of these choices, iIlustrate a philosophical or ideolog-
ical debate about the appropriate relationship between government action and
private action. The policy decisions fall into three categories (identified here
with today's nomenclature): technology policy-what the government should
do to encourage better scientific understanding of the causes and conse-
quences of the potato blight; trade policy-what the government should do to
increase food imports or reduce food exports during a time of famine; and
poverty alleviation policy-what the government should do to help the poor.
The British government recognized the possibility of ending the famine
with a technological fix, but its efforts never came to fruition. The government
instituted a board of scientific experts to draw conclusions about how to save
potatoes that had been infected by the blight. The board's recommendations
involved complex chemical procedures requiring materials and training un-
available to the starving Irish masses. Even if followed, the program promised
little hope of success. The government also appealed to the private sector by
promising to purchase and donate to all farmers any treatment that would kill
the blight. No successful antifimgal treatment was discovered until years after
the Irish famine.
Trade policy in the mid-nineteenth century was the subject of intense ide-
ological debate. The individuals in power during much of the famine were ar-
dent proponents of free trade, or laissez-faire-a policy of minimal govern-
ment intervention in markets. The Irish famine put pressure on both sides of
the debate over free trade. On the one hand, the famine provided the impetus
for repeal of the Com Laws that restricted imports of food into Ireland. On the
other hand, exports offood from Ireland continued. The rigidity ofthe position
in favor of free trade is reflected in an exchange between Randolph Routh, an
official in Ireland administering food distribution, and Charles Trevelyan, the
permanent head of the treasury for the British government (quoted in Donnelly
2001:69):
Routh: "I know there is great and serious objection to any interference
with these [food] exports, yet it is a most serious evil."
•v The FactsAbout Malnutrition
Trevelyan: ..\ e beg of you not to COuntenance in any way the idea of pro-
hibiting . ponation. The di Couragemem and feeling of insecurity to the
[grain] Irllde from such a proceeding would prevent its doing even any im-
mediare good; and there cannot be a doubt that it would inflict a perma-
nent injury On the country."
ars
m hol point 10 evidence of ubstantial reductions in grain exports
to n rude that "even if exports had been prohibited, Ireland lacked sufficient
food ... to lave off famine" (Gray 1982:46). Kinealy notes that exports of
ther food commodities remained high, and concludes: "The Irish poor did not
larve becau e there was an inadequate supply of food within the country, they
tarv d becau e political, cOmmercial, and individuaJ greed was given priority
ever thc saving of lives" (2002: 116).
If trade policy illu trates the role of ideology in policy, poverty assistance
Or relief policy illu trate the law of unintended consequences. Policies to help
the poor during the famine were under constant discussion and revision. The
government polieie included such aspects as:
The Cost of these programs was financed in large part through a tax on
Irish landlords. The amount of the tax depended on how many poor house-
holds Or tenants l.ived on the landlord's property. Landlords realized that they
could reduce their tax burden by eVicting tenants from their farms and destroy-
ing the tenant cottages. In this way, the policy intended to help the poor actu-
ally ended up separating many poor people from their shelter and from their
means of growing food.
Some of the better-off tenants Who lost their homes to eviction had suffi-
cient resources to emigrate to the Americas. During the 1840s, an estimated
1.3 million Irish people emigra.ted. The conditions of their voyages were
harsh: perhaps as many as 40 percent ofthe emigrants died during the passage
to the Americas (Abbot 2003).
Mike Davis (200 1), in his book on late-.Victorian era hoJocausts, de-
Famines: The Historical C,ontext 11
scribes a set of circumstances and ideologies that led to and exacerbated the
Bengal famine of the 1870s that are quite similar to those described here for
the Irish famine.
Stepan Schevchenko was a poor farmer ... like the rest of us [but different}
from us in only one way: he had categorically refused to join the collective
farm. He paid off all his taxes for the year 1932, and apparently thought that
the government would leave him alone .... But he was overly optimistic.
