Joachim von Braun is director of the Food Consumption and Nutrition Division at IFPRI. John McComb is a Ph.D. candidate in the Nutrition Program at the University of Queensland, Australia. Ben K. Fred-Mensah is a Ph.D. candidate at the Paul H. Nitze School of Advanced International Studies, Johns Hopkins University. Rajul Pandya-Lorch is a research analyst at IFPRI.

URBAN FOOD INSECURITY AND MALNUTRITION IN DEVELOPING COUNTRIES: TRENDS, POLICIES, AND RESEARCH IMPLICATIONS

JOACHIM VON BRAUN JOHN McCOMB BEN K. FRED-MENSAH RAJUL PANDYA-LORCH

INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE WASHINGTON. D.C.

Published in 1993 by the

International Food Policy Research Institute 1200 Seventeenth Street, N.W. Washington, D.C. 20036-3006 U.S.A.

Library of Congress Cataloging-in-Publication Data

Urban food insecurity and ntalnutrition in developing countries : trends, policies, and research implications I Joachim von Braun ... [eta!.].

p. em. Includes bibliographical references. ISBN 0-89629-326-2 1. Food supply--Developing countries. 2. Malnutrition--Developing

countries. 3. Urbanization--Developing countries. I. von Braun, Joachim, 1950-HD9018.D44U73 1993 363.8'09172'4--

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. Conceptual Issues and Policy Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3. Urbanization in the Developing World: Implications for Growth and Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4. Urban Food Insecurity and Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

5. Policy Choices and Research Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6. Policy Research Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

iii

Tables

1. Average annual urban population growth rates, 1965-80 and 1980-89 . . . . . . . . . . . . . . . . 6

2. · Trends and projections in urban population shares, developing-country regions, 1950-2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3. Trends and projections in urban population shares, selected developing countries, 1950-2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4. Population size and growth of selected developing-country cities, 1950-2000 . . . . . . . . . . . 8

5. Share of total population in urban centers of developing countries, by city size, 1950-2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

6. Incomes and urbanization in selected developing countries . . . . . . . . . . . . . . . . . . . . . . . 9

7. Sectoral change and urbanization in selected developing countries .................. 10

8. Characteristics of squatter and nonsquatter settlements in Manila, Philippines . . . . . . . . . . . 11

9. Extent of undernutrition in selected developing countries . . . . . . . . . . . . . . . . . . . . . . . . 13

10. Per capita energy intake in urban and rural areas of selected developing countries ........ 15

11. Total calorie availability per adult equivalent, by income group and location in selected countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

12. Energy and nutrient intakes and health indicators of rural-to-urban migrant and rural families, Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

13. Per capita daily energy and nutrient consumption and adequacy by income class in Manaus, Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

14. Energy- and nutrient-deficient families, by income group in a Manaus slum, Brazil ....... 19

15. Mean calorie intake per capita and income elasticities for calorie intake by income group, Brazil, 1974175 ............................................. 20

16. Calorie intake, budget shares, and costs of different population groups, Thailand, 1976177 ...................................................... 21

17. Prevalence of malnutrition in children aged Q-59 months, by rural and urban location ...... 22

iv

18. Per capita income, gross domestic product growth, degree of urbanization, and urban nutritional status in selected developing countries . . . . . . . . . . . . . . . . . . . . . . . . 24

19. Prevalence of malnutrition in preschool-aged children, Egypt, 1978 ................. 25

20. Prevalence of child malnutrition by location and by per capita expenditure decile, Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

21. Proportion of children with severe protein-calorie malnutrition in Morocco, 1973 . . . . . . . . 26

22. Prevalence of malnutrition in rural, less-privileged urban, and privileged urban children in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

23. National income, urbanization, and urban nutrition: regression analyses for 20 countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

24. Frequency distribution of reasons given by mothers for starting supplements, Pelotas, Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

25. Frequency distribution of reasons given by mothers for why other women stop breast-feeding, at 1st and 26th weeks of study, Pelotas, Brazil .................... 30

26. Percentage of exclusively breast-fed infants in three social groups, Kenya, Mexico, and Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

27. Percentage of breast-fed infants receiving supplementary milk or other foods in three social groups, Kenya, Mexico, and Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

28. Prevalence of diarrhea, fever, and other illnesses among preschool children in poor urban and rural areas in selected countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Figures

1. Determinants of food security for urban households, and related policies . . . . . . . . . . . . . . 4

2. Rural and urban malnutrition related to gross national product per capita in developing countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

v

Foreword

Although most of the food insecurity and malnutrition in low-income countries is still found in rural areas, the size, growth, and nature of urban food security and nutrition problems also require attention. IFPRI has in the past addressed urban food problems and policies in the context of its research on food subsidies and related targeted interventions.

Most of IFPRI's food security and nutrition research continues to be focused on the rural poor given the weight of the problem in rural areas. At the same time, IFPRI is planning more comprehen-sive research on urban food security and nutrition policy in the framework of an integrated multi-country project. This research will incorporate the specific linkages of labor markets to food security and of the health environment in urban slum areas to nutrition and related policy alternatives.

The potentials and limitations of agricultural policies in mitigating the food problems of poor households in urban and peri-urban areas and in reducing the speed of urbanization will figure prominently on IFPRI's research agenda. This report is an attempt to conceptualize and review fmdings that will both assist future IFPRI research in this area and stimulate others to contribute to the answering of identified research questions.

Joachim von Braun, Director Food Consumption and Nutrition Division

vii

Acknowledgments

We are grateful to a number of colleagues at the International Food Policy Research Institute and elsewhere, in particular to Harold Alderman, Rainer Gross, Maarten Immink, Shubh Kumar, Per Pinstrup-Andersen, Sudhir Wanmali, and Patrick Webb, for carefully reviewing earlier drafts and for guiding discussions that helped to shape this report.

viii

1

Summary

Urbanization in the context of development is not a new phenomenon. However, the unprece-dented rate of urbanization that has taken place in developing countries in recent decades poses new challenges to food security and nutrition policies in these countries. In countries whose per capita incomes have been declining while urbanization has continued to increase, urban food security issues are particularly challenging. This is especially the case where increased fiscal and foreign exchange con-straints have reduced the capacity of many low-income countries to provide public support through food subsidy systems, which tend to target urban areas. Widespread efforts to reduce the govern-ment's administrative involvement in food distribu-tion and to move toward privatization also pose transitional problems in countries that have relied heavily on state planning of food distribution to urban areas. A new food policy research agenda is emerging in the quest for effective policies to provide food security for the urban poor.

This report reviews and takes stock of the food and nutrition policy implications of urbanization in the developing world and, from this review, derives policy and research implications for urban food security. The report compares urbanization process-es in regions and countries in the developing·world. It relates urbanization and urban population growth to economic growth, links urban poverty and malnu-trition, and explores the relationship between health and sanitation and children's nutritional status. Available studies on food consumption and dietary patterns in urban and rural areas are reviewed, gaps in knowledge identified, and areas for further

research suggested. Six sets of policies for urban food security and

nutritional improvement are reviewed for their effectiveness in providing food security for the urban poor: macroeconomic policies and market development; food subsidies and targeted food transfers; supplementary feeding programs; health, sanitation, and food safety policies; community development and urban agriculture; and access to credit and savings opportunities. This review sug-gests that in addition to more comprehensive assess-ments of effects, effectiveness, and sustainability of policy actions, research on food and nutrition policies for urban areas in developing countries should focus on three main areas: (1) problems with policy implementation, including the design of effective and appropriate policy interventions; (2) identification of criteria for choosing among policies for urban food security and nutritional improvement; and (3) synergistic effects of program components and how they interact.

A disaggregated view of urban poverty in developing countries is needed. People cope with food insecurity in different ways, and urban food security policies mnst be designed for specific circumstances. Research is needed tu improve the understanding of the behavior and coping strategies of the urban poor. The nature of urban growth and urbanization, of urban food markets, and of urban labor markets needs to be reexamined. Policy research must go beyond individu-al programs or interventions tu provide an under-standing of how programs interact. This is the central research priority for designing policies for urban food security.

1

2

Conceptual Issues and Policy Focus

INTRODUCTION

Developing countries have experienced unprec-edented rates of urbanization in recent decades; the urban population's share of the total population in low- and middle-income countries increased from 24 percent in 1965 to 42 percent in 1989 (World Bank 1991). The numbers involved are staggering: the inhabitants of towns and cities in developing coun-tries increased from 300 million in 1950 to 1.8 billion in the 1980s @arris 1992). Moreover, urbanization shows no signs of slowing down in developing countries. On the contrary, the annual growth rate of the urban population in low- and middle-income countries accelerated from 3.7 percent during 1965-80 to 6.8 percent during 1980-89 (World Bank 1991).1 While urbanization is not bad in itself, since it is an integral element of a healthy social and economic development process, the speed at which it is occurring in developing countries2 and the resulting spatial imbalance in the distribution of urban centers can pose problems for human welfare and development policy, especially when economic growth is stagnant or deteriorating.

The economic deterioration of the past decade in many developing countries has tended to hit the urban poor particularly hard, given their dependence on wage employment for income, on the market for food supplies, and on government subsidy policies for a safety net. Fiscal constraints have prevented the continuation of many urban-biased food policies. Many governments have been forced to restructure their policies by cutting back on urban food subsi-

dies and on employment opportunities in govern-ment and parastatal organizations, for example. These measures have frequently resulted in a re-duced standard of living, intensified food insecurity, and increased unemployment in urban areas, at least in the short run. These hardships and the increased rate of urbanization are adding to the urgency of addressing the problems of food insecurity in urban areas, despite the continued large proportion of the undernourished population in low-income countries living in rural areas.

