It is impossible to measure accurately the number of malnourished people in the world's developing countries, where nutritional problems are most prevalent. Counting households that are malnourished in a society on the basis of their average intake of protein, calories, vitamins, and minerals is difficult enough; measuring differences in food access by members of a hungry family is even more so.
Estimates of the Number of Malnourished People
The most recent estimate of the number of people that over a period of a year do not have access to enough food to meet their energy needs was published in a 1992 joint report by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO). It estimated that 786 million people had a chronic dietary energy deficiency in 1988-90. This is the equivalent of 20 percent of the total population of developing countries.
However, the actual number of undernourished people is likely to be higher, because this estimate does not take into account (1) problems of intrahousehold food distribution, (2) people facing seasonal or acute problems of malnutrition, or (3) those with infections.
The above estimate is based on the minimum energy requirement level for adults and adolescents doing light activity, expressed as 1.54 times the basal metabolic rate (BMR), a common physiological measure of energy consumed by the human body in a fasting state and at complete rest.
Another recent study by the International Food Policy Research Institute (IFPRI) estimated that in developing countries outside of China, 595 million people are calorie-deficient. The Chinese, though poor, are generally seen as being better nourished than many developing-country populations. However, no accurate nationwide data are available for China.
Other figures give a general idea of the nutritional deficiencies prevalent in developing countries. The United Nations recently estimated that some 150 million children are underweight, about half a billion women are anemic due to iron deficiency, about 20 million low birth weight infants are born each year, some 40 million children are afflicted with vitamin A deficiency, and over a billion people are deficient in iodine.
Where the Malnourished Are Located
Despite the wide margin of potential error in the aggregate figures, it is clear that the nutritional situation varies greatly from one country to the next, and can change favorably or unfavorably over time. For example, in China a major surge in aggregate food availability and consumption levels occurred during the 1970's and early 1980's. This coincided with the initiation of agricultural reforms and resulting increases in food production. Estimates of China's food-deficient poor in the early 1980's range from 70 to 100 million, or less than 10 percent of the population. In Africa, on the other hand, some countries lost ground in their struggle to provide their people with access to adequate food. In Rwanda, a recent estimate was that aggregate calories available per capita per day fell from 2,034 in 1986 to 1,866 in 1987 and 1,822 in 1988. These figures imply a significant increase in the numbers of malnourished people in a relatively short time.
In locating the malnourished, one cannot rely on national data on aggregate food supplies or calories supplied per capita to give an accurate picture. Even when food production and imports in a country are fairly accurately known and the country's population is known within some acceptable margin of error, we are still not likely to have an accurate idea of how well nourished its people are.
We generally have limited knowledge of how these calorie supplies are distributed within the country. The sheer magnitude of the task of moving food from food-surplus areas to food-deficit areas, where presumably it will be available to feed hungry people, is usually sufficient to skew actual distribution patterns considerably. There have been a few cases where countries have followed policies of continuing to export food when some of their own people are starving, as Sudan exported sorghum during the 1984 famine. Uneven distributions of available food tend to result from uneven distribution of income.
Data collected at the household level are really essential to understanding the distribution of malnourished people in a developing country and seeing beneath the national aggregates. The simplest way to collect such data in rural areas is to include questions about the adequacy of the household's food production in an ongoing household survey. Whelan has suggested using the subsistence potential ratio (SPR) as a cost-effective indicator of nutrition. The SPR is a ratio of the energy or protein value of the household's food production over a year to the household's energy or protein requirements over the year. Data on production and household composition suffice to calculate this SPR ratio. Whelan calls the SPR a better proxy for nutritional status than household income.
The most accurate guide to locating the malnourished, however, comes from nutrition surveys in which anthropomorphic measures are used to identify malnutrition. Aside from being recent, the surveys claim to be nationally representative (with the few indicated exceptions), and have been verified for reliability in terms of information provided on sample size, ages, and nutrition standards used. Regional averages have been calculated for the countries surveyed by using a weighting scheme based on the country population in the year of the reported survey.
Asia is the region with the largest malnutrition problem, both in terms of the percentage of its population that is malnourished and in terms of absolute numbers. Of the eight countries in Asia with national surveys reported, seven had rates of protein-energy malnutrition in excess of 35 percent at the time of the survey, and four had ratios in excess of 50 percent. These are extremely high rates. (Data were not presented on China because no nationally representative data are available that can be interpreted according to international norms.)
Ranking second in regional malnutrition levels is sub-Saharan Africa, but with country rates that are considerably below those found in Asia. Only one surveyed country, Niger, had a rate equal to the Asian regional average.
Following closely behind sub-Saharan Africa is the Middle East/North Africa region. Egypt, with a relatively low rate of 13.3 percent malnutrition, is a large recipient of food aid and the government subsidizes food prices. Kuwait, while producing little of its own food, is one of the richest countries in the world.