12 The Facts About Malnutrition
One day he received a requisition order demanding him to deliver 500 kilo-
grams of wheat to the state. He delivered it in full. But no sooner had he done
so when he received another order. This time they demanded twice as much
wheat, ... [even though] he had none left .... The officials ... threatened
him with Siberia, ... [and) he was forced to sell everything he had of value,
including his cow, to buy the order of wheat. ... He SOon received the inex-
orable third order: 2.000 kilograms of wheat immediately! ... The Bread
Procurement Commission paid him a visit. ... He and his family were or-
dered to leave their house .... All that belonged to the Shevchenkos was con-
fiscated and [became) "socialist property." (Dolor 1985:146)
The seizure of all available stocks of food in the Ukraine caused wide-
spread starvation among the very people who produced the food in the first
place. The most extreme famine conditions were suffered in the Ukraine for
several reasons: the more active resistance to collectivization in the Ukraine,
a nationalistic Or ethnic bias against Ukrainians on the part of the Russo-cen-
tric decisionmakers in Moscow, and a desire to hide evidence that the agricul-
tural collectivization experiment was less than perfectly successful.
An estimated 6-8 million Ukrainians died during the famine (of a pre-
famine population of about 34 million) (see Mace 1984:vi). This leads some
i great was the famine and poverty in Moscovia that even mothers ate their chil-
dren."
One of the changes that accompanied the Great Leap Forward campaign was a
change in the way group farms were organized. Economist Justin Yifu Lin
(1990) examined the details of farm organization and concludes that the changes
in the rules of these organizations contributed to the famine of 1959-1961.
After the revolution of 1949. many Chinese fanners voluntarily fanned co-
operatives of different types. In "mutual aid teams," a handful of neighboring
families would share tools and draft animals and would help on each other's
plots when needed. Each [ann household continued to own land, tools, and an-
imals; each family made its own decisions about which crops to plant; each fam-
ily received the output from its land for consumption or sale. In "elementary co-
operatives," twenty to thirty households agreed to combine into a single farm.
Here, each family continued to own land, tools, and animals, but the decisions
were communal, and output was shared. The sharing of output depended on how
much land, tools, and animals the household contributed to the cooperative, and
on how much work each household contributed. In "advanced cooperatives" the
cooperative itself owned the land, tools, and animals, and members shared in
output based solely on their labor contribution.
Each of these three kinds of organization provided an incentive for people
to work hard: the harder you work, the more you earn. Even in the most "com-
munal" of these organizations-advanced cooperatives-each farm household
received a bigger share of the commune's output if it contributed more labor.
What is more, Lin points out, the fact that membership was voluntary created an
additional reason for families not to be laggards. If one family became known
as a lazy household, the ether, hardworking households could form a new coop-
erative the following year, leaving out the lazy household. The initial collec-
tivization effort in China was quite successful; agricultural output increased 28
percent from 1952 to 1958.
J
, J
In 1958, the central government disbanded existing agricultural coopera-
tives and forced all fanners to join large communes of about 5,000 households
and 10,000 acres. As well as these communes being larger than previous coop-
eratives, the rules of organization were different in two important respects. First,
peasants were paid "based mainly on subsistence needs and only partly on
worked performed" (p. 1236). Second, membership in the communes was no
longer voluntary, and peasants were forbidden from withdrawing from the com-
mune. With this change, it became "impossible to use withdrawal [from the
commune J either as a way to protect oneself or as a means to check the possi-
bility of shirking by the other members .... Since supervision in agricultural
production is extremely difficult, . incentives to work in a compulsorily
formed ... collective must be low. A peasant will not work as hard as on the
household farm. Therefore the productivity level of a collective will be lower
than the level reached on the individual household farm" (p. 1242).
J
I Lin notes that the downturn in production coincided exactly with the adop-
II tion of these new rules for cooperatives. The rules were abandoned in 1961,
again coinciding exactly with the rebound in agricultural production.
Famines: The Historical Context 15
Jisbeng and Mao s Great Famine by Frank Dikotter) detail the hardship
brougbt about by famine conditions and the cruelty of local party leaders and
law enforcement officials. Yang Jisheng (2012) estimates 36 million died in
the famine; Dikotter (20 I 0) puts the number at 45 million.
Recent Famines
The famines described here were in a sense national problems. In none of the
cases was there much discussion about how the world community could or
should respond to the famine. More recent experiences with famine illustrate
an evolving internationalist perspective.
Previous editions of this book have included more extensive descriptions
of the famines in North Korea and Zimbabwe. Those countries continue to ap-
pear on lists of food-crisis countries. But the very fact that these countries have
been in crisis for a decade or more illustrates a difference between the famine
situations of today and those historical famines described earlier that have
lasted two or three years. Here, we condense our discussion of North Korea
and Zimbabwe (focusing on southern Africa in general in the latter case) and
begin with an added description of the situation in Sudan.