Urban food security problems have been somewhat marginal in contemporary nutrition research, beinf superseded by concerns about rural food security. This was not always the case. Until the 1970s, the impression was widespread among nutritionists that urban nutrition problems were more severe than rural nutrition problems. This impression arose partly because surveys of urban nutrition tended to concentrate on slum areas, and, therefore, a comparison with the "average" rural village was likely to favor the rural situation. In the 1970s, the focus shifted to rural nutrition and food security problems in response to concerns about urban bias and to research, based on representative samples, which showed that, overall, the urban situation appeared to be better than the rural situa-tion (Lipton 1977; Kumar 1987). However, well-designed systematic studies that adequately compare intraurban differences in income, food consumption, malnutrition, and health are long overdue, and it is quite likely that the full dimensions of urban poverty and hunger are greater than documented to date.

1 In the high-income countries, in contrast, the share of the total population that was urban increased from 71 to 77 percent over this period, and the annual growth rate of the urban population slowed down from 1.4 percent to 0.9 percent (World Bank 1991).

2 By the year 2025, developing countries are projected to have four out of every five of the world's urban dwellers.

3 An example of this neglect is provided by the English-language publications of the Institute of Nutrition of Central America and Panama (INCAP). Of 1,324 citations between 1949 and 1985, 35 related to urban communities and only 3 were exclusively focused on urban nutrition (Solomons 1987).

2

The policy actions that achieve food security in urban areas may be distinctly different from those that address rural food security. Whereas technological changes in agriculture and expansion of the rural infrastructure go a long way toward mitigating rural food security problems, in urban areas the focus may have to be on generation of employment, social safety nets, and food safety and health policies. There are indications that the diversity in causes of food insecuri-ty and undernutrition observed in rural areas can be similarly observed in urban settings. That these diverse causes may not lend themselves to broad generaliza-tions gives further support to the argument for specific research.

Policies and programs to provide urban food security and improve nutrition must not be imple-mented in isolation, but as part of a national food and nutrition strategy (Hussain 1990) and an appro-priate development strategy. The fundamental question is, How can measures directed at urban food security problems be made part of an appropri-ate strategy to alleviate the overall problem of food poverty in the entire population?

This report has three objectives: • .Assess the scale and speed of urbanization in

developing countries in an effort to determine how fast the problem of urban food insecurity is growing;

• Review food consumption and nutrition situa-tions in the urban areas of developing coun-tries and note how they differ from the rural situation in an effort to identify issues of particular concern to urban households; and

• Review the experience with policies and pro-grams for mitigating or preventing urban food insecurity and identify policy research gaps and emerging research issues in urban food policy. The report argues for a household and intra-

household focus to improve understanding of urban food security and nutrition problems, and takes note of the considerable diversity and dynamics of households in urban settings. Before proceeding further, the major concepts need to be defined and the relationships between them clarified.

CONCEPTS

Urbanization is the concentration of population in relatively permanent locations within geographical

boundaries. According to Gross and Monteiro's (1989, 14) functional point of view, "a rural society lives maiuly from agriculture, whereas urban society depends on a higher level of economic diversifica-tion." Urbanization is characterized by, among other things, crowding; a cash economy; a low level of physical activity in occupations; predominance of manufacturing, bureaucratic, and service activities; and some degree of organized public services (Viteri 1988).

Food security is defined in its most basic form as access by all people at all times to the food required for a healthy life. The food security con-cept addresses the risks of not having access to needed food. These risks can arise from incomes or food production, for instance. Thus, at the house-hold level, food security is defined by the ability of the household to secure enough food to ensure adequate dietary intake for all of its members (von Braun et al. 1992). This includes meeting the need for micronutrients such as vitamin A and iron. Even when individuals are consuming sufficient calories, they may not necessarily be meeting their micronu-trient or protein requirements, which depend on the nature of the food being consumed.

Actual food consumption is oul y one determi-nant of nutritional status. Food consumption inter-acts in a complex fashion with health and sanitary conditions. For instance, contaminated water sup-plies and unsafe food may lead to frequent episodes of infectious diseases. Hence, increased food con-sumption may only marginally improve nutrition.

Figure 1 presents a simplified conceptual overview of the relationships among employment, income, consumption, and nutrition in urban areas, and specifies the policy approaches that can affect household food security. Employment and wages, along with prices and incomes, play the central role in determining the food security status of urban households. Poverty and fluctuations in employment availability, wage levels, and prices (of the com-modities purchased by the poor) are hypothesized to be main causes of food insecurity in urban house-holds. It is not well known how the urban poor cope with fluctuations in these key variables, and factual information is scarce. The urban poor have extreme-ly limited assets to draw upon when current incomes fall short. Extended families, neighbors, and com-munities may assist during crises, but this safety net appears to be weaker than in rural areas.

3

Figure !-Determinants of food security for urban households, and related policies

Determinants Policies

~----------T------

Macroeconomic Policies (trade, exchange rate, fiscal policies; agricultural/other sector policies) 1 I

- -j161 =F=o=o=d=P=r=i=c=e=S=ub=s=i=d=i=e=s.dl -

-

Employment Programs {for example) public works

Income-Generation Programs {for example,

urban agriculture)

Food-Related Transfers (for example, food stamps)

Supplementary - Feeding Programs

Health and Sanitation **'"t::J.~-- Policies, Services

Note: Solid lines indicate market and household links; broken lines indicate interventions.

4

3

Urbanization in the Developing World: Implications for Growth and Poverty

A large body of research already exists on urbanization, and it is not the intent here to focus on that. This chapter describes the context for nutrition-related research and points out some of the major unresolved issues of statistics and data that affect research on urban food security and nutrition.

PROBLEMS OF INTERNATIONAL COMPARABILITY

There is no consistent usable definition of "urban." The United Nations (UN) defines urban populations as those "localities with 20,000 or more inhabitants" (United Nations 1968, 9). However, the UN itself uses national definitions, which vary considerably from country to country and even sometimes within the same country! The lack of reliable and detailed national census records in most developing countries makes it . very difficult to determine the size of the urban population, let alone make any accurate projections and comparisons.

A concentration of population is a major feature of an urban area. However, population concentration is not enough; there are many con-glomerations with thousands of inhabitants that are just large villages. A certain level and type of economic activity is also required (Gross and Monteiro 1989).

Statistical and data problems are not restricted

to the definition of urban but are also encountered when classifying urban centers into categories such as overurbanized, primary cities, urban agglomera-tions, metropolitan areas, megalopolitan centers, large cities, secondary cities, intermediate cities, small cities, and so forth. Variations in national statistical definitions result in countries and researchers alike using different class intervals, with their attendant problems of comparability. It is difficult to assemble internationally comparable data on urbanization, given these definitional inconsisten-cies and data limitations. The international figures presented below must be interpreted with due caution.

URBANIZATION AND URBAN POPULATION GROWTH

In the past few decades, rapid growth in the urban populations of developing countries has dramatically altered the distribution of the world's urban population.' In the 1950s, about 60 percent of the world's urban population was found in the developed countries, which contained only about 30 percent of the world's population. However, by 1980 the pattern had reversed, and developing countries accounted for 55 percent of the world's urban population (United Nations 1985).

4 For example, China's definition of "urban" varies from locality to locality. Sometimes the proportion of residents in nonagricultural occupations is a criterion (Kojima 1987). Criteria can be arbitrarily applied. In Jiangsu, for example, people on urban grain rations, irrespective of their residence, are defined as urban, but in Gansu, all residents, irrespective of their grain ration status, are counted in the urban population (Henderson 1986). Moreover, people can be officially designated either "urban" or "rural" regardless of their place of residence. For example, state employees and cadres in rural areas are "urban" people. Elsewhere, Mexico defines urban centers as "localities with 2,500 or more inhabitants" and Nigeria defines urban settlements as settlements of 20,000 or more inhabitants (United Nations 1985). Guatemala's urban settlements are simply "cities, towns, and villages that have been officially recognized as urban," whereas Haiti's urban areas are "administrative centers of communes" (United Nations 1985). There are many examples of such variations in definitions.

5 The definitional and conceptual problems discussed in the preceding section need to be kept in perspective when available urbanization data, with their shortcomings, are cited in this and following sections.

5

Growth rates for urban populations are sub-stantially higher among low- and middle-income countries than in high-income countries (fable 1). Moreover, only in Latin America and the Caribbean and in the high-income countries has the urban population growth rate slowed down in recent years; elsewhere, it shows either no change or an increase, as in Sub-Saharan Africa, where it is already the highest for developing countries.

Trends in urban population as a percent of total population in developing countries are shown in Table 2. Urban population shares are much higher in Latin America and western Asia than in Africa or southern Asia or southeast Asia. The annual growth rate of the urban population share fell generally beginning in 1985 (in Latin America and the Caribbean, this change had begun much earlier, in the early 1950s), but is projected to remain positive in all developing regions. Trends in urban population shares are presented for selected large developing countries in Table 3. Cities in develop-ing countries are growing rapidly, as indicated by population growth rates of selected cities in Table 4. Of the 414 cities projected to have a population of one million or more in the year 2000, 264 are expected to be in developing countries.

The population growth rates for cities differ quite noticeably by city size. The relationship between

city size and city growth rates is U-shaped in developing countries as a group. Cities with popula-tions of between 100,000 and 500,000 persons and those with over 4 million grew at an average rate of 3.9 percent annually in the 1970s and 1980s, where-as those with populations between 500,000 and 4 million grew at a slower rate, about 3.1 percent (Preston 1988). The most pronounced shift in urban population structure has occurred in cities of 4 million and more inhabitants (fable 5). Of course, this growth pattern differs from country to. country. As the United Nations (1985) observes, "countries with similar levels of urbanization can be very different with respect to their urban structure; that is, the distribution of urban population according to the size of locality."

