Module 5: Social Determinants of Malnutrition

Malnutrition has both micro- and macro-level consequences. Micronutrient deficiencies impair individual cognitive capacity and lower national IQ scores; they weaken individual immune systems and increase national mortality rates, and they hinder individual productivity, lowering national income and inhibiting economic growth. We have discussed health complications on the personal level. Macroscopically, the long-term consequences of malnutrition are daunting to overall economic and social development.

A framework developed by UNICEF demonstrates that the underlying causes of malnutrition are multifaceted, including economic, social, and political factors.(1) Poverty is recognized as both a cause and consequence of malnutrition. 

Poverty as a Cause of Malnutrition

Income poverty (due to unemployment, low wages, or lack of education) can lead to household food insecurity, inadequate care, “unhealthy household environment, and lack of health services.”(2) People of low socioeconomic status are most vulnerable to food insecurity since purchasing power serves as a main determinant of the ability-to-afford nutritional food sources. Households that cannot attain nutritious foods due to income poverty are most associated with the inadequate diet and disease that leads to malnutrition.(3)   

Severe malnutrition can result in many disease-related consequences, and effects on morbidity, mortality, and disability all contribute to increased healthcare costs. Low-income households usually spend the majority of total household income on food. In these cases, even the lowest out-of-pocket healthcare service can severely diminish the remaining income to be used for food supply, further perpetuating the issue of food insecurity. Many adults living in low-income countries cannot afford to be sick: healthcare costs are high, transportation costs to health facilities accumulate, and taking days off work means lost productivity and lost wages. Undernutrition is a major underlying cause of illness and disease, and one that contributes to additional healthcare spending.   

Poverty as a Consequence of Malnutrition

Malnutrition at an early age can cause a spiraling effect that deepens the influence of poverty and entraps individuals and societies in what is known as the “cycle of poverty.” The theory incorporates many factors that reinforce one another, from the social to economic to political contexts that consequently affect individual well-being. The “spiral of disinvestment and decline” is difficult to escape, and it has been shown that damage from undernutrition in early life is a contributing factor to this cycle and disadvantages individuals in their adult years.(4) For instance, if a child experiences malnutrition or poor fetal growth within the first two years of life, the associated health consequences may irreversibly jeopardize adult health.(5) The period between birth and two years has been called the “window of opportunity” for nutrition intervention, since it is during this critical time when improved nutrition can help avoid permanent damage. Infant undernutrition has been associated with shorter adult stature, less schooling achieved, lower adult income, and for women, a higher chance of also giving birth to an underweight baby.(6) 

Undernutrition affects cognitive development and intellectual capacity, factors that contribute to poor educational performance. Nutrition-related health problems can contribute to days missed from school and reduced school attendance. Disruption in education is a factor that contributes to the spiraling “cycle of poverty,” as it leads to restricted income-earning potential. 

Many adult men living in low-income countries rely on manual labor to earn an income. Reduced lean body mass and symptoms of fatigue can lead to poor work performance and limited productivity. Iron deficiency has been recognized as a barrier to economic development because it impairs the work performance of innumerable men and women. In some countries, adult iron deficiency contributes to an estimated loss of up to 2% of the national GDP.(7)

Navigating the Complexities

The interconnected nature of poverty and malnutrition demonstrate the complexities in identifying major determinants of health as they relate to food security. Without a direct cause or consequence of malnutrition, the development of effective interventions to improve health and nutritional status poses as an even greater challenge. To gain a better understanding of the complexities involved in the attainment of adequate nutrition, it is helpful to explore the existing body of research and development that has gone into finding solutions for some of the greatest burdens in global health.

Case Study: HIV/AIDS and Food Insecurity in Sub-Saharan Africa

HIV/AIDS has ravaged sub-Saharan Africa for decades and is still a major cause of adult morbidity and mortality in the region. Described as a disease of poverty, HIV/AIDS has been of greatest risk to poor populations, impacting livelihood and development at the individual, household, and country-levels.(8) 

The HIV/AIDS pandemic in Africa has created a new form of vulnerability for households with regards to food security and nutrition. The “New Variant Famine” hypothesis has been used as a framework to understand the complex associations between HIV/AIDS and household food insecurity. The framework is based on four tenets:(9)

  1. Morbidity and mortality from HIV/AIDS deprive adults of income-earning potential and ability to perform labor, leaving households of dependents vulnerable to food insecurity.  
  2. HIV/AIDS leads to labor shortages, loss of household assets, and the loss of the generational transfer of agricultural knowledge and skills to children. When combined with the HIV/AIDS epidemic, recurring droughts further reduce crop production and leave households more vulnerable to food insecurity.(10)    
  3. Relatives assume the burden of providing care for adults with HIV/AIDS, orphaned children, and dependent elderly (including costs of health care, transportation, and food).
  4. The interplay between HIV/AIDS and malnutrition increases the burden of each condition alone. Individuals with HIV/AIDS require greater protein and micronutrient intake to support a weakened immune system.(11) Poverty and food insecurity further threaten access to a nutrition-rich diet, hindering the chance of good health outcomes.    

Ethnographic fieldwork conducted in Mozambique has provided a descriptive account of the perception of HIV/AIDS-induced food insecurity:  “When HIV arrives in a house, one knows that impoverishment has arrived as well. This disease is a guest that stays with us so much time! It consumes all of our things and will finish us all. This guest eats so much!”(12) 

Under the “New Variant Famine” framework, the threat of food insecurity is especially dire for HIV/AIDS-affected households. The widespread consequences of HIV/AIDS on health and livelihood for individuals and families are indicative of the social complexities of disease. In the arena of international aid and development, many campaigns targeted towards HIV/AIDS in sub-Saharan Africa have been centered on the distribution of antiretroviral drugs. However, it is equally important to address the social consequences of disease, including household food insecurity. 

