26
food shortages, food aid played no role in pre-
venting starvation and that if, instead, "Darfur
had been provided with clean water, better sani-
tation, and measles vaccination, most or even
all of the famine deaths could have been pre-
vented." An important observation supporting
DeWaal's assertion that good health is more
important than food consumption for nutritional
well-being is that many calorie-deficit house-
holds had both the market access and purchas-
ing power to buy more food, but chose not to
because they were more concerned with avoid-
ing health crises associated with migration, due
to poor water and sanitation quality and in-
creased exposure to diseases.
Although several reviewers of an earlier
draft of this report find DeWaal's conclusions
suspect, or at least overstated, many of his ar-
guments are quite compelling. But DeWaal's
observations obviously cannot be interpreted to
mean that food access is not an important nutri-
tional determinant. As one reviewer put it, you
cannot live off of a clean toilet alone. But food
access is also important because hunger, or the
threat of it, is often what eventually induces
families to migrate to areas where they become
susceptible to disease. Second, hunger and dis-
ease are often mutually reinforcing factors, and
it may not always be clear which is the first
cause. Thus, the most valuable lesson of
DeWaal's findings is not whether or not the
level of food access is an important nutritional
determinant, but rather their suggestion of the
need to reconsider the pathway by which fail-
ures of food access may lead to malnutrition.
It is thus essential, when evaluating the nu-
tritional impacts of food security policies and
projects, to consider the impacts on health fac-
tors in addition to effects on income and food
consumption, especially since these impacts may
be opposite in nature. The sources of income
gains which make the food consumption gains
possible are important to consider. Migration to
cities, or changes in agricultural practices, for
instance, may be associated with negative health
factors that negate any food consumption ben-
efits (Mason et al. 1985). For example, irriga-
tion technology in sub-Saharan Africa, which is
important for increasing agricultural productiv-
ity and stability, has been associated with seri-
ous negative health consequences, such as in-
creased incidences of cholera, malaria,
schistosomiasios, and river blindness (Kennedy
and Bouis 1993).
The effects of food consumption and health
factors are not independent, however. Their
relationship is synergistic in that undernourish-
ment and illness tend to occur together, and
their combined negative effects on nutritional
status are worse than the sum of their individual
effects would be (Lutter et al. 1992). This means
that the importance of adequate food intake for
nutritional well-being is even greater when
health status is poor, and the importance of
good health for nutritional well-being is even
greater when consumption is inadequate.
Studies on children's nutritional status also
suggest that both food consumption and health
factors are important. Birth weight, considered
the single most important determinant of child
mortality and child growth up to the age of
seven, is linked to a number of maternal nutri-
tional factors, including preconception weight,
weight gain during pregnancy, and morbidity
(Kennedy and Bouis 1993). Inadequate weight
gain during pregnancy, in turn, can occur when
labor demands exceed calorie intakes.
In a Gambian study, for example, "birth
weights were below average only after the peak
period of agricultural labor; during nonpeak
seasons, birth weights were close to interna-
tional norms" (Kennedy and Bouis 1993). Be-
yond birth, a three-country study in Egypt, Ke-
nya, and Mexico by Kennedy and Bouis (1993)
indicated that "disease patterns were the key
determinant of how well a child grew in the first
years of life, [and that] in order to have dramatic
influence on decreasing malnutrition in the short
to medium term, agricultural policies and pro-
grams have to be promoted in tandem with health
and sanitation programs in rural areas."
Mothers' education has also been suggested