Three major forces are spurring the rapid growth of urban populations in developing coun-tries: natural increase (the difference between births and deaths); rural-urban migration and, to a lesser extent, international migration; and reclassification of rural areas into urban areas (United Nations Institute for Training and Research 1986).

Preston (1988) considers national population growth and the natural increase of existing urban populations to have powerful effects on a city's growth rate. The relative contribution of rural-urban migration to the growth in urban populations

Table !-Average annual urban population growth rates, 1965-80 and 1980-89

Region

Low- and middle-income economies

Sub-Saharan Africa

East Asia

South Asia

Europe, Middle East, and North Africa

Latin America and Caribbean

High-income economies

Average Annual Growth Rate 1965-80 1980-89

(percent)

3.7 6.8

5.8 6.0

3.0 n.a.

3.9 3.9

3.4 3.4

3.9 3.1

1.4 0.9

Source: World Bank, World Development Repon 1991 (New York: Oxford University Press, 1991).

Note: n.a. means not available.

6

Table 2-Trends and projections in urban population shares, developing-country regions, 1950-2025

Average Annual Growth in Urban Urbl!!! Poi!ulation Shar!l§ PQI!!!liltiQn Shares

1950- 1965- 1990- 1995- 2000-Region 1950 1960 1970 1980 1990 2000 2025 1955 1970 1995 2000 2025

(percent) (percent)

Africa 14.5 18.3 22.9 27.8 33.9 40.7 57.1 2.3 2.0 1.9 1.7 1.2

Latin America 41.5 49.3 57.3 65.0 71.5 76.4 84.2 1.8 1.4 0.7 0.6 0.3

Southeast Asia 14.8 17.6 20.2 24.0 29.9 36.9 55.4 1.8 1.4 2.2 2.1 1.3

Southern Asia 16.0 17.3 19.5 23.1 27.3 32.8 51.5 0.8 1.3 1.8 1.9 1.5

Western Asia 23.9 32.9 43.2 51.5 . 62.7 70.3 79.8 3.4 2.5 1.3 1.0 0.4

Source: United Nations, 1990 Revision of Estimates and Projections of Urban Populations, 1990.

Note: Because of the geographical demarcation used by the United Nations, the data on growth rates for the Asian regions exclude China, the Koreas, Mongolia, and Hong Kong, but include Turkey and Israel.

Table 3-Trends and projections in urban population shares, selected developing countries, 1950-2025

Average Annual Growth in Urban Urban Poi!ulation l}har!l§ Poi!ulatiQn Shil!:!l!!

1950- 1965- 1990- 1995- 2000-Country 1950 1960 1970 1980 1990 2000 2025 1955 1970 1995 2000 2025

(percent) (percent)

Brazil 36.0 44.9 55.8 66.2 74.9 80.6 87.7 2.3 2.1 0.8 0.6 0.3

Mexico 42.7 50.8 59.0 66.4 72.6 77.4 85.4 1.8 1.4 0.7 0.6 0.3

India 17.3 18.0 19.8 23.1 27.0 32.3 51.5 0.4 1.0 1.7 1.9 1.6

China 11.0 19.0 17.4 19.6 33.4 47.3 65.8 3.8 -0.9 4.0 3.0 0.9

Kenya 5.6 7.4 10.3 16.1 23.6 31.8 51.5 2.8 3.6 3.2 2.8 1.6

Nigeria 10.1 14.4 20.0 27.1 35.2 43.3 61.6 3.5 3.2 2.2 1.9 1.1

Source: United Nations, 1990 Revision of Estimates and Projections of Urban Populations, 1990.

7

Table 4-Population size and growth of selected developing-country cities, 1950-2000

Ponu!ation Size

City 1950 1975 1990 2000 1960 1980 1995 2000

(millions) (percent)

Mexico City 2.88 11.05 19.37 24.44 5.4 4.7 2.6 2.1

Slio Paulo 2.75 10.05 18.42 23.60 5.3 4.4 2.8 2.2

Greater Bombay 2.90 5.81 11.13 15.43 3.4 3.2 3.3 3.2

Shanghai 10.26 11.59 12.55 14.69 0.7 0.4 1.3 1.9

Delhi 1.39 4.42 8.62 12.77 5.0 4.5 4.1 3.8

Lagos 0.29 3.29 7.60 12.45 9.7 6.1 5.2 4.7

Beijing 6.64 8.91 9.74 11.47 1.2 0.4 1.4 2.0

Guadalajara 0.40 1.86 3.06 3.89 7.8 4.1 2.5 2.3

Zibo 0.48 1.65 2.82 3.76 5.6 4.1 3.0 2.8

Brasilia 0.04 0.79 2.35 3.66 13.3 7.8 5.0 3.8

Poona 0.59 1.34 2.44 3.56 2.1 4.0 3.9 3.7

Nairobi 0.13 0.68 1.53 2.81 5.8 4.9 6.1 6.1

Source: United Nations, Prospects of World Urbanization, 1989.

Table 5-Sbare of total population in urban centers of developing countries, by city size, 1950-2025

City Size 1950 1980 2000 2025

(percent) More than 4 million 11.1 17.3 23.2 28.2

1-4 million 14.7 17.3 21.0 18.2

Less than 1 million 74.2 65.4 55.8 53.6

Source: United Nations, Estimates and Projections of Urban, Rural, and City Populations, 1950-2025, 1985.

of developing countries is not conclusively settled. From a study of 1,212 cities worldwide, it appears that, on average, 60.7 percent of urban population growth in the 1960s and 1970s is attributable to natural increase (Preston 1988). This proportion was 55.1 percent in Brazil, 64.3 percent in Indonesia, and 67.7 percent in India, for example. The contri-bution of rural-urban migration to population growth

8

appears to be much higher in African cities (63, 62, and 59 percent, respectively, in Dar es Salaam, Yaounde, and Lagos, for example) than in Asian cities (23 and 34 percent in Jakarta and Seoul, for example) (Stren and White 1988).

Generally, it is the younger and better educated people who migrate from rural areas to urban centers. Development programs have ensured

educational gains in rural areas, which, together with greater access to the media, have raised expec-tations for better opportunities. Combined with low agricultural and economic growth and high rates of population increase in rural areas, these expectations have encouraged increased migration to the cities.

The growth of cities and towns is also influ-enced by the level of economic development, the natural resource endowment, historical development, topography, size of out-migration area of potential rural-urban migrants, and, above all, national policies.

URBANIZATION AND ECONOMIC GROWTH

There is a strong, positive relationship between urbanization and economic development (Henderson 1986). Urbanization in both developed and devel-oping countries was associated with higher rates of economic growth during the 1960s and 1970s.

Hence, it can be observed that countries with higher per capita incomes are urbanized to a greater extent than countries with lower per capita incomes (see Table 6 for data on selected developing countries).

African countries are substantially more urbanized than is probably justified by their degree of economic development, including urban infra-structure. Africa's rapid urbanization (an urban population growth of about 6 percent annually, the highest in the world) is taking place in the context oflow or even negative economic growth. • It is thus debatable whether African countries can accommo-date either the natural increase of their already existing urban populations or the further migration from rural areas.

It is generally asserted that urbanization is inversely related to the proportion of a country's population that is engaged in agriculture and to the relative contribution of agriculture to the country's gross domestic product. These patterns can be inferred from Table 7. Intersectoral shifts

Table 6-Incomes and urbanization in selected developing countries

Urban Population Gross National Average Annual Growth Share of Total Average Annual Growth Product in Gross National

in Urban Ponulation ner Cani!.ll Prody~ ner Canita Country 1965-80 1980-89 1989 1965-89

(percent) (percent) (US$) (percent)

Brazil 74 4.3 3.5 2,540 3.5

Mexico 72 4.4 3.0 2,010 3.0

India 27 3.7 3.8 340 1.8

China 59 2.3 n.a. 350 5.7

Kenya 23 8.1 8.2 360 2.0

Nigeria 35 5.7 6.2 250 0.2

Source: World Bank, World Development Repon 1991 (New York: Oxford University Press).

Note: n.a. means not available.

'During the period 1980-89, gross domestic product (GDP) in Sub-saharan Africa grew at 2.1 percent annually; industry, which is primarily an urban activity, grew at 0. 7 percent annually; and agriculture grew at 2.0 percent annually (World Bank 1991). Annual population growth during this period was 3.2 percent.

7 Africa seems to be the exception to the general finding that rural outmigration is fastest in those developing countries whose economic perfonnanceallows the best possibilities for accommodstingthat exodus; Preston (1988), studying 29 developing countries b-een 1960 and 1970, found a simple correlation of 0.61 b-een the rate of rural out-migration and gross national product per capita.

Table 7-Sectoral change and urbanization in selected developing countries

Urban Population Share Average Annual Growth Agriculture's Contribution to Qf Total Poouli!tiQ!l in A!lii!a!ltl!r!l QrQSS Dom~ti~; Pro!!uct

Country 1965 1989 1965-80 1980-89 1965 1989

(percent)

Brazil 50 74 3.8 3.0 19 9

Mexico 55 72 3.2 0.8 14 9

India 19 27 2.5 2.9 44 30

China 18 53 2.8 6.3 44 32

Kenya 9 23 5.0 3.2 35 31

Nigeria 17 35 1.7 1.3 54 31

Source: World Bank:, World Development Repon 1991 (New York: Oxford University Press, 1991).

from subsistence agriculture to a diversified market economy occur in tandem with spatial shifts in the distribution of economic activity and population that involve urbanization.

