Health, livelihoods, and nutrition in low-income rural systems.
BACKGROUND
Absolute poverty remains a major challenge: the proportion of the world population living with hunger, food insecurity, and undernutrition has fallen, but the absolute number remains stubbornly large. An even larger number of people have enough to eat but suffer from severe micronutrient deficiencies.


OBJECTIVE
To provide a conceptual framework showing the interdependence of hunger and poverty with ill health among the rural poor.


METHODS
Review of the relevant health, nutrition, agriculture, and economics literature and organization of the findings into a systems framework.


RESULTS
Economic growth is not a sufficient answer to rural poverty. The predicament of poor households can be represented in terms of a self-reinforcing cycle involving nutrition, health, and productivity. The degree of poverty limits the quantity and quality of food intake. Macro- and micronutrient deficiencies interfere with child growth and development and impair immune function, resulting in a predisposition to infectious diseases. Health status strongly influences the quantity and quality of labor and achieved educational status. The high risk of child mortality prevents households from going through the demographic transition to smaller families and better-educated children. The death of a working adult may be catastrophic for the household. This self-reinforcing cycle means that the beneficial effects of an intervention are propagated around the cycle, potentiating its impact. Each main element--nutrition, health, and productivity--also has numerous other determinants and can be influenced by interventions. Interventions that increase the carrying capacity of the household's environment are likely to be more sustainable than "technical fixes," such as lifesaving medical treatment.


CONCLUSIONS
The self-reinforcing cycle is likely to be self-perpetuating without outside intervention. For any rural area where poverty reduction is planned, the key bottlenecks need to be identified. This can be done by using a causal diagram, as described in this paper.
Department of Epidemiology and Public Health, Imperial College School of Medicine, London, UK. m.joffe@imperial.ac.uk
Michael
M
Joffe
D004522:Educational Status; D005191:Family Characteristics; D006293:Health Promotion; D006304:Health Status; D006801:Humans; D006815:Hunger / Q000502:physiology*; D018977:Micronutrients / Q000172:deficiency; D009747:Nutritional Physiological Phenomena / Q000502:physiology*; D011203:Poverty; D012423:Rural Health
D018977:Micronutrients