In Latin America, percentages of malnutrition levels fall to single digits in several countries. Only one country surveyed, Guatemala, had a rate above 25 percent.
Who Are the Malnourished?
Within the same country, and even within the same village, people have different access to adequate food. Obviously, poor people are at a severe disadvantage when it comes to food access, whether they live in rural, food-producing areas or in cities, unless they benefit from ameliorative programs. Food access for small farmers or farm laborers may be reduced by natural hazards of crop and livestock production (drought, floods, insect infestations, epidemic diseases), or by obstacles caused by human institutions. These problems reduce people's access to food, and thus their nutritional status. Urban poor people depend on markets to buy food or to receive food assistance, and food prices affect their livelihood and nutritional status whether they purchase food or it is purchased for them.
Other groups of people especially vulnerable to malnutrition are those who face health risks from infectious diseases or inadequate sanitation. Such conditions are often linked with malnutrition. For example, in reviewing data from two surveys in an area of Rwanda, researchers found a discrepancy between the geographic areas with a prevalence of child malnutrition and those with a high percentage of households whose average food intake provided less than the recommended daily allowance of nutrients. Two conclusions were reached: First, malnutrition is a household problem, and average figures could mask malnutrition within households. Second, malnutrition in the sample was more related to other factors, such as sanitation, than to calorie supply.
Obviously, people living in areas of warfare or civil strife are likely to have had their sources of livelihood destroyed or markets disrupted, reducing their ability to gain access to food. When such people become displaced and are forced to live in crowded refugee camps, they become more vulnerable to the complex knot of nutrition/health causes and effects that are known to result in high mortality rates. Finally, other vulnerable groups, such as pregnant or lactating mothers and small infants, can be identified just from their relatively higher temporary need for food, or certain types of food.
Beyond such readily identifiable groups, others may emerge as nutritionally vulnerable. Many of these are the objects of specific effects that are only now being identified and studied in detail. Household surveys, which can help in this process of study, are costly. The paucity of primary data and the large number of variables that affect nutrition serve to mask many specific nutritional problems. For example, education level, particularly of women who usually handle food in the household, is known to be correlated with the household's nutritional status because of nutrition's link with sanitation.
During the 1980's, many structural adjustment programs in developing countries reduced nutritional well-being for the poor. These programs frequently have involved the deliberate short-run reduction of demand in order to bring macroeconomic variables, such as budget deficits, back into balance. By reducing purchasing power, these programs reduced nutritional well-being in the short run—even if they provide long term benefits. Other effects, which are not so simple to detect, include such things as changing consumer food habits through currency devaluation that reduces food imports.
Sometimes, the effect on nutritional status of these policies is minimal, as when domestically produced cereals such as sorghum and millet replace imported wheat and rice, which have become prohibitively expensive. In other instances, the effects can be damaging unless measures are taken to offset them. For example, in Nigeria traditional, coastal, and brackish water fish catches fell by 52.4 percent after the introduction of a structural adjustment program in 1986. This was because local fishermen depended on imported outboard motors and fishing nets, the prices of which rose steeply as a result of currency devaluation. In this case, the threat to consumers' well-being was not one susceptible to remedial action by controlling staple food prices, because one class of staples had dropped out of the picture altogether.
Nutritionists believe that gender is one of the principal factors behind the high levels of malnutrition in Asian countries when compared with African countries. They point out that children's access to good nutrition in rural Asia is much more related to gender than it is in Africa. In the Indian state of Punjab, according to one recent study, youngest daughters in households with many children are often selectively deprived of both medicine and the more nutritious foods so that their brothers may be better cared for. Under normal circumstances, the communal land tenure systems that prevail in Africa and the recognized role of women in food production ensure that, in African societies, children of both sexes get a more equitable distribution of the food available. This does not prevent African communities from collapsing, however, when drought and warfare wipe out their productive assets, defeat their coping mechanisms, and turn people into refugees.
An important point to remember is that very short-term nutrient deficiencies can have long-lasting effects. In an urban area of Niamey (Niger) surveyed between 1985 and 1987, a very strong relationship was found between food price increases due to crop production shortfalls and undernutrition. Such fluctuations may lead to sudden weight loss and serious consequences for child survival and welfare. Thus a famine can affect an entire generation in terms of its consequences on human development. Beyond the immediate human cost, there may also be a cost in terms of economic development. A number of studies have demonstrated that among rural populations where agricultural production is labor-intensive, malnourishment will in turn have a negative effect on agricultural productivity.
Conclusion
Asia has the largest nutritional problems, in terms of both the absolute number of malnourished people and the percentage of the population that is malnourished. A high correlation exists between malnourishment and poverty. But within the general category of the poor in developing countries, certain well-defined subgroups, such as urban poor people and rural laborers, may be particularly affected by food price changes that make food inaccessible.