Sudan
A serious famine threat has arisen from the conflict in South Sudan. The con-
flict is both personal/political (the president of South Sudan in conflict with
his former deputy) and ethnic (the Dinka tribe in conflict with the Nuer
tribe). As one side of the conflict gains military advantage in an area, sup-
porters of the losing side become landless, homeless (and foodless) refugees,
with the conflict taking place against a background of extreme poverty and
food insecurity: people spend 80-85 percent of their income on food. The
food security situation depends on three factors: (I) the degree of economic
and geographical dislocation caused by the internal conflict, (2) local agri-
cultural conditions (weather, extreme events) that influence the size of the
locally produced food supply, and (3) policy-especially the size offood aid
deliveries to the region.
In early 2015, the Food and Agriculture Organization (FAD) of the United
Nations estimated that more than 1.3 million people had been forced out of their
homes by the fighting. Three and a half million people--40 percent of the Su-
danese population-are in need of emergency food aid. The armed conflict also
reduces crop production by making it impossible for fanners to keep to a regular
schedule of planting, weeding, and harvesting. Farm animals are killed or stolen,
or weakened by forced movement away from conflict zones (see FAD 2015b).
The root cause ofthe Sudanese famine is the internal political conflict. Ef-
forts at peacekeeping have led to the signing of a series of ceasefire agree-
ments, going back as far as 2005, but these agreements have not been effective
in ending the conflict.
16 The FactsAbout Malnutrition
The United Nations has been active in trying to force the parties to find a
more permanent end to the hostilities, and has in the interim been coordinating
outside assistance to shelter refugees and provide food aid. Between January
2015 and June 2015, the World Food Programme (WFP) of the United Nations
distributed 178,000 metric tons of food and $31 million in cash vouchers in
southern Sudan. The WFP acts as the coordinating agency, with funds from
donor countries such as the United States, the European Union, and Japan. But
the conditions of war have made it difficult to move food aid to the areas of
greatest need.
North Korea
Since the 1990s, North Korea (the Democratic People's Republic of Korea)
has suffered from famine conditions of varying intensity. The roots of this
famine are found in the Cold War. During the Cold War, North Korea was
closely allied with the Soviet Union and China, often playing one of those su-
perpowers off against the other to get increased aid. With the breakup of the
Soviet Union and the end of the Cold War, this aid dried up. Not only did food
donations dwindle but domestic agriculture in North Korea, which had been
designed to utilize subsidized imports of energy and fertilizer, now required
radical restructuring. Drought struck in 1995, and an estimated 2-3 million
people (about 10 percent of the population) died from famine-related illness in
the 1994--1998 period.
The response of the government undoubtedly made things worse. Prior
to the famine, nearly all grain in North Korea was produced on state or com-
munal farms. The workers on these farms were given a grain ration out of
the barvest that was nutritionally sufficient. As grain yields began to fall be-
cause of poor weather and insufficient inputs, the central government cut
peasant worker rations by over a third. The intention was to preserve more
of the grain harvest for shipment to hungry urban areas. The unintended im-
pact was to reduce tbe grain harvest even further, for two reasons (Natsios
1999). First, farm workers secretly "preharvested"-taking grain out of the
communal fields before it was ready for harvest-and hid the grain for their
Own consumption. Because the grain was harvested before it was fully ripe,
the grain yield was lower than it would have been if harvested according to
plan. Second, farmers diverted effort from communal fields to legal and il-
legal private plots. These private plots were often in poor terrain and so the
yields were lower than on the collective farms, but the output did not have
to be shared.
The international response to the famine was substantial. Shipments from
'I
"
all sources averaged over 1 million metric tons per year from 1995 to 1998
(Natsios 1999). (To put this in context, the World Food Programme estimated
that in 2001, North Korea would produce 3 million metric tons of food, but
would require 4.8 million metric tons to feed its population [Struck 200IJ.)
Famines: The Historical Context 17
Reliance on food donations from abroad has created pressure on the North Ko-
reans to bring their foreign affairs and military policies into conformance with
demands by countries making the food donations. For example, in 2002 the
United States suspended food aid to North Korea (see Dao 2003). Observers
suspected that the suspension was a reaction to North Korea's refusal to halt
its nuclear weapons program, although US officials denied that this was the
reason. Support for aid to North Korea was also undermined by reports of cor-
ruption in the aid distribution system and fears that the aid was not helping
those most in need. (For more detailed accounts of the continuing North Ko-
rean food crisis, see Natsios 2001 and Haggard and Noland 2007.) The New
Yorker magazine ran an article describing the life of one woman's suffering
and escape from the North Korean famine (Demick 2009).
