Public health vs. food security in the 21st century

When we talk about rehabilitating a failed state, current economic development paradigms are such that we imagine we’re treating a sick patient. There are some symptoms (a rebel insurgence, poor governance, poor levels of foreign investment), some direct medicines (UN peacekeepers, capacity building, ODA grants, etc.) and some basic assistance that has to be given to ensure that the patient survives (much in the way a patient is given food, water and heat, economic development calls for general investment in public health, education and the provision of food).

In the end, development is seen as a holistic process – help in all the necessary sectors and, with a little bit of luck, the country will be on its feet enough to no longer need care. There is never much consideration given to the possibility that medicines may have harmful interactive effects – food is good and education is good and health is good and the three of them are even better. Unfortunately, the interests of food safety and domestic stability may soon be at odds with the interests of development work more broadly and public health work more specifically.

The first important issue to understand is that the dynamics of hunger are changing. In the past, hunger has largely been decentralized and rural – famines happened. Hunger was rarely a city phenomenon (except in wartime – Leningrad, West Berlin, etc.). This is because while farmers in poor countries often have only one source of food (themselves, and maybe the immediate surrounding area), urban dwellers have access to food being brought in from around the country (and imported from other countries). If one source fails, the city might see a marginal price increase. In a poor rural area, crop failure leads to famine.

The nature of this type of hunger fits in well with the typical view of development. Having a famine would set a region back significantly in terms of development, and so international food aid is like temporary insurance for the occasional drought. If we can provide that insurance, we likely improve other development outcomes, like education, health, etc.

No large-scale famines emerged on account of the major rise in food prices in 2007-08. The situation was becoming critical in a number of countries, but again, they avoided famine. It is interesting that African countries avoided famine in spite of staple foods like cassava almost doubling in price in a lot of areas, when for years many countries were seen as famine risks even with low food prices. Why is this? The reason has a lot to do with the fact that rural, subsistence farming populations, the most “at-risk” famine group, were not especially affected, since they grow their own food, and often (especially among the poorest segment) without a lot of petroleum-based inputs, like fertilizer, whose price increases were pushing food prices up in the first place.

The lack of famine, though, was compensated by the rise of something almost as bad – civil unrest. “Food riots” became a common theme in the news, hitting a number of countries like Haiti, Egypt, India, Yemen and Indonesia. Famines have rarely provoked riots, as the rural poor are typically spread out, far from the government and too busy trying to do anything they can to get food to be an effective source of unrest. Urban poor, on the other hand, are concentrated and usually semi-employed, and make great rioters.

Where does public health fit into all this? International public health aid organizations are largely responsible for the urbanization of many poor countries, especially in Africa. Many of these countries have never had and continue to lack any of their own public health infrastructure, so NGOs fill that space. At the same time, the world has, in the 20th century, seen some pretty major advancements in terms of making people healthy – remember that the first vaccine was not found until 1885, and penicillin was invented after John McCain was born.

What has happened, and continues to happen, in much of sub-Saharan Africa is what is termed ”Stage 2” of demographic transition – where health advances reduce mortality, while fertility rates remain high. Because in Stage 1 the highest risk of mortality is in infancy, it is specifically in child mortality rate reductions that we have seen the most progress (and it should come as no surprise that child mortality is such a common focus of NGOs – it’s one thing, along with primary education, that we’ve done a good job of making progress in).

Not coincidentally, the period of improving health outcomes has also been one of urbanization. Between 1950 and 2000, the percentage of Africa’s population living in urban areas rose from 14.7% to 37.2%. By 2015 it is predicted to be 45.3%. Interestingly, though perhaps not surprisingly, the fastest growth in urbanization has been in poorer areas, with West Africa seeing much faster rates than Southern Africa, and South Africa itself seeing the slowest rates of all. The reasons are easy – more children, but a finite amount of farmland, means that more people will venture to cities.

And yet, while NGOs have done well in creating conditions for urbanization, the development establishment has been much less successful in creating economic growth. One of the most amazing aspects of the public health success in Africa is that it has largely been done with income stagnation or even declines. These graphs from the excellent illustrates this perfectly. Looking at a few countries for the sake of example, we can see that while incomes in these countries have hardly grown in real terms, and sometimes fallen, life expectancy has grown significantly (the blue trails tracks year-to-year the change in lifespan over income – a vertical line means life span is growing over time while income is stagnant, a horizontal line would mean income is growing while life span is stagnant. The first year is the end-point indicated at by the marker, the final year is the other end point). DR Congo is an extreme example of this: 1936 income per capita was $644, and life expectancy was 32 years. In 2007, income was a mere $278, while the average person lived 46 years. (Click on the images to enlarge)

And so now we have large, urbanized populations with incomes similar to those of farmers 50 or 60 years ago. This increased demand for food, among a population that is not producing any, has luckily been counteracted by vast increases in supply, as just as Africa was gaining independence, the Green Revolution was starting to get underway. In other words, stagnant incomes were not a problem because purchasing power remained the same, and probably increased. Living in the city meant having access to relatively cheap food from a relatively diverse set of sources, a much better bargain than living in a rural area.