Out-migration drains rural areas of their eco-nomically most productive population, but very little is known about how that affects food production. Hussain and Lunven (1987) suggest that large outflows of working-age food producers reduce the size of the rural agricultural labor force and could thus cause seasonal labor shortages. At the same time, as out-migrants move to the cities, the number of urban food consumers is increased, as is the rural dependency ratio. With reductions in the agricultural labor force, the productivity of the remaining workers must be increased. Labor shortages may be met by hiring unemployed persons, by mechaniza-tion, by adjustments in the cropping calendar, and by seasonal migration from urban areas.

URBANIZATION-POVERTY-MALNUTRITION LINKS

Urban malnutrition is a manifestation of a larger syndrome-urban poverty-with multiple causes in which low incomes, food system deficien-cies, sociocultural practices, and the health environ-ment are linked. As noted later (Chapter 5), policies

that improve incomes, wages and employment, and health can also improve nutrition.

Despite poor national economic performance, many cities in developing countries continue to grow, overloading their existing facilities. Peri-urban areas (the areas immediately surrounding the city) and city centers attract most of the new mi-grants and have become the locus of hunger in the cities. The rural poor may contribute significantly to migrant populations (Austin 1980). Peri-urban areas tend to be unplanned, poorly serviced, and very densely populated. Urban slums often grow faster than other established parts of a city (Hussain and Lunven 1987).' A large part of the urban slum population is mobile, which exacerbates the prob-lems of collecting population data and also makes it difficult to reach this population through services.

Economic growth may generally facilitate reduction of poverty. However, there is insufficient evidence on how faltering economic growth affects the absolute numbers and proportion of the urban poor. Furthermore, there is insufficient direct evidence from developing countries to show whether inequality decreases, remains the same, or even, in fact, increases as urbanization proceeds. Numerous researchers (Popkin and Bisgrove 1988; Hussain and Lunven 1987; Wray 1986; Austin 1980; Basta 1977; Berg 1973) have attempted to address these issues,

8 For example, the slum population of Nairobi, Kenya, is reportedly increasing by 25-30 pe~t a year, compared with the city's total population growth rate of 6-8 percent a year. In Manila, Philippines, the slum population is growing at 7 percent a year, compared with 1.5 percent for the whole metropolitan area. Latin American cities grow at 4-6 percent a year, while their slums grow at 12-lS percent a year (Husaain and Lunven 1987).

10

but have been constrained by the limited data available. Hence, significant gaps remain in the literature. Crude indicators• have been used to develop a picture of the dimensions and distribution of urban poverty in developing countries, but a more thorough analysis is needed. These crude indicators of poverty are usually higher in peri-urban slums and shantytowns than in the general urban population. For example, broad differences in health indicators can be observed between squatter and nonsquatter settlements in Manila, Philippines (Table 8). Even when average infant mortality and

disease rates in cities are high relative to the norm, similar statistics for squatter settlements indicate far worse conditions.

While economists have long assumed that chang-es in household incomes are unambiguous indicators of changes in household welfare, many planners and government officials also consider health and nutrition-al status as indicators of social welfare (Alderman 1990), and the intrahousehold dimension requires attention. Insights into the causes of undernutrition assist planners in effectively meeting their social objectives (Gross and Solomons 1987).

Table 8-Characteristics of squatter and nonsquatter settlements in Manila, Philippines

Indicator Nonsquatter Squatter

Hospital bed to population ratio 1:300 1:4,000

Infant mortality rate (per 1,000 live births) 76 210

Birthrate (per 1,000 population) 33 177

Neonatal mortality rate (per 1, 000 live births) 40 105

Tuberculosis (per 100,000 population) 800 7,000

Gastroenteritis (per 100,000 population) 780 1,352

Typhoid (per 100,000 population) 33 135

Diphtheria (per 100,000 population) 48 77

Measles (per 100,000 population) 130 160

Source: S. S. Basta, "Nutrition and Health in Low-Income Urban Areas of the Third World," Ecology of Food and Nutrition 6: 113-124 (1977).

9 These include incidence of low birth weight, infant mortality rate, and pre' \lence of anemia and malnutrition.

11

4

Urban Food Insecurity and Malnutrition

Urbanization influences domestic food produc-tion and consumption, promotes rural-urban compe-tition for natural resources, and stimulates social and economic change, all of which affect the food security and nutritional status of urban populations (and, to a certain extent, that of rural populations). Naturally, not all of the urban population is affected in similar ways or to similar extents. Yet, the heterogeneity of cities has not been appropriately incorporated into food consumption and nutrition surveys, as several researchers have noted in recent years (Basta 1977; Wray 1986; von Braun 1987; Hussain and Lunven 1987; Popkin and Bisgrove 1988; Rossi-Espagnet 1987; Hussain 1990). It is difficult, therefore, to avoid making inequitable and discriminatory policy recommendations for certain population groups in urban areas. Future research on urban issues must take into account the diversity of urban populations.

URBAN POVERTY, ECONOMIC GROWTH, AND FOOD SECURITY

Problems with defmition and measurement, together with inadequate data, make it very difficult to know exactly how many households and individu-als (given different intrahousehold inequalities in different regions) are food insecure. There have been efforts to estimate the number of poor and food-insecure people in developing countries (World Bank 1986; Reutlinger and Selowsky 1976; FAO 1988; Broca and Oram 1991), but there are few estimates of the number of urban poor in developing countries. Using two criteria based on basal meta-bolic rate (BMR), 10 Hussain and Lunven (1987) calculated the percentage of the population, urban and rural, that was undernourished in eight countries

(Table 9). Under the more conservative estimate ( < 1.2 BMR), up to one-fourth of the urban population was malnourished in these eight coun-tries, and under the other estimate ( < 1.4 BMR), up to one-third was malnourished. However, esti-mates vary widely among the countries; the propor-tion of the population that was undernourished was higher in urban areas than in rural areas in five countries and lower in urban areas in the remaining three countries. As Hussain and Lunven (1987, 55) conclude, "this shows that dynamics of undernutri-tion and malnutrition may differ among populations and countries, and strongly suggests the need for further research to determine the extent and causes of urban hunger."

For effective policymaking, detailed knowledge is needed on the number and characteristics of urban food-insecure households and individuals, but in the meantime, the lack of precise numbers must not hinder conceptualization and implementation of policies to improve urban food security.

In the following discussion, aggregate as well as case study information is used to indicate the size and nature of the urban malnutrition problem. The nutritional information (anthropometric) mainly focuses on children. This is not to imply that there are not other urban population groups at risk. The magnitude and gravity of food insecurity and nutri-tional problems of the elderly, the urban homeless, and individuals with psychosocial disorders are far from known, for instance (Gross and Monteiro 1989). The impact of human immunodeficiency virus (HIV) infections can be expected to change the nature of urban communities, with the poor being particularly vulnerable. Contamination of the atmo-sphere and water supply as industrialization pro-ceeds places the entire urban community at risk, but

10 Their method involved "calculating from the distribution of dietary energy supply the number of people whose intake falls below certain minimum levels of energy requirements set by an FAOIWHO/UNU Expert Consultation on Energy and Protein Requirements as cutoff points below which people should be designated undernourished. These levels of requirements allow for only a minimum level of activity, below which maintenance of health is not possible, and thus provide a very conservative estimate of undernutrition" (Hussain and Lunven 1987, 55).

12

Table 9-Extent of undernutrition in selected developing countries

!,!ngjlrnQllri§hll!l PonullltiQn

manufactured goods or for services, such as a place to stay. Urban families may also grow their own food in home gardens or on lots on the perimeter of the city. Often, unemployed female members of urban households return to their rural birthplace during the planting and harvesting seasons and provide labor as a means of supple-menting their family's food supply (Bryceson 1989).

During times of economic growth, the urban poor generally benefit, as do most other popula-tion groups. However, economic growth may not always result in increased food consumption and improved nutritional status of the urban poor. For example, during the economic expansion in the Philippines in the 1970s, because real wages fell, the urban poor did not significantly improve their nutritional status, despite lower cereal prices (Bouis 1990a).

FOOD CONSUMPTION

There is little recent information on food consumption in urban areas of developing countries, and data comparing urban and rural food consump-tion are available for only a few countries.

Urban-Rural Differences

From the limited information available, it appears that per capita energy consumption is generally higher in rural than in urban areas (Table 10), regardless of income or expenditures. Similar findings are noted by other researchers (Arnauld 1983; FAO 1977; Allaya and Padilla 1983). This does not necessarily imply that urban residents are not as well nourished as rural residents, since their energy needs, costs for calories, and diet composi-tion may be different.

Moderate to severe nutritional deficiencies are common among the lower socioeconomic strata in both urban and rural settings. The effect of location on food availability and intake has not been completely resolved. Some of the urban poor may be more vulnerable to food insecurity than the rural poor who are engaged in subsistence agriculture. However, the rural landless and inhabitants of rural areas undergoing commercial-ization are particularly sensitive to food insecurity (von Braun and Kennedy 1986). The impact of seasonality in food availability also needs to be considered; the urban poor are subject to smaller seasonal fluctuations in food availability and, hence, in food intake than are the rural poor (Tomkins eta!. 1986).

14

It is reasonable to assume that rural occupa-tions tend to use more energy than urban occupa-tions, and, hence, rural energy requirements tend to be greater and the rural diet is more often based on staples (since staples are a relatively inexpensive source of calories) than is the urban diet (Bouis 1990b; Hussain 1990). However, the urban poor are often employed in manual activities, which are likely to have higher energy requirements than the average urban job.

Another possible reason for higher energy intakes in rural populations is that the staples pro-duced in rural areas are likely to be relatively cheaper to purchase locally, particularly from the producers themselves, thus avoiding middlemen retail costs (Bouis 1990b). Researchers (Monteiro et a!. 1987; Trairatvorakul 1984; Musgrove and Galindo 1988) have found that the cost of calories, particularly of cereals, sugar, and animal products, is lower in rural than urban areas. Within urban areas, calorie costs are higher in metropolitan areas than in small or midsized cities.