Southern Africa
International response also played a major role in ameliorating the impacts of
faunine conditions in southern Africa in the years 2002-2003. By June 2002, it
was obvious that poor weather conditions (a drought followed by heavy rains
during the harvest season) would devastate crop production in a large part of
southeastern Africa, affecting Zimbabwe, Zambia, Lesotho, Malawi, Mozam-
bique, and Swaziland.
The situation in Zambia was one of unusually poor weather occurring in
an extremely poor country where much of the population suffers from under-
nutrition during "normal" or nonfamine times. Production of Zambia's staple
crop--maize-fell in 2002 to a level about half that of the average output over
the previous four years. Between mid-2002 and early 2003, the World Food
Prograrnme directed shipments of 130,000 metric tons of food to Zambia,
helping to feed 1.7 million people. The weather conditions improved consid-
erably for the 2003 crop, with maize production double that of 2002. Zambia
faces ongoing problems of poverty, AIDS, and undernutrition, but the acute
crisis of the 2002 famine has ebbed.
The weather situation in 2001-2002 in Zimbabwe was similar to that in
Zambia. But in Zimbabwe food output was suppressed further by a govern-
ment program to redistribute agricultural land. During Zimbabwe's period as
a colony of Britain (when it was known as Southern Rhodesia), prime agricul-
turalland along the railway line was given over to white commercial fanners.
After independence in 1980, these farmers continued to farm the land, but the
government was under increasing pressure from its supporters to seize the
white-owned land and distribnte it to indigenous supporters ofthe ruling party.
The land redistribution proceeded slowly from 1980 to 1998, but then ac-
celerated. In addition to a formal process of government purchases of white-
owned farms, an extra-legal process offann invasions forced white fanners to
give up their farms. The area planted with maize on large commercial farms
fell from 163,000'hectares in 1998 to 61,000 hectares in 2000. Much of the
..
18 The Facts About Malnutrition
land remained in Cultivation in smaller parcels by the recipients of the land re-
form, but yield dropped precipitously. Zimbabwe's cereal production in 2002
wa Ie than one-quarter of the peak production of 1996.
The Zimbabwean government purchased substantial amounts of food, but
additional help was needed from the international community. The ruthless-
ne of the land reform activities and the impression that the Zimbabwean
g vcmment wa turning a blind eye to lawless farm invasions created a reluc-
tan e On the pan of developed-country donors to provide assistance. Ulti-
mate/yo the World Food Programme did make substantial amounts of food aid
vailable (in 2002-2003 arnounting to about 500,000 metric tons of food).
H we cr, a of the summer of 2003 nearly half of Zimbabwe's population
c nrinucd 10 face the specter of famine.
Over U1Cnext five years, little changed. The actions of the Zimbabwean
leadership were widely condemned (Lynch 2008). Rural violence and land
cizurc continued (Dixon 2008). Price controls kept farm prices low, discour-
aging f od production (Lynch 2008). Annual maize production in the five
years prior to 199 was about 2 million metric tonnes; in the most recent five-
year period, it wa about half that amount. In 2015 the FAO's famine early
warning ystern projected that 16 percent of the rural population of Zimbabwe
\\ ould uffer from food insecurity during the "peak lean" season of January to
'larch 2016 (FEWS 2015).
***
In Haiti we had ... a problem of theft and mishandling. In [a] town ... fairly
near to us and very badly hit by drought, the magistrate [appointed mayor]
was known to sell PL480 [international relief] food for $7.00 a 50 pound bag.
At other times the CARE food distributors were so desperate that they would
just throw bags of food off the truck and drive on, so that the food would go
to the strong and the swift. (Jackson and Eade 1982;9)
When disaster has created the need for assistance, but the local food sup-
plies are adequate, supplying emergency food relief can be counterproductive.
It depresses the local price of food, in tum depressing the income of the local
fanning community, and may lead to other socially undesirable results (see
Box 2.4).