There is no cure for HIV/AIDS but antiretroviral therapy (ART) can “suppress the HIV virus and stop the progression of HIV disease.”(13) ART has the potential to prolong life, but requires high patient adherence and is associated with harsh side effects. The coexistence of AIDS and hunger can be especially detrimental. Not only does malnutrition exacerbate the symptoms of the disease, but it also impedes the effectiveness of ART. It has been found that “malnutrition and food insecurity are persistent cofactors of the HIV/AIDS pandemic and have been linked to problems with treatment adherence as well as an increase in transactional sex.”(14) Proper nutrition is vital for increasing the chance of recovery. 

Two independent anthropological studies in Mozambique and South Africa, which are discussed below, investigate how improving access and availability of antiretroviral therapy (ART) is not a comprehensive enough strategy to combat the full complexity of the disease. Social anthropologists often approach global health problems with a political-economic perspective, which takes local context and history into consideration when trying to understand an issue. The social, economic, and political aspects of HIV/AIDS must be taken into consideration in order to develop a well-rounded and sustainable solution.

HIV/AIDS campaigns in Mozambique have provided free ART to the public since early 2004. Rapid expansion of ART has led to a decline in AIDS mortality in Mozambique and has helped people live longer.(15) Despite improved access to treatment, the underlying factors of poverty, unemployment, and low socioeconomic status are still prevalent and continue to affect the lives of HIV/AIDS-infected individuals. A main complaint of ART patients is the prevailing hunger from food insecurity. Medical intervention, although leading to improved recovery and health outcome, “did not adequately anticipate or account for the impact of hunger among the people whose lives were being saved, leading to competition for scarce food resources.”(16)

In the context of poverty and food insecurity, people living with HIV/AIDS must rely on aid from international agencies such as the World Food Program (WFP). However, organizational aid is still limited in supply, and eligibility regulations may exclude other individuals in need. Unequal distribution has led to social issues of disparity, resentment, and broken trust. Field observations in Mozambique have outlined stories of people being brought to tears by a negative HIV test because it meant they would not receive food aid.(17) In this scenario, positivity for HIV grants the benefit of food, suggesting a trade-off between food security and health.

South Africa represents another case where improved availability of ART has been unable to resolve the economic and structural barriers that create hunger and food insecurity among the population.(18) Patients who are HIV-positive have even refused ART due to reluctance of beginning treatment on an empty stomach.(19) One informant in South Africa described his situation as such:

“It’s ok to not have the ARVs. I do feel that the treatment of the [anti-retroviral medication (ARVs)] will bring a difference, but with treatment you have to take it with food. If I don’t have any income, am I still going to take my ARVs? ARVs are strong and you need to take them with food. This is my concern. Although I do feel that there will be a difference with ARVs.”(20) 

In South Africa, a disability grant is designated to HIV/AIDS patients with a CD4 count lower than 200. Coincidentally, a CD4 count lower than 200 is also the qualifier for ART. There have been cases of patients modifying treatment regimens in order to keep a low CD4 count in order to remain eligible for the food grant.(21) It is crucial for patients to maintain high adherence to ART regimens due to the risk of drug resistance, but existing social issues have threatened the requirement for drug adherence.  

Effective HIV/AIDS interventions must go beyond ART and consider how patients’ lives are shaped around the disease. Although there is no simple panacea to rid the problems of malnutrition and HIV/AIDS instantly, interventions that target poverty alleviation and the equal provision of food aid and security could make a world of a difference.

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(1) Black, R.E., Allen, L.H., Bhutta, Z.A, Caulfield, L.E., de Onis, M., Ezzati, M. et al. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371: 243-260.

(2) Ibid.

(3) Ibid.

(4) Bradshaw, T. Theories of poverty and anti-poverty programs in community development. Rural Poverty Research Center, Working Paper No. 06-05(2006).

(5) Victora, C.G., Adair, L., Fall, C., Hallal, P.C., Martorell, R., Richter, L., et al. (2008). Maternal and child undernutrition: consequences for adult health and human capital. The Lancet, 371(9609): 340-357.

(6) Ibid.

(7) The Micronutrient Initiative. (2004) Vitamin and Mineral Deficiency: a global progress report. 

(8) Masanjala, W. (2007). The poverty-HIV/AIDS nexus in africa: A livelihood approach. Social Science & Medicine, 64(5): 1032-1041.

(9) de Waal, A., & Whiteside, A. (2003). New variant famine: AIDS and food crisis in southern africa. The Lancet, 362(9391): 1234-7.

(10) Mazzeo, J. (2011). The double threat of HIV/AIDS and drought on rural household food security in southeastern Zimbabwe. Annals of Anthropological Practice, 35: 167-186.  

(11) Kalofonos, I.P. (2010). “All I Eat is ARVs”: The paradox of AIDS treatment in central Mozambique. Medical Anthropology Quarterly, 24(3): 363-380. 

(12) Ibid.  

(13) WHO. (2011). HIV/AIDS Antiretroviral Therapy. 

(14) Kalofonos, I.P. (2010). “All I Eat is ARVs”: The paradox of AIDS treatment in central Mozambique. Medical Anthropology Quarterly, 24(3): 363-380.

(15) Ibid.

(16) Ibid.

(17) Ibid.

(18) Jones, C. (2011). “If I take my pills I’ll go hungry”: The choice between economic security and HIV/AIDS treatment in Grahamstown, South Africa. Annals of Anthropological Practice, 35: 67-80. 

(19) Ibid. 

(20) Ibid. 

(21) Ibid.