A demographic revolution is moving hunger and poverty problems in developing countries from rural to urban areas. Since 1950 the proportion of the Third World population living in cities has more than doubled to an estimated 36 percent or 1.3 billion people. About half of these urban dwellers are migrants from rural areas and the majority live in overcrowded slums or makeshift squatter settlements. And their numbers are increasing rapidly. The developing world's urban population is growing at an annual rate of 3.7 per cent a year, almost four times faster than population growth in the countryside. Slums and shantytowns are generally expanding faster than other urban zones and certainly faster than city infrastructure, essential services and employment. At the end of the century, UN projections indicate, total urban population in the Third World will be more than 2000 million people. By then, more than half the developing world's poor will be living in cities, a major shift in the locus of poverty. The relative changes in city sizes since 1950 is dramatic, Europe and the U.S. being displaced by Asia and Latin America, as illustrated in the graph.
UN agencies are concerned about the effects of this unprecedented urbanization on the nutritional status of the urban poor. This was the subject of a Symposium on the SCN's annual session in February 1987. By one estimate, at least half of the urban population in eight developing countries - Brazil, India, Egypt, Indonesia, Sri Lanka, Sudan, Thailand and Tunisia - is undernourished. Studies in several large Third World cities indicate that energy intake in slums and squatter areas is as little as half of city averages. Anaemia is twice as prevalent and up to 50 percent of children may show signs of malnutrition, 10 percent in severe form. In New Delhi, 40 to 55 percent of shantytown children have been found to suffer various grades of malnutrition and mortality rates among children under five years have reached up to 450 per 1000.
Rural Diets “Superior”?
The health and nutrition status of the urban poor may, in fact, be worse than that of the rural poor, despite the concentration of health facilities in cities. Research indicates that urban infants suffer growth retardation at an earlier age than their rural counterparts, and that urban children are more likely to have rickets. While the urban diets are often more varied and include higher levels of animal protein and fat, rural diets may be superior in terms of calories and total protein intake. Average food consumption is lower and estimates of undernutrition generally higher in urban areas. However, physical malnutrition in children is markedly worse in the rural population, possibly because urban dwellers, of whatever social group, have lower energy demand than subsistence farmers.
Several associated factors account for nutritional deprivation among slum dwellers. One problem is the inability to adapt to new staples and a new structure of food prices. Food purchases of the urban poor are heavily dependent on competing demand for unavoidable non-food expenditure such as transport to work, housing and remittances to relatives in the countryside. The urban poor seldom have easy access to central markets due to public transport costs and are thus compelled to buy their food in small quantities from local shops at higher prices. They may have little time to prepare food, no suitable space for cooking and no money for fuel. Result: the poor often rely mainly on small-scale local vendors to prepare meals with little regard for hygiene or food safety.
Projected population and rank of major cities for the year 2010 (rank shown in brackets)
Source: UN Estimates and projections of urban, rural and city populations. 1950-2025. The 1980 Assessment (ST/ESA/SER.R/45)One major issue in urban undernutrition identified by most UN agencies is that of time constraints on urban women. They are more likely to be household heads, particularly in Latin America, and often lack social support networks found in rural areas. For many low-income female workers who leave home early in the morning and return late at night, bottle feeding of infants has become an absolute necessity. But commercial milk powders are often unhygienically prepared, creating a positive threat to infants' health. In some urban communities, large scale introduction of bottle feeding has already changed the type and incidence of protein-energy malnutrition. Marasmus, a severe form of protein-energy deficiency, is becoming more frequent among younger children in urban areas. In four Bangkok slums, the prevalence of protein-calorie malnutrition was attributed to failure to breastfeed, early weaning and inadequate artificial feeding.
Solutions: Rural Development
The basic cause of hunger and malnutrition in cities is poverty. Long-term solutions will depend, therefore, on the provision of jobs and services to match the requirements of a growing urban population. Because this could take generations to achieve in some low-income countries, urgent action is needed to avert serious problems in the near future. One priority is a slow-down in the pace of urbanization by expanding rural infrastructure and services and creating rural employment. In addition, improvements are needed in the production, marketing, distribution, handling and control of food for the urban market. Recent FAO studies in eight developing countries indicate that much more attention should be paid to the “supply side” in the urban food equation: a decreasing number of rural producers are ill-prepared to meet the food needs of ever-increasing numbers of urban dwellers. Responding to urban food demand is also difficult because of marked differences in diet composition between rural and urban areas.
[Source: FAO Photo Library]Primary Health Care
Improvements to urban health services would have significant impact. More comprehensive health coverage, including immunization campaigns, would improve nutrition among the urban poor by preventing gastrointestinal and infectious diseases, promoting adequate diet among pregnant and lactating women and encouraging proper infant and child feeding. However, urban health services often observe an “inverse care law”: those in greatest need of care have the poorest access to it. Few governments have formulated urban health policies giving priority to the poor and, even when such plans and programmes do exist, their implementation is hampered by resource shortages aggravated in recent years by economic recession. A further barrier is the chaotic administration typical of many overcrowded Third World cities.