In areas where food aid has become a yearly occurrence, food aid "depen-
dency" can develop. Thielke (2006) describes the situation in Kenya:
Imported food may not be necessary at all, despite a major disaster, and its ar-
rival may do more harm than good. The classic example of this comes from
Guatemala where the earthquake in 1976 killed an estimated 23,000 people, in-
jured over three times as many and left a million and a quarter homeless. The
earthquake occurred in the middJe of a record harvest. Local grain was plentiful
and the crops were not destroyed but left. standing in the fields or buried under
the rubble but easy to recover.
During the first few weeks, small consumer items-salt, sugar, soap, etc.c-.
were in shon supply and temporarily unavailable in the shops. Some of these
small items, such as salt, were lost when the houses collapsed. People expressed
a need for these food items in the short period before commercial supplies were
resumed. However, during that year, about 25,400 tons of basic grains and
blends were brought in as food aid from the US. A further 5,000 tons of US food
aid already stored in Guatemala were released and suppLies were also sent in
from elsewhere in the region.
Catholic Relief Services (CRS) ... field staff objected to the importing of
food aid but they were overruled by their headquarters in New York .... The Co-
ordinator of tbe National Emergency Committee of the Government of
Guatemala asked voluntary agencies to stop imports of food aid ....
Finally, the Government of Guatemala invoked a presidential decree to
prohibit imports of basic grains from May 1976 onwards. Yet after this decree,
quantities of food aid were still imported in the form of blended foodstuffs. One
article refers to these blends as "basic grains in disguise."
Field staff and local leaders identified three negative results. Firstly, they
considered that food aid contributed to a drop in the price of local grain that oc-
curred soon after the earthquake and continued throughout 1976. As to the need
for basic grains, a peasant fanner explained: 'There was no shortage. There was
no need to bring food from outside. On the contrary, our problem was to sell
what we had." ...
An OXFAM-World Neighbors official reported: "Virtually everyone in the
area is selling more grain this year than he does normally. Furthermore, emer-
gency food shipments have drastically curtailed demand for grains. Thus the
prices of the farmers' produce have plummeted."
Later, the then Director of CRS in Guatemala was to tell the New York
Times: "The general effect was that we knocked the bottom out of the grain mar-
ket in the country for nine to twelve months ....
The second negative effect of the continuing supply of free food was to en-
courage the survivors to queue for rations instead of engaging in reconstruction
or normal agricultural work.
Thirdly, it brought about a change in the quality and motivation of local
It::adership. The OXFAM-World Neighbors official, quoted above, noted:
began seeing fellas who Iknew were totally dishonest. They'd go into
the different agencies and. . say that theirs was the most affected vil-
lage in the Highlands, and they'd get more food. So largely because
of the give-aways, the villages started to tum more to leaders who
could produce free things like this, whether they were honest or dis-
honest, rather than to the leaders they'd been putting their trust in for
years. .
With larger and larger quantities of free food coming in, there are
increased incentives to corruption. . Groups that had worked to-
gether previously became enemies over the question of recipients for
free food.
mer health commissioner explains:] "There are more and more people and
there is less and less water .... The desert is expanding In the past people
slaughtered their animals for food during difficult times But ever since
the World Food Program began feeding us, hardly anyone does this anymore.
Everyone just waits for the next delivery."
• Small-scale fanners or tenants whose crops bave failed and who cannot
lind other employment in agriculture (the Wollo in Ethiopia in 1973).
• Landless agricultural workers who lose their jobs when agricultural pro-
duction declines (Bangladesh in 1974) or who face rapidly rising food
prices and constant or declining wages (the great Bengal famine of
1943).
• Other rural people, including beggars who are affected by a decline in
real income in the famine regions (almost all famines).
22 The Facts About Malnutrition
Thousands of Number of
Deaths from Deaths per
Famine 100,000 Population
1900-1910 541 3
1910-1920 162 9
1920-1930 16,280 814
1930-1940 7,200 343
1940-1950 9.400 409
1950-1960 15.950 578
1960-1970 16.650 500
1970-1980 3.820 94
1980-1990 1.400 29
1990-2000 4,820 84
2000-2010 200 3
Source: The Economist 2013b .
• Pastoralists who get most of their food hy trading animals for food
grains; their herds may he ravaged by the drought, or animal prices may
collapse relative to food-grain prices (the Harerghe region of Ethiopia in
1974 and the drought-stricken Sahel in 1973).
more effective relief than the usual pnlicy of importing and distributing
food" (p. 1230) .