Rapidly rising food prices threaten this dynamic. If food prices rise rapidly, then it suddenly matters a lot that incomes have not risen along with life expectancies, because all these urban poor don’t have any income cushion with which to absorb the price increases. Suddenly, they’re at the other end of the bargain – farmers will be relatively better off because they grow their own food, with the most primitive being best off because they don’t rely on many petroleum-based inputs, while urban residents will essentially be priced into malnutrition or potentially even famine. Famine scholar Alex de Waal has stated that famine can be quantitatively measured by looking at grain prices – he noted how during the Ethiopian famine, prices of grains increased by 4 or 5 times in heavy hit regions. In 2008, we saw staple food prices double – a fourfold increase is hardly out of the realm of possibility.

Unfortunately, urban famine will probably have much worse consequences than rural famine. In rural famine, people die of hunger. If city-dwellers cannot buy enough food, they will first turn on their government. In most of the countries we’re talking about, there is not much of a government to turn on. Traditionally, African cultural structures are such that in many countries these individuals could return to their village to seek help from their families or tribe, but these are being eroded, and anyway the countryside is not so bountiful as to be able to sustain a re-ruralization of a third or more of the population (it’s so unheard of that ruralization is not even a word). The easier choice for a lot of urban poor will simply be to get hands on a gun and go out into the countryside to raid farmers for the food that they need (this is certainly not unheard of – rebel militias have been doing this for years). If this were to occur on a mass scale, the results would be devastating. Not only would the rural population be decimated, but food production would grind to a halt – remember what happened during Mugabe’s most recent “land reform” and picture something much worse.

The wild card in this situation is the international community. Timely food aid could solve the problem, but it would depend on how bad the situation is. If oil prices run that high, Western economies will stagnate, and the Western public may not be so quick to subsidize food for the rest of the world. Depending on how high food prices rise, it may take a lot of money to prevent the crisis I’m talking about, especially as food exporters put up export bans to curb domestic price increases. Furthermore, if the price of food rises permanently, these subsidies would have to be permanent as well. And if they come late, after serious violence has broken out, it may be too late. Finally, remember than development is an industry – somewhere around 10% of the Central African Republic’s GDP, for instance, will be accounted for by aid in 2009, and probably an even larger percentage when you consider multiplier effects. Especially in cities, there is a lot of employment that comes just from servicing expat development workers. If these workers are pulled out due to instability, the effect will be all the larger.

My main point is not necessarily to paint a doomsday scenario, as real as I think it is, but to point out to what extent Western public health efforts have generated this risk. In fighting the scourge of disease, we have inadvertently created the risk for a major social crisis. This is not a blame game – no one was smart enough to predict the skyrocketing of food prices. Now that it has emerged as a distinct possibility, however, the development world has to consider a few things.

Firstly, is the focus on reducing mortality, and the lack focus on reducing fertility, actually going to save lives in the long run? Life is one of the hardest things to not hyperbolically discount – saving a child who is dying now is always going to have a lot more force than possibly saving 10 or even 100 children 10 years from now. And yet the difficulty of this task should not prevent the development establishment from considering the tradeoff. I think that in the end, an optimal allocation of resources would include more efforts to try to control population growth.

Secondly, whether or not this happens, the development community has to at least acknowledge its role in creating fast rates of population growth and urbanization. It may choose to hope and pray that food prices won’t go out of control as they did last year, but the acknowledgement has to exist so that if shit hits the fan, food wise, the Western world feels responsible for helping these countries. It would be a serious moral offense, in my view, if we helped countries develop, according to our model, which rests on an implicit assumption of low food prices, only to disappear when that assumption turns out to have been wrong, because we could create more problems and suffering by doing that than if we had never tried to help develop those countries in the first place.


2 Responses to “Public health vs. food security in the 21st century”

  1. 1 Lisa May 28, 2009 at 11:32 am

    Excellent point about the interactive effects or health, food and education, and nice attempt here to tie together some current trends.

    A few things to add to the discussion.

    Has the public health service provided by NGOs actually been the primary driver of urbanization, or has it just contributed to a trend? My guess would be, at least in Africa, it has a lot to do with droughts and increasingly tired land. Perhaps others have been able to accumulate enough wealth to support a son or daughter seeking education and work in a higher-paying commercial enterprise.

    Second, it seems the environment is much more a wild card than the international community in the next 50 years, i.e. if climate change and water shortages render some land practically un-useable, the current focus of the development community and the ability of the international community to provide short-term food relief even more stop-gap than at present.

    This doesn’t mean the Western world shouldn’t acknowledge the impact its development work may have had in contributing to food shortages in these countries – maybe if correct it just adds impetus to change our relationship with the environment in the Western world.

    Hey, and this article is more interesting after your post:

    • 2 JSC7 May 28, 2009 at 12:48 pm

      Both good points – I think with regard to the former, tired land certainly plays a big role, but tired land is also linked to the population increases that I’m talking about – subsequent generations getting smaller and smaller plots of land, harvesting more intensively, etc. I don’t know much about the frequency of droughts, but I think it ties into the second point of climate change – I did totally skirt of the issue of rural famine becoming more common because West Africa is turning into a desert and what not, and I agree that that may be a more relevant and dangerous issue in the next 50 years. I guess the post was as much about pointing out the tradeoffs implicit in a focus on public as about putting out a warning.

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This is a group blog. JSC5 currently writes from the US. JSC7 writes from behind the Great Firewall of China.

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