Agencies agree, therefore, on the need to adapt WHO's Primary Health Care (PHC) approach - until now a mainly rural phenomenon - to the needs of the urban poor. Described as a “renaissance in community health”, PHC is a strategy encompassing total, primary-level health coverage as well as action to attack the fundamental causes of health problems through policies establishing equity in employment, income, education, housing and planning. One increasingly popular instrument for applying this approach in poor urban areas is neighbourhood health programmes, the equivalent district level PHC arrangements promoted by WHO in rural areas. While no established blueprint for such programmes exists, successful neighbourhood schemes have emerged in Cali, Addis Ababa, Djakarta and Manila, usually based on community health centres with a wide deployment of health workers and emphasis on public health education campaigns. Coverage so far has been limited, but the neighbourhood programmes could be expanded and consolidated. Essential to the PHC approach, WHO stresses, is the parallel development of a decentralized network of hospitals supporting the primary system. This reorganization was successful in Cali, where the strengthening of peripheral health units benefited particularly the poor populations of outlying barrios.
But improved health coverage is only one part of PHC. It is unrealistic, research has shown, to expect healthy behaviour and compliance with medical advice from a population whose basic needs are grossly unsatisfied. All relevant sectors of socio-economic development must be mobilized and organized into functional networks to contribute to clearly defined health objectives. This entails multisectoral action, including the upgrading of water supply and sanitation facilities, development of income-generating activities and the provision of basic education, family planning advice, decent housing and low-cost transport.
Nutrition Programmes
Along with primary health care, there is an urgent need to expand direct nutrition intervention programmes. Among the easier and less costly interventions are fortification of food and mass distributions of capsules and tablets to eliminate deficiencies of iodine, iron, folic acid, and vitamin A. Success in fortification programmes will depend on the choice of a food carrier which is centrally processed and consumed on a regular basis. Another delivery system, successfully operated in Sri Lanka during the 1970's, is fair price (or ration) shops which distribute staples at subsidized prices in low-income urban areas. While many international agencies advise against the general use of food subsidies, studies show that it is possible to design targeted interventions based on particular commodities or types of ration shop.
Large-scale feeding programmes are able to reach vulnerable groups, such as young children and pregnant and lactating women, but present logistical and some targeting problems. On-site meals programmes require infrastructure, while take-home programmes carry the risk of “leakage” - the sharing of food with others or the sale of the rations. Other problems encountered include sporadic attendance, difficulties in maintaining the ration size and generally high cost. FAO says supplementary feeding programmes are likely to be cost effective if the food supplement is sufficient to provide the incentive for regular participation, if criteria based on the degree of malnutrition and response to feeding are established for entry to and exit from the programme, and if the programme is integrated with nutrition education and primary health care. Active community participation is also recommended: in Calcutta, slum residents pooled resources to buy staple food in bulk and ran community kitchens which fed 135,000 pre-school children. In Latin America, communities have addressed one of the most critical nutritional problems facing the urban poor - the feeding of infants - by establishing creches for working mothers. Nutrition education aimed at motivating people to change their dietary behaviour and make better use of available food is a basic component of intervention programmes for the rural poor. In urban areas, where malnutrition is normally the result of low purchasing power, advice will concentrate mainly on making the best use of limited money by purchasing the cheapest combinations of nutritious food and making better combinations of weaning foods for children. Nutrition education can also be designed to promote improved food handling and preparation and address constraints on slum dwellers' time and use of fuel.
UN Action
Although UN agencies agree on the broad outlines of strategies and programmes, members of the SCN believe more information, more awareness and more concerted action are needed in order to deal with the urban poor's nutrition needs. Of major concern to the UN agencies at present is the effect of economic recession in the 1980's and of structural adjustment policies. Since the urban poor rely more heavily than rural people on cash for survival, reductions in employment and wage rates, increases in food and petrol prices and cuts in government services could lead to greater hardship. “There is a real danger,” the SCN noted at its 1987 annual session, “that the current policy pursued by many low-income countries, combined with stringent economic conditions, might lead to a decline in the nutritional status of the urban poor due to neglect of programmes and policies needed to secure essential services.” At the same time, the report cautioned, socio-economic policies aimed at assisting the urban poor should take into account the possibility of negative consequences for the rural poor.
The SCN Symposium identified three areas for action by UN and bilateral agencies. First, more information is needed for formulating cost-effective nutrition and health policies for the urban poor. UN agencies' efforts should assist in achieving better cohesion in research, help define priority questions and stimulate work to obtain answers. Second, UN and bilateral agencies should make high level contact with governments to advocate greater attention to the dimensions of the urban nutrition problem. The Symposium suggested that UNICEF introduce the topic with higher priority in its contacts with governments and country programme planning and urged all UN agencies - particularly UNDP, with its key role in country programming - to focus attention on the problem and mobilize resources for its solution. Third, nutrition objectives should be introduced into a much wider range of programmes. This could entail either more efficient use of resources already available for urban areas, or allocation of new resources.
