Module 8: Nutrition

Thus far, we’ve considered how the limitations of healthcare personnel can shape the delivery of healthcare, and how the limitations of technology have considerable impact in the developing world. In these next few modules, we will consider some of the social determinants of health, such as the upstream factors that are not necessarily linked to the healthcare domain, but which are equally if not more important in determining one’s health outcome. The opinion that health must be considered broadly is expressed in the following view:

“No infrastructure investment leads to better health outcomes unless it is accompanied by consumables that allow patients to live without malnutrition, unattended injuries and grave personal danger, and to live with clean drinking water and primary education, including fundamental knowledge about the causes of illness. Investments in these dimensions are as important to health outcomes as investments in interventions commonly classified as healthcare. No investment in health systems is efficacious, much less sustainable, unless these prerequisite complementary conditions are satisfied.”(1)

The challenge in developing primary care programs are often undervalued because ongoing impact in communities is frequently not measured in the organization’s impact(2). A basic level of primary care is a prerequisite to future successful interventions.

The Challenge of Food Delivery

Any solution to the food shortage problem must be sustainable and go beyond one-time food supplies. Food is a basic human right that is a primary social determinant of health. For an individual to have food security, food needs to be accessible, affordable, and nutritious. The long-term effects of food deprivation can be severe and lead to lower country productivity. (3) In Rwanda, 22 % of children are underweight and 50 % are growth-stunted. Nutritional defects can lead to neural tube defects (insufficient folic acid), night blindness (vitamin A), and goiters (iodine). Food deprivation can be prevented by three main strategies: using vitamin supplements, fortifying food, or providing a balanced diet.

While straightforward in theory, the use of vitamin supplements can be expensive.(4) Fortification does seem more economically feasible, as it costs between 2 and 80 cents per year per individual to operate, and can prevent up to 6 % of GDP loss.(5) Although purchasing and donating food to provide individuals with a balanced diet is challenging because of volatile food prices, there is an alternative: promoting local communities to grow their own food, which is the more sustainable practice. Indeed, Africa has the lowest food productivity in the world, having yields of approximately 1 ton per hectare in Africa, in contrast to the 3-5 tons per hectare in other areas of the world.(6) Much of this disparity is due to poor farming practices such as using poor quality seeds and too little fertilizer.

A Case Study: Gardens for Health International

The scourge of HIV/AIDS now affects approximately 30 million individuals, most of whom live in Sub-Saharan Africa. Over the past 20 years, medical researchers and physicians have used antiretroviral drugs to effectively slow the progression and the transmission of the disease, allowing individuals to survive for long periods with the disease. Although the cost of the drugs was once a barrier to care, charitable foundations such as the Clinton Foundation have worked to make HIV/AIDS therapy affordable around the world. Administering drugs to patients is one thing, but healthcare workers soon realized that the antiretroviral drug therapy in many cases was not reaching optimal efficacy. This inefficacy was partly due to the malnourishment of the patients; even hospitals often did not have the resources to supply their patients with food.(7)  This level of malnourishment weakened the immune system of the patients, and made them less able to properly absorb their medication.

In 2006, Gardens for Health International was formed to promote sustainable food practices. In Rwanda, HIV/AIDS affects about 5 % of Rwanda’s 10 million inhabitants.(8) Gardens for Health promotes sustainable, long-term farming practices to improve the socioeconomic status of Rwandans. Rather than implementing new protocols and structures, Gardens for Health has made a point of strengthening the local and existing infrastructure by setting up home gardens for HIV/AIDS patients. The location of the gardens ensures that it is possible for weakened HIV/AIDS patients to access the gardens and to practice basic farming techniques. Each of these gardens consist of a fruit tree, a variety of nutritious vegetable seeds, and a moringa tree. Moringa trees are exceptionally hardy plants that are surprisingly nutritious. Their leaves have been said to contain more vitamin C than oranges, more beta-carotene than carrots, and more calcium than milk.(9)

To further realize sustainable agricultural practices, Gardens for Health also pursues a number of community developments. The first is that it helps to organize the formation of cooperatives between villagers, which allows for labor sharing, days of rest, and even shares of harvests for those unable to work due to sickness. It also gives otherwise unattainable resources to the community, such as tools and high quality seeds and fertilizer to help grow high nutrient crops. At this time, there is also dialogue with local farmers to determine which crops will be most useful for the local community. The crops grown have their produce divided among members, and the excess is sold in markets. To provide relevant agriculture and nutrition training, two agronomists visit the villages daily. The agronomists monitor and evaluate community harvests and home garden implementation. Furthermore, the community elects representatives to attend workshops and visit other household gardens, allowing a way to track the villagers’ progress and to improve practices. Additionally, Gardens for Health International helps to provide resources for income generation, which helps communities grow commercial, easy-to-grow crops such as mushrooms and tomatoes.  

Gardens for Health has now planted hundreds of home gardens in Rwanda. By partnering with local communities and supporting already existing programs, Gardens for Health has been able to be highly cost effective: its budget is less than $100,000.(10) Perhaps the greatest benefit that Gardens for Health has done is empower HIV/AIDS communities to take control of their own nutrition. Paul Farmer explains:

“Gardens for Health is precisely the sort of effort that might permit us to break the cycle of disease and poverty. If we neglect either affliction—disease or poverty—we won’t be able to help our patients and their families lift themselves out of poverty. The great majority of Rwandans, especially in rural areas, are involved in agriculture. They need land as much as they need health care.”(11)

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(1) Yang, A., Farmer, P.E., McGahan, A.M. “’Sustainability in Global Health.” Global Public Health. 5.2 (2010): 129-135.

(2) Ibid.

(3) Lawrence, R. “Food Security and the Right to Health.” Unite For Sight Global Health and Innovation Conference. 2010. New Haven, CT, Yale University. 

(4) Lockwood, A. “Development of a National Food Fortification Program in Rwanda.” Unite For Sight Global Health and Innovation Conference. 2010. New Haven, CT, Yale University. 

(5) Ibid.

(6) Turshen, M. “Child Poverty in Africa.” Review of African Political Economy. 2009. P. 494-500.

(7) Dujardin, R.C. “Grass-roots effort reaps lifesaving harvest.” 27 Nov 2008. The Providence Journal.

(8) Ibid.

(9) BBC News. “Trees are crucial ‘famine food.’” 4 August 2009. BBC News.

(10) Mundy, L. “The Amazing Adventures of Supergrad.” 8 June 2010. The Washington Post.

(11) Gardens for Health. Gardens For Health. Accessed on June 7, 2010.