It is quite difficult to compare average urban and rural food consumption, health, and nutrition statistics, since averages may mask wide disparities across population groups, especially in terms of income distribution, which usually tends to be more skewed in urban than in rural areas (see the next section on intraurban differences). For instance, people such as slum dwellers and squatters easily slip through the statistical net because they are not officially accounted for, they are mobile, and they are not actively sought by data collectors. In partic-ular, rural migrants who have settled in poorer peri-urban areas, and whose numbers increase the more nutritionally vulnerable population of the city, are seldom included in nutritional surveys because they do not official! y exist (de Mello Amorozo and Shrimpton 1984).

lntraurban Differences

Little is known about intraurban differences in food consumption, and any comparisons face the same problems as comparisons of rural-urban data. A study from Manila, Philippines, shows that per capita energy intake was less by 200 calories in the slums than in the prosperous parts of the city (Basta 1977). Basta also finds, using per capita energy consumption data for income groups in northeast Brazil, that, in many cases, intraurban differences are greater than rural-urban differences. However, other researchers find that intraurban differences in energy availability are lower than or about the same as intrarural differences (Table 11).

Table 10-Per capita energy intake in urban and rural areas of selected developing countries

En~rgx Intake Urban Intake as Country Year Rural Urban Share of Rural Intake

(calories/capita/day) (percent)

Brazil 1960 2,640 2,428 92 Brazil 1974/75 2,208 2,051 93 East Brazil 1960 2,258 2,331 104 South Brazil 1970s 3,072 2,451 80 Trinidad and Tobago 1970 3,011 2,550 95 Bangladesh 1962/63 2,254 1,732 77 India 1975 2,090 1,480 71 Indonesia 1976 1,885 1,633 87 Pakistan 1965/66 2,126 1,806 85 Philippines 1978 1,769 1,872 106 Philippines 1982 1,797 1,831 102 Republic of Korea 1969 2,181 1,946 89 Sri Lanka 1981182 2,246 2,229 98 Thailand 1974 1,821 1,504 83 Thailand 1975/76 1,978 1,978 100 Algeria 1978 3,210 2,138 67 Chad 1965 2,467 2,113 86 Dahomey 1966/67 2,141 1,908 89 Egypt 1981182 2,654 2,798 105 Morocco 1970/71 2,888 2,521 87 Sudan 1978/79 2,824 2,137 76 Tunisia 1980 2,452 2,247 92

Sources: For East and South Brazil, J. E. Austin, C01!fronting Urban Malnutrition, World Bank Staff Occasional Paper 28 (Washington, D.C.: World Bank, 1980); for Brazil (1974/75), C. W. Gray, Food Consumption Parameters for Brazil and Their Application to Food Policy, Research Report 32 (Washington, D.C.: International Food Policy Research Institute, 1982); for Philippines, H. Bouis, "Evaluating Demand for Calories for Urban and Rural Populations in the Philippines: Implications for Nutrition Policy Under Economic Recovery," World Development 18 (February 1990), 281-299; for Thailand (1975/76), P. Trairatvorakul, The Effects on Income Distribution and Nutrition of Alternative Rice Price Policies in Thailand, Research Report 46 (Washington, D.C.: International Food Policy Research Institute, 1984); for Egypt, H. Alderman and J. von Braun, The Effects of the Egyptian Food Ration and Subsidy System on Income Distribution and Consumption, Research Report 45 (Washington, D.C.: International Food Policy Research Institute, 1984); for Brazil (1960), Trinidad and Tobago, Bangladesh, India, Indonesia, Pakistan, Republic of Korea, Thailand (1974), Algeria, Chad, Dahomey, Morocco, and Tunisia, Food and Agriculture Organization of the United Nations, The Fifth World Food Survey (Rome: FAO, 1985); for Sudan, The Democratic Republic of the Sudan, Ministry of Finance and Economic Planning, Household Income and Expenditure Survey 1978-80, Khartoum Province (urban), Khartoum, 1982; for Sri Lanka, N. Edirisinghe, The Food Stamp Scheme in Sri Lanka: Costs, Benefits, and Options for Modification, Research Report 58 (Washington, D.C.: International Food Policy Research Institute, 1987).

15

Table 11-Total calorie availability per adult equivalent, by income group and location in selected countries

Intraurban Difference Country Income Groups• Urban Rural Versus Intrarural Difference•

(calories/day)

Bangladesh 1 2,141 1,669 Smaller 2 2,242 1,985 3 2,303 2,187 4 2,523 2,561

India 1 1,929 1,972 Smaller 2 2,388 2,637 3 2,736 3,115 4 3,367 4,011

Indonesia 1 1,914 2,134 Same 2 2,345 2,632 3 2,723 3,094

Pakistan 1 1,935 2,335 Smaller 2 2,005 2,467 3 2,012 2,664 4 2,165 2,910

Sri Lanka 1 1,738 1,828 Smaller 2 2,234 2,385 3 2,598 2,914 4 2,882 3,408

Thailand 1 2,207 2,255 Same 2 2,463 2,618 3 2,704 2,790 4 3,019 3,055

Egypt 1 2,420 2,273 Smaller 2 2,850 2,892 3 3,072 3,409 4 3,731 4,571

Philippines 1 1,540 1,598 Larger (approximate 2 1,612 1,722 income quintiles) 3 1,711 1,830

4 1,909 1,976 5 2,165 2,099

Brazil' 1 1,713 1,963 Larger 2 2,008 2,162 3 2,293 2,369

Sources: For all countries except Brazil, H. E. Bouis, "Prospects for Rice Supply/Demand Balances in Asia" (International Food Policy Research Institute, Washington, D.C., 1989, mimeographed); for Brazil, C. W. Gray, Food Consumption Parameters for Brazil and Their Application to Food Policy, Research Report 32 (Washington, D.C.: International Food Policy Research Institute, 1982).

• These groups are variously shown as terciles, quartiles, or quintiles, except for Brazil. • "Larger" ("smaller") means that the relative difference in consumption between top and bottom income groups in urban areas is larger (or smaller) than in rural areas. "Same" indicates cases where differences are below 5 percent. ' The lowest 30 percent, the middle 50 percent, and the highest 20 percent of the population, respectively.

16

Changes in Dietary Patterns Through Urbanization

Urbanization is associated with important changes in food consumption patterns. Rural dwell-ers eat a more plentiful (higher-calorie) but less diversified diet, whereas the urban diet may be more varied and may include higher levels of animal proteins and fats while being lower in calories. Fresh foods, vegetables, meat, poultry, and milk and dairy products are consumed more by urban than by rural people.

Research on Bangladesh, India, Pakistan, Sri Lanka, and Thailand finds that while urban con-sumption of meat is higher than rural consumption, rural consumption of staple foods tends to be higher than urban consumption for the same income quar-tile (Bouis 1992). The latter is particularly true for rice, the main staple in these countries. Bouis offers two possible explanations for this pattern: (1) rural populations may be engaged in more active occupa-tions and have higher energy requirements, and (2) rice may be cheaper to obtain in rural areas, espe-cially by rice producers themselves. Bouis also finds that consumption of staples tends to rise more rapidly with income in rural than in urban areas. Urban consumption of vegetables and fruits is higher than rural consumption in these countries, except in Sri Lanka.

Surveys from Tunisia show that in smaller cities consumption of locally grown durum wheat products was half that of rural areas, and in the larger cities it was only one-fourth; imported wheat flour was often substituted (Perisse and Kamoun 1987). According to Hussain (1990), the trend in cities is for traditional carbohydrate sources to be replaced by sugar, soft drinks, highly milled cereals, and other processed foods.

Some researchers contend that, on the whole, the nutrition of urban populations is more balanced than that of rural people (Austin 1980; Hussain 1990; Popkin and Bisgrove 1988). Other researchers question whether this is the case; when the diets of rural migrants to Mexico City are compared with those of the families that stayed behind, it appears at first glance that the migrants are better-Qff nutri-tionally (Cerqueira 1984). However, when intakes of fat and salt are compared, along with blood cholesterol levels and blood pressure, it may be suggested that 10 years after leaving their village, the migrants are encountering health problems common among urban populations in developed countries (fable 12). ·

In The Gambia, recent migrant households consumed significantly more calories than other households and received their additional caloric intake from more dairy products, fish, oils, sugar,

fruits, and vegetables (folvanen 1992). For children from urban-born, short-term migrant, and long-term migrant households, there was no difference in mean values of common nutritional indicators, such as weight-for-age, height-for-age, and weight-for-height, although the mean values were significantly higher for urban than for rural children.

Field-Horine (1967) noted that a decline in breast-feeding in urban areas of Africa was accom-panied by a rising incidence of kwashiorkor and diarrheal and infectious diseases. Consumption of white bread aod polished rice in urban areas reduced vitamin B intake and, in some cases, introduced the problem of beriberi.

In Sub-Saharan Africa, a strong tendency has been observed in urban areas for the so-called "pre-ferred" cereals of wheat, rice, and maize to displace traditional African staples such as sorghum and millet. More highly milled grain (a whiter and fmer ·product with a reduced nutritional content) also tends to be preferred. In Latin America, wheat, sugar, oil, aod animal protein intake has increased, while intake of the more traditional staple foods based on com, beans or other legumes, and tubers has decreased.