• Stabilization policies. "An effective but affordable ... stabilization pol-
icy in famine-prone economies ... will probably combine buffer stocks
and ... a relatively open external trade regime" (p. 1233). Buffer stocks
are programs in which the government purchases food in periods when
it is plentiful and sells food out of their stocks when shortages occur .
• Other policies. Ravallion argues that there are potential synergies be-
tween policies to address famines and other policies to spur economic
development, including credit programs, improved infrastructure, and
assignment of prnperty rights.
Overnutrition
When a person consumes too many calories, the resulting condition is called
overnutrition. Overnutrition is the most common nutritional problem in high-
income countries such as the United States, although high-income people in
low-income countries also suffer from this type of malnutrition. The diet of the
world's high-income people is usually overladen with calories, saturated fats,
salt, and sugar. Their diet-related illnesses include obesity, diabetes, hyperten-
sion, and atherosclerosis. Overnutrition is a serious problem. For example,
Martorell (200 I) reports research showing that in Latin America, 35 percent of
women age fifteen to nineteen are either overweight or obese. Another report
shows that the percentage of the Chinese population who are obese rose from
16.4 percent in 1992 to 22.6 percent in 2002 (Luo, Mu, and Zhaog 2006). The
problem of overnutrition in the developing world is being addressed through
an international effort coordinated by the World Health Organization (WHO
2002). The WHO (20 15b) estimates that in 2014, 39 percent of adults world-
wide were overweight, and 13 percent were obese.
This book will have relatively little to say about the problem of overnu-
trition. It is an important and serious public health problem, but it is not the
subject of this book. Here we will be concerned with problems that are prima-
25
26 The FactsAbout Ma/nutrition
Secondary Malnutrition
When a person has a condition or illness that prevents proper digestion or ab-
sorption of food, that person suffers what is called secondary malnutrition. It
is called "secondary" because it does not result directly from the nature of the
diet, as do the other types of malnutrition, which are termed "primary." Com-
mon causes of secondary malnutrition are diarrhea, respiratory illnesses,
measles, and intestinal parasites. The following mechanisms cause secondary
malnutrition:
The World Bank estimated in 1994 that it would cost about $3 per year to
meet a person's entire needs for vitamin A, iron, and iodine. (Other rnicronu-
trients are not so inexpensive: an antioxidant formula of vitamin E, beta-
carotene, and vitamin C may cost $60 per person per year.)
Despite the apparently easy solution to these vitamin and mineral defi-
ciencies, the problems have remained surprisingly persistent, though progress
is being made. For iodine: "Out of ... 130 countries ... there are only 47
countries where [deficiency] still remains as a public bealth problem [in 2006],
compared to 54 in 2004 and 126 in 1993" (WHO 2007: 14). By 2011, tbe num-
ber of countries had fallen further to 32 (UNICEF 20 13:24). ln 2002, under the
multinational Micronutrient Initiative 300 million children under the age of
five were given a high-dose vitamin A supplement. The United Nations Chil-
dren's Fund (UNICEF 2007:9) reports that the proportion of children receiv-
Defining Malnutrition 29
ing the full (two-doses per year) treatment for vitamin A deficiency increased
from 16 percent in 1999 to 72 percent in 2005. By 2011 the proportion had in-
creased to 75 percent, and to 82 percent in the least developed countries.
(UNICEF 2013:23). According to the World Health Organization's most re-
cent estimates, anemia affects about 25 percent of the world's population,
compared to 37 percent of the world's population in the early 1990s, although
it still affects almost 50 percent of preschool-aged children and 40 percent of
pregnant women (WHO 2001, 2008). By 20 II, slight progress was reported,
with 47 percent of preschool-aged children and 42 percent of pregnant womeo
suffering from anaemia (UNICEF 2013:23).
Policies to reduce micronutrient malnutrition will continue to be impor-
tant because of the huge impact on public health that relatively small expendi-
tures can have. As we shall see in the next chapter, the health impacts of mi-
cronutrient deficiencies arc significant. However, the solutions to these
deficiencies are more likely to come from fortification programs, supplemen-
tation, and research into biofortification such as the efforts described earlier,
and less likely to come from additional food consumption and production.