Another change that has occurred in urban food consumption habits is an increase in the amount of food eaten outside of the household. These foods tend to be eaten by the roadside and are quite cheap. Ease of preparation, savings of time and money, taste, identification with an urban lifestyle, and inaccessibility to cooking facilities in crowded urban slums are among the reasons for the shifts in food consumption patterns (Delgado 1989). The value of women's time is an important factor affecting household expenditure on food; in C6te d'Ivoire, the opportunity cost of women's time was found to be positively correlated with household expenditures on bread and rice, and negatively correlated with expenditures on traditional staples such as maize, cassava, and yams, which require more preparation (Abdi 1992). A greater variety of foods is also available in urban areas, leading to more diversified diets. Studies show that a desire for dietary variety influences people's food choices (Shah 1983; Reardon, Delgado, and Thiombiano 1992).

Micronutrients

Little information is available on rural-urban differences in consumption of micronutrients. Information from a slum in Manaus, Brazil, indi-cates that the lower income class tended to meet a smaller amount of its energy and nutrient require-ments than did the higher income class (fable 13), and that micronutrient deficiencies were much more

17

Table 12-Energy and nutrient intakes and health indicators of rural-to-urban migrant and rural families, Mexico

R!!rlll-1!!-l!rl!m MiCiant Fil!!lili!l!! Rurlll Fll!llili!l§ Standard Standard

Intake/Indicator Mean Deviation Adequacy Mean Deviation Adequacy

(percent) (percent) Energy and nutrient intake

Energy (calories) 2,134 428 93 1,869 431 7l

Protein (grams) 72 26 100 58 13 82

Carbohydrate (grams) 236 49 351 57

Fat (grams) 131 48 42 23

Calcium (milligrams) 440 239 70 605 279 91

Iron {milligrams) 10 6 73 8.6 3.9 60

Vitamin C (milligrams) 86 21 170 82 26 168

Retinol (milligrams) 581 230 83 935 208 94

Salt (grams) 5.5 2 2.5 1.5 Health indicators

Cholesterol (milligrams) 612 235 354 109

Plasma levels (milligrams/liter) 364 180 190 47

Diastolic blood pra~sure (millimeters of mercury) 100 10 70 10

Source: M. T. Cerqueira, "Effects of Urbanization and Acculturation on Food Habits: Studies in Mexico," in Malnutrition: Determinants and Consequences; Proceedings of the Western Hemisphere Nutrition Congress, VII (New York: Alan R. Liss, 1984).

Note: Data are means and standard deviations of group values (men, women, and children).

prevalent among lower-income families than among higher-income families (Table 14). The difference in consumption was most marked in the case of vita-min A. Energy sufficiency does not ensure micronu-trient sufficiency; whereas only 15 percent of lower-income families in Manaus were energy deficient, 75 percent were deficient in vitamin A, 50 percent were deficient in thiamine, and 100 percent were deficient in zinc (Table 14).

Role of Income and Prices

Food consumption is greatly influenced by income levels and food prices. On average, consump-tion of calories increases with income in both rural and urban areas, but it increases to a greater extent in rural areas. In both areas, marginal intake of calories decreases with increasing income levels, but this effect

18

is more pronounced in urban areas. Data from Brazil (Gray 1982), presented in Table 15, confirm this pattern; at all income levels, any additional expenditure provides more calories to rural than to urban consum-ers, and as incomes increase, fewer calories are obtained for each additional cruzado spent by urban or rural consumers.

When patterns of nonfood expenditures in Brazil were analyzed, Gray (1982) found that not only did minimum nonfood requirements cost more in urban areas, but, even for the most malnourished groups, the desire to increase consumption of nonfood goods was at least as strong as the desire to increase food intake.

Income was identified as the most important factor explaining nutritional status in the Brazilian study (Gray 1982). Nevertheless, the income elasticity of food consumption was quite low. Musgrove (1988)

Table 13-Per capita dally energy and nutrient consumption and adequacy by income class in Manaus, Brazil

Income !:;li!§s Energy /Nutrient Lower Higher All

Energy Calories 1,776 2,312 2,044 Percent" 86 110 98

Protein Grams 62 79 70 Percent" 169 208 189

Vitamin A Milligrams 270 649 460 Percent" 53 116 85

Thiamine Milligrams 0.6 0.8 0.7 Percent" 71 94 83

Riboflavin Milligrams 0.7 1.0 0.9 Percent" 63 89 76

Iron Milligrams 16 19 17 Percent" 165 184 174

Zinc Milligrams 5.3 7.1 6.2 Percent" 44 55 50

Source: M. C. de Mello Amorozo and R. Shrimpton, "The Effect of Income and Lenglh of Urban Residence on Food Patterns, Food Intake, and Nutrient Adequacy in an Amazonian Peri-Urban Slum Population," Ecology of Food and Nutrition 14 (4): 307-323 (1984).

• Percent refers to percentage of recommended intake.

Table 14-Energy- and nutrient-deficient families, by income group in a Manaus slum, Brazil

Defi!;;iencl: bl: Income Clas§ Energy /Nutrient Lower Higher

(percent) Energy 15 4

Protein 0 0 Vitamin A 75 41

Thiamine 50 26

Riboflavin 60 30 Iron 0 0 Zinc 100 74

Source: M. C. de Mello Amorozo and R. Shrimpton, "The Effect of Income and Lenglh of Urban Residence on Food Patterns, Food Intake, and Nutrient Adequacy in an Amazonian Peri-Urban Slum Population," Ecology of Food and Nutrition 14 (4): 307-323 (1984).

19

Table 15-Mean calorie intake per capita and income elasticities for calorie intake by income group, Brazil, 1974/75

Low~t ~Q P~r£1lnt Mil!!ll~ ~Q fm~ Hi&h!l§l 2Q P~r£1lnt Indicator Urban Rural Urban Rural Urban Rural

Mean calorie intake 1,713 1,963 2,008 2,432 2,293 2,771 per capita

Mean expenditure per capita 1,712 1,151 (Cr$)

3,698 2,429 16,934 8,685

Marginal calorie intake' 0.280 0.793 0.097 0.202 0.005 0.018

Source: C. W. Gray, Food Consumption Parameters for Brazil and Their Application to Food Policy, Research Report 32 (Washington, D.C.: International Food Policy Research Institute, 1982).

• This is the increase in daily per capita calorie intake from an increase of Cr$1.00 in annual per capita income.

suggested that if this was the case, food consumption and nutritional status are not as closely associated as expected, or else poor households did not recognize malnutrition and therefore did not devote additional income to overcoming it. Either conclusion suggests that nutritional knowledge, food habits, and preferenc-es may have large effects on nutritional status.

The budget share allocated to food and bever-ages varies across income groups. In Thailand, Trairatvorakul (1984) identified four consumer groups according to iocome level (low or high) and adequacy of calorie intake (deficient or nondeficient) and noted that (1) the high-iocome energy-deficient groups withio each area had the highest average cost of calories and high margioal costs; and (2) budget shares allocated to food and beverages were lowest io the urban high-iocome energy-deficient group, followed by the rural Iow-iocome energy-deficient group, which may be extremely poor (Table 16). Calories from rice appear to explaio the difference between deficiency and nondeficiency io the two low-iocome groups (Trairatvorakul 1984).

It is argued that the poor tend to pay more per unit of consumption because they are forced ioto "inefficient shoppiog practices" (Popkin and Bisgrove 1988). They tend to purchase io smaller quantities and to purchase from a number of sources rather than purchasiog io bulk, sioce they lack storage facilities and a source of ready cash. Because they tend not to be located near large supermarkets, they also have to pay more for transportation, io both money and time, to purchase from such locations.

Household budget surveys (for 1975, 1980, and 1985) of income (usiog expenditure as a proxy) and

20

consumption from Tunisia found that, after adjusting for iocome level, expenditures on food were nearly the same io urban and rural areas (Perisse and Kamoun 1987). Calorie costs rose rapidly with changes io consumption patterns. At very low income levels, io both rural and urban areas, consumers were already eating minimal amounts of expensive calories (from meat, milk, fish, and fruit). They could not reduce their consumption further and therefore had little if any scope for changiog their consumption patterns to reduce the cost of their diet. They were thus extremely vulnerable to iocreases io the price of staples.

A limited price iocrease may create a temporary ioconvenience for middlt7elass households, who can adjust their budgets without any serious effect on their nutrition. The same price iocrease, however, becomes a nightmare for poor households, not only because their budgets are smaller, but also because it affects a larger proportion of their total diet, with a danger of causiog energy and nutrient deficiencies (Perisse and Kamoun 1987).

The importance of iocome as the most powerful determinant of nutrient and energy adequacy is a critical issue. Musgrove's (1988) work on Brazil arrives at three major conclusions. First, the greater variation io elasticities of purchased foods among iocome groups io metropolitan areas than io rural areas possibly reflects the typically smaller budget for food io urban areas, so that a given iocrease io a low total expenditure base allows a larger proportional iocrease io spendiog for food. Second, the iocome effects of price iocreases are generally more sensitive to iocome levels than previously recognized, with elasticities sometimes being quite high when incomes are low.

Table 16-Calorie intake, budget shares, and costs of different population groups, Thailand, 1976177

Urban Ryra! Indicator LID HID LIND IDND LID HID LIND HIND

Calorie intake/adult/day 1,886 1,905 3,193 3,378 1,961 1,995 3,148 3,371

Average budget share of food 56 44 61 48 61 49 66 55 and beverages (percent)

Marginal budget share of 28 11 37 15 13 15 33 17 food and beverages (percent)

Average calorie cost 3.38 5.14 2.95 4.36 2.39 3.59 2.15 3.03 (baht/1,000 calories)

Marginal calorie cost 2.75 3.56 2.45 3.58 1.95 2.65 1.67 2.23 (baht/1,000 calories)

Source: P. Trairatvorakul, The Effects on Income Distribution and Nutrition of Alternative Rice Price Policies in Thailand, Research Report 46 (Washington, D.C.: International Food Policy Research Institote, 1984).

Notes: Calorie deficient is defined as less than 2,500 calories daily per adult. Nondeficient groups consume more than this. Low income means monthly incomes of less than 291.14 baht (urban) and 205.15 baht (rural); high income means monthly incomes of more than these amounts.

LID = low income, calorie deficient. HID = high income, calorie deficient. LIND = low income, calorie nondeficient. HIND = high income, calorie nondeficient.

According to Musgrove, this may partly explain the paradox noted earlier of low incomes appearing to be the chief cause of malnutrition, while additional income on average results in only a small increase in consumption. Third, poor Brazilian families use their extra income to improve the quality and variety of their diet (particularly by substituting rice for manioc flour), without necessarily increasing total calorie intake appreciably, even when con-sumption is quite inadequate. Thus, as prices or incomes change, there is a greater tendency among urban consumers to diversify their diet and substi-tute more readily. This reflects the greater variety of foods available in cities and, to a lesser extent, the higher relative prices for the cheapest tradi-tional staples. Surveys from Lima, Peru, also indi-

cate that food prices and availability significantly influence consumption patterns and nutrient sources in the diets of the urban poor (Kanashiro and Graham 1984).

DEFICIENCIES IN CHILDREN'S NUTRITIONAL STATUS

Anthropometric indicators of children's growth are a widely used measure of nutritional status. 12

Data from 33 developing countries suggest that the nutritional status (as measured by the preva-lence of underweightedness, stunting, and wasting) of urban children is generally better than that of rural children (fable 17). In almost all of the countries with available data, the proportion of rural

12 Acute malnutrition or wasting occurs when there is a fairly rapid loss in weight. It is measured by comparing a child's weight relative to that expected for a child of the same height and sex from a reference population. The weight-for-age index thus developed is an indicator of the medium-term nutritional status of a child. Chronic malnutrition or stunting occurs over a longer period of time and is measured by compariog the height of a child relative to a population standard for the same age and sex. The height-for-age index thus developed is an indicator of the long-term nutritional status of a child.

21

Table 17-Prevalence of malnutrition in chlldren aged 0-59 months, by rural and urban location

Urban Population Pr~vl!!~n~ Qf Ml!!nmritiQif Share of Underweight Smnting Wasting

Country Year Total (1990) Rural Urban rtu• Rural Urban rtu• Rural Urban rtu•

(percent) (percent) (percent) (percent) Africa Burundi 1987 25 38.9 20.2 1.9 48.8 27.1 1.8 5.6 6.5 0.9 Egypt 1988 49 17.0 8.9 1.9 35.1 25.5 1.4 0.9 1.3 0.7 Ghana 1987-88 33 31.4 22.8 1.4 20.4 12.1 1.7 7.7 9.9 0.8 C6te d'lvoire 1986 47 13.7 10.3 1.3 36.1 24.8 1.5 8.0 6.6 1.2 Kenya 1978-79 24 n.a n.a n.a 36.8 26.4 1.4 5.0 6.8 0.7 Lesotho' 1976 20 24.9 18.7 1.3 23.7 21.6 1.1 4.3 3.0 1.4 Madagascar 1983-84 25 36.9 28.4 1.3 37.7 28.8 1.3 12.9 10.5 1.2 Mali 1987 19 33.8 25.7 1.3 26.7 19.7 1.4 11.1 10.7 1.0 Mauritius 1985 42 26.6 20.2 1.3 n.a n.a n.a 18.4 13.1 1.4 Morocco 1987 49 19.7 8.0 2.5 29.8 17.2 1.7 4.7 1.9 2.5 Niger 1985 20 53.0 27.4 1.9 39.5 22.0 1.8 24.2 14.9 1.6 Nigeria 1983-84 35 n.a n.a n.a n.a n.a n.a 24.4 21.1 1.2 Senegal 1986 38 25.2 15.2 1.7 25.5 17.7 1.4 7.2 4.5 1.6 Sierra Leone' 1978 32 32.4 24.3 1.3 26.6 17.4 1.5 3.2 3.2 1.0 Togo 1988 26 27.8 15.9 1.7 33.0 21.3 1.5 5.9 3.7 1.6 Tunisia 1988 54 14.0 6.7 2.1 24.6 11.8 2.1 2.7 3.4 0.8 Uganda 1988 10 24.3 12.8 1.9 46.3 35.6 1.3 2.0 1.0 2.0 Zimbabwe 1988 28 13.6 5.2 2.6 33.6 14.3 2.3 1.3 1.5 0.9

Asia Bangladesh' 1985-86 14 61.6 50.2 1.2 57.6 44.2 1.3 8.2 6.9 1.2 Indonesia' 1987 29 54.8 40.6 1.3 n.a n.a n.a n.a n.a n.a Myanmar 1983-85 25 39.2 34.4 1.1 51.7 44.3 1.2 10.4 7.5 1.4 Sri Lanka 1987 32 38.7 27.6 1.4 26.6 21.8 1.2 13.6 13.4 1.0 Thailand 1987 23 28.6 11.7 2.4 24.5 11.3 2.2 6.0 4.3 1.4 Yemen Arab Republic 1979 25 78.9 58.4 1.4 62.7 48.4 1.3 10.9 3.4 3.2

Yemen, PDR 1982-83 43 27.3 19.4 1.4 38.7 20.0 1.9 6.5 8.2 0.8

Americas Bolivia 1981 51 18.0 9.9 1.8 49.5 34.5 1.4 0.6 0.7 0.9 Brazil 1986 77 15.5 9.8 1.6 35.2 21.3 1.7 0.9 0.9 1.0 Colombia 1986 70 14.7 10.2 1.4 27.8 19.3 1.4 0.7 1.2 0.6 Dominican Republic 1986 60 16.6 9.6 1.7 28.8 15.1 1.9 2.5 2.2 1.1

Guatemala 1987 42 36.5 25.6 1.4 62.1 47.2 1.3 14.2 10.8 1.3 Jamaica 1985 52 8.9 7.0 1.3 n.a n.a n.a n.a n.a n.a Peru 1984 70 22.6 6.5 3.5 56.7 23.7 2.4 1.1 0.8 1.4 Trinidad and Tobago 1987 26 8.2 5.0 1.6 5.0 5.0 1.0 4.6 2.7 1.7

Source: Derived from data compiled by B. A. Carlson and T. M. Wardlaw, A Global, Regio1Ull and Country Assessment of Child Malnutrition, UNICEF Staff Working Paper 7 (New York: UNICEF, 1990).

Note: n.a. means not available. (continued)

22

Table 17-Continued

• Percent below -2 standard deviations from median of reference population unless otherwise stated. • The r/u ratio is the ratio of the prevalence of rural malnutrition to urban malnutrition. A ratio of 1.0 indicates equality, 1.5 indicates that the rural prevalence is 50 percent higher than the urban, and 0.5 indicates that the rural prevalence is half that of the urban. ' Underweight: < 80 percent of reference median. Stunting: < 90 percent of reference median. Wasting: < 85 percent of reference median. • Underweight: < 80 percent of reference median. Stunting: < 90 percent of reference median. Wasting: < 80 percent of reference median. 'Underweight: < 75 percent of reference median. Stunting: < 90 percent of reference median. Wasting: < 80 percent of reference median. 1 Underweight: < 80 percent of reference median.

preschool children who are malnourished is greater than the respective proportion in urban areas-on average, it is 1.6 times higher with respect to the underweightedness measure, 1.5 times higher with the stunting measure, and 1.2 times higher with the wasting measure. Nevertheless, the prevalence of malnutrition in large, primary cities approaches that of rural areas in some countries, possibly reflecting the poor living conditions of a larger percentage of low-income households and the difficulty of meeting the demand for services in rapidly growing metropo-lises. Smaller cities and towns appear to have lower rates of malnutrition. Countries with a high degree of urbanization tend to have a lower prevalence of underweight preschoolers than countries with a low degree of urbanization (fable 18).

Urban malnutrition rates are generally given for urban areas as a whole and do not distinguish between children in slums and shantytowns and those in the more prosperous middle-class areas. Separate rates for children from urban slums are generally not available, but it is likely that malnu-trition levels in many countries are higher in urban slums than in the average rural area. There are few well-designed studies that systematically include children from low-income urban families living in slums, which qualifies confidence in the findings reported here. Given the growing size of underserved urban populations, survey practices should be corrected so that future nutritional status surveys are designed to provide estimates for urban slum areas.

A more detailed examination of the rural-urban prevalence of malnutrition finds that in Egypt, for instance, the rate of malnutrition in Cairo-Giza is nearly as high as that in the "lower" rural areas of Egypt (fable 19); small towns and cities have the lowest rates of stunting (Jansen 1985). In Ghana, no clear pattern of nutritional

status by expenditure level and location emerges, except that the percentage of urban children who are chronically malnourished is slightly lower (fable 20). In Morocco, in 1973, the prevalence rates for protein-energy malnutrition in low-income urban areas were somewhat similar to rates in rural areas and somewhat higher than the average rates for urban areas as a whole (fable 21). In Saudi Arabia, detailed studies (Serenius 1988; Serenius and Swailem 1988; Serenius, Fougerouse, and Sebai 1988) show large differ-ences in prevalence rates of malnutrition in pre-school children from rural, less-privileged urban, and privileged urban households (fable 22). Al-though privileged Saudi children have growth patterns resembling those of Western reference populations, the growth of the less-privileged and rural children becomes progressively worse.

Generally, urban children tend to be taller and heavier than their rural counterparts, but the differences in growth between them are narrow-ing. For instance, in China, a survey of children from birth to seven years in 1985 noted that, in relation to a previous survey conducted in 1978, urban-rural differences in growth still persist-ed-urban children being taller and heavier than their rural peers-but the difference had become consistently smaller (Zhang and Huang 1988).