Protein-Calorie Malnutrition
The underconsumption of calories or protein-known as protein-calorie mal-
nutrition (PCM) or protein-energy malnutrition (PEM}--is a problem that can
he solved only by increasing the amount of food that an individual eats. A per-
son suffering from PCM is not obtaining enough of the protein or calories
needed for normal growtb, health, and activity. PCM hardly ever occurs in
families with enough income to satisfy their basic needs for food, shelter,
clothing, and beat; it is found predominantly in low-income countries where
poverty is widespread.
In extreme fonms, PCM manifests itself as the potentially fatal nutritional
disorders known as kwashiorkor and marasmus. Kwashiorkor results from
protein deficiency, usually as the child is weaned from breast milk, which pro-
vides adequate protein to newborns. In fact, kwashiorkor is a Ghanaian word
meaning "the evil spirit which infects the first child when the second child is
bam." Children with kwashiorkor exhibit swollen bellies, or edema, and de-
pigmentation of hair (black hair turns a reddish hue). Marasmus is a condition
of both protein and calorie deficiency. The tenm derives from a Greek word
meaning "wasting away," and the physical effects are just that-low body
weight, or emaciation. One observer described children with marasmus as
"wizened little old people ... ,just skin and bones" (Whitney and Hamilton
1990). As daily food intake is inadequate to meet requirements for protein and
calories, the body begins to use reserves stored in the fat cells. As those re-
serves are used up, the person enters the end stages of starvation, a condition
known as catabolysis (Zeigler 2012:343-345).
30 The FactsAbout Malnutrition
o Mental activity.
o Fighting disease.
• Growth.
The human body makes the millions of differeot proteins that it needs
from some twenty amino acids, which are the building blocks of the body's
proteins. Proteins function in ways other than providing a source of calories:
• They are necessary for building the cells that make up muscles, mem-
branes, cartilage, and hair.
• They carry oxygen throughout the body.
• They carry nutrients into and out of cells and help assimilate food.
o They contribute to the development of antibodies that fight disease.
• They work as enzymes that speed up the digestive process.
Simple organisms such as yeasts and algae can synthesize almost all of
the amino acids they need. But humans cannot synthesize or make sufficient
quantities of some amino acids. To live, therefore, we must consume enough
essential amino acids (those that the body cannot produce in sufficient quan-
tities). Of the approximately twenty amino acids needed, nine are essential.
Because the body cannot manufacture them, we must consume them as part of
our diets. All of these amino acids are found in eggs, ntilk, and meat-proteins
from these dietary sources that contain all the essent.ial amino acids are re-
ferred to as complete proteins.
Proteins from vegetahle sources tend to he deficient in at least one of the
essential amino acids and are therefore "incomplete. To understand the im-
H
Defining Malnutrition 31
In physics, chemistry, and engineering, a calorie is the amount of heat energy re-
quired at sea level to raise the temperature of I gram of water by I degree centi-
grade. A kilocalorie (abbreviated Kcal) is the energy it takes at sea level to raise
the temperature of 1,000 grams of water (a kilogram-also a liter) by 1 degree
centigrade.
Nutritionists always quote their data in kilocalories, but unfortunately they
commonly shorten the word to "Calories"--capitaJized to indicate kilocalories
as distinguished from calories. But the convention is not always observed. Re-
gardless, in nutrition literature the lowercased word calorie usually means kilo-
calorie.
portance of this for diet, we need to understand the way that the human body
takes the amino acids from protein in food and constructs protein for the
body's use. Protein molecules in food are composed of fixed proportions of
amino acids. A balanced protein is one in which the essential amino acids ap-
pear in the same ratio to each other as the body needs them for constructing its
protein molecuJes. (Information about dietary reference intakes for essential
amino acids can be found in National Academy of Science 2002:10-65-10-
66).
If you consume more amino acids than you need, your body cannot use
them for making proteins; instead, it bums the amino acids for energy. [f you
consume less of an amino acid than you need, a portion of other amino acids
goes to waste for want of the "matching" part needed to manufacture protein
molecules. Whitney and Hamilton provide a delightful analogy:
Suppose that a signmaker plans to make 100 identical signs, each saying left
turn onJy. He needs 200 L's, 200 N's, 200 T's and 100 each of the other let-
ters. If he has only 20 L's, he can make only 10 signs, even if all the other ler-
rers are available in unlimited quantities. The L's limit the number of signs
that can be made. The quality of dietary protein depends first on whether or
DOl the protein supplies all tbe essentiaJ amino acids, and second on the ex-
tent to which it supplies them in the relative proportions needed. (1990:92)