Aggregate Income Effects

The relationship of rural and urban malnutri-tion to per capita gross national product (GNP) in some developing countries is depicted in Figure 2. Table 23 contains regression analyses of three models that explore the extent to which urban malnutrition (the prevalence of underweight pre-schoolers) is related to national income (GNP), degree of urbanization, and concentration of urban

23

Table 18-Per capita income, gross domestic product growth, degree of urbanization, and urban nutritional status in selected developing countries

Gross Urban Share of Urban National Average Annual Population Population in Prevalence of Product Gross Domestic Share of Total Cities of More Underweight

per Capita Product Growth Population Than 1 million Children Aged Country 1989 1980-89 1989 (1990) 0-59 Months•

(US$) (percent) (percent) (percent) (percent)

Myanmar n.a. n.a. 25 32 34.4 Sierra Leone 220 0.6 32 n.a. 24.3 Bangladesh 180 3.5 16 47 50.2 Madagascar 230 0.8 24 n.a. 28.4 Mali 270 3.8 19 n.a. 25.7 Burundi 220 4.3 5 n.a. 20.2 Uganda 250 2.5 10 n.a. 12.8 Nigeria 250 -0.4 35 24 Niger 290 -1.6 19 n.a. 27.4 Kenya 360 4.1 23 27 Togo 390 1.4 25 n.a. 15.9 Ghana 390 2.8 33 22 22.8 Lesotho 470 3.7 20 n.a. 18.7 Sri Lanka 430 4.0 21 n.a. 27.6 Yemen (PDR) 650 28 n.a. 19.4 Yemen Arab Republic 58.4 Indonesia 500 5.3 30 33 40.6 Bolivia 620 -0.9 51 33 9.9 Zimbabwe 650 2.7 27 n.a. 5.2 Senegal 650 3.1 38 53 15.2 Egypt 640 5.4 46 52 8.9 Dominican

Republic 790 2.4 59 51 9.6 COte d 'lvoire 790 1.2 40 45 10.3 Morocco 880 4.1 47 36 8.0 Guatemala 910 0.4 39 n.a. 25.6 Thailand 1,220 7.0 22 57 11.7 Jamaica 1,260 1.2 52 n.a. 7.0 Colombia 1,200 3.5 69 39 10.2 Tunisia 1,260 3.4 54 37 6.7 Peru 1,010 0.4 70 41 6.5 Mauritania 500 1.4 45 n.a. 20.2 Brazil 2,540 3.0 74 47 9.8 Trinidad

and Tobago 3,230 -5.5 68 n.a. 5.0

Sources: World Bank, World Development Repon 1991 (Washington, D.C.: World Bank, 1991); B. A. Carlson and T. M. Wardlaw, A Global, Regional, and Country Assessment of Olild Malnutrition, UNICEF Staff Working Paper 7 (New York: UNICEF, 1990).

Note: n.a. means not available.

• Percent below -2 standard deviations from median of reference population unless otherwise stated in Table 17.

24

Table 19-Prevalence of malnutrition in preschool-aged children, Egypt, 1978

Sample Wasting and Geographic Area Size Wasting Stunting Stunting

(percent)

Lower Egypt (rural) 3,552 0.5 21.5 0.3

Upper Egypt (rural) 1,784 0.2 27.0 0.6

Large villages 889 24.0 0.3

Small towns 894 0.3 14.5 0.2

Small cities 897 0.3 10.6

Major cities

Cairo-Giza 890 0.6 18.8 0.2

Alexandria 888 0.1 15.7 0.1

Source: G. R. Jansen, "The Nutritional Status of Preschool Children in Egypt," in Minerals in Food and Nutrition Topics: World Review of Nutrition and Dietetics, vol. 45, ed. G. H. Bourne (Basel: Karger, 1985), 42-{)7.

Notes: Wasting is defined as less than 80 percent of National Center for Health Statistics (NCHS) standard. Stunting is defined as less than 90 percent of NCHS standard.

Table 20-Prevalence of child malnutrition by location and by per capita expenditure decile, Ghana

Per Capita Rural Jlrban Expenditure Sample Chronic Acute Sample Chronic Acute Decile Size Malnutrition Malnutrition Size Malnutrition Malnutrition

(percent) (percent)

1 215 33.5 11.1 27 25.9 7.4

2 204 33.8 7.3 42 33.3 2.3

3 208 37.9 10.1 35 22.9 2.9

4 194 41.2 7.2 50 24.0 10.0

5 188 30.9 2.7 55 20.0 3.6

6 169 34.3 9.5 76 21.1 2.6

7 146 36.9 5.5 97 26.8 5.1

8 142 28.8 9.9 102 22.5 7.8

9 117 37.6 9.4 128 17.9 7.8

10 106 22.6 16.0 137 18.3 7.3

Source: H. Alderman, Nutritional Status in Ghana and Its Determinants, Social Dimensions of Adjustment in Sub-Saharan Africa Working Paper 3 (Washington, D.C.: World Bank, 1990).

25

Table 21-Proportion of chlldren with severe protein-calorie malnutrition in Morocco, 1973

Age

(months)

3

9

15

21

27

33

39

45

Average Urban

1.0

2.0

2.5

2.5

3.0

Figure 2-Rural and urban maluutrition related to gross national product per capita in developing countries

Malnutrition (percent)

•• sa

•• 38

'X ' ' ZB . ' .... ,.

' 18

x Rura 1 • Urban

'~: xx R~al ~- . • --~----.:_ ____ --;,-· Urban

a+----r---1----+---~---+----+---~ 8 288 488 688 888 1888 1288 1488

Gross National Product (1987 US$)

Sources: World Bank, World Development Repon 1989 (New York: Oxford University Press, 1989); and B. A. Carlson and T. M. Wardlaw, A Global, Regional and Country Assessment of Child Malnutri-tion, UNlCEF Staff Working Paper 7 (New York: UNlCEF, 1990).

population in large cities. 13 The regression results suggest that GNP has a strong effect on nutritional improvement in urban areas, but a declining effect at the margin. Doubling GNP per capita from US$300 to US$600 suggests a reduction in malnutri-tion of 10 percentage points (note that the mean is 16.4 percent), according to Model 2. The specifica-tions of Models 1 and 3 include urban population shares as explanatory variables, which may entail some multicollinearity problems due to the relation-ship between GNP and urbanization. Nevertheless, in none of the specifications did the degree of urbanization or the urban concentration in large cities turn out to be significant.

Investigations into the prevalence and determi-nants of malnutrition in C6te d 'lvoire and in Ghana suggest that expenditure on consumption (as a proxy for permanent income) is an important determinant of chronic malnutrition, although it does not appear to have a significant effect on acute malnutrition (Sahn 1990; Alderman 1990). However, mothers with more education are less likely to have children who suffer from acute malnutrition. Other studies also suggest that the educational level of mothers and the children's health environment contribute to children's nutritional status (Garcia and Alderman 1990; Sahn 1990; Alderman 1990). Garcia and Alderman (1990) note that physiological and envi-ronmental factors such as limited stomach capacity, cultural practices, feeding and weaning practices, sanitation, and water quality may play a bigger role than increases in income in determining the nutri-tional status of preschoolers and infants. Studies from Saudi Arabia show that although the material standard of living for less-privileged Saudi families was relatively high, 14 the educational attainment of the parents was low, and the poor education of mothers was identified as a risk to children's health (Serenius and Swailem 1988; Serenius and Hofvander 1988). The relationship between income and food consumption observed in the general population may not hold true among children be-cause of possible differences and inequitable alloca-tion of food, relative to need, within the household.

Numerous studies from around the world report that the incidence of stunting peaks from about 6 to 36 months of age (Jansen 1985; IRD and Burundi 1988; IRD and Liberia 1988; IRD and Senegal 1988, IRD and Ghana 1989; IRD and Institut du Sahel 1989; IRD and Nigeria 1989; and IRD and Uganda 1989). It is not coincidental that this occurs during the period when children are being weaned from breast milk onto other substi-tutes and solid foods. Breast -feeding and weaning are recognized as being critical periods in determin-ing the nutritional status of children.

Breast-Feeding

The nutritional status of urban children is affected by the almost universal decline in breast-feeding in low-income households in the developing world" and by the concomitant increase in the use

13 The differing age ranges of children included in the surveys are accounted for by a dummy variable. 14 Half of the families had their own house, 90 percent owned a car, and the mean monthly income was US$800.

15 Breast-feeding is much more common in Asia, where, in most countries, 90 to 97 percent of infants are still breast-fed at the age of six months, than in Latin America, where a significant percentage of infants have never been breast-fed (Popkin, Bilsborrow, and Akin 1982). In Africa and the Near East, breast-feeding patterns are intennediate between Asia and Latin America.

27

Table 23-National income, urbanization, and urban nutrition: regression analyses for 20 countries

Exogeno!!l! Variillll~ Urban Urban Popula- Dummy for

Gross (Gross Population tion Share in Age-Group National National Share Large Cities Differences

Model Product Product)2 (1988) ( > l Million) in Survey" Constant R•

Modell: -0.0353 l.296(E-5) -0.1927 -0.1126 -2.134 47.68 .37 (-1.74) (1.65) (-0.95) (-0.61) (-0.44)

Model2: -0.0467 l.54l(E-5) -0.0896 -1.381 45.20 .37 (-2.85) (2.08) (-0.49) (-0.29)

Model3: -0.0381 l.382(E-5) -0.1765 -1.629 42.84 .40 (-1.97) (1.82) (-0.90) (-0.35)

Mean 779.5 814,745 40.70 47.55 0.55

Standard deviation 466.9 1,035,982 19.00 12.64 0.51

Notes: t-statistics are in parentheses. The dependent variable is the percentage of children below -2 Z-scores of weight-for-age (mean, 16.35; standa