The Threat of Hunger and Ill-Health

By Ray Wheeler

Vol. 2, No. 2., 1979, pp. 5-8

The existence of hunger and malnutrition among the poor and occurring throughout the United States has been established beyond debate. It seems likely also beyond argument that the expansion of the Federal Food Assistance Programs has significantly altered the face of hunger in our country. We know, however, that there continues to be many people in our nation who are malnourished and who do not have the food or the health care necessary to restore themselves to health and full productivity.

The number of persons in poverty began to increase in 1970 and has not declined since then. There is reason to believe that the real incidence of poverty is higher than the poverty statistics would indicate.Whether the real poverty count is 25 million or more likely 30 million Americans, the incredible fact remains that we have in this country an enormous number of people living at or below the federally defined poverty level and, by definition, they cannot afford to purchase a minimally adequate diet unless they receive assistance.

During the past twelve years I have taken part in surveys of hunger and malnutrition and remember well the conditions and people who faced a blighted future without much hope and assistance. In the spring of 1967 shortly after a Senate Subcommittee, led by Joseph Clark and Robert Kennedy first brought hunger to the attention of the American people, I was one of a group of physicians who went as a team to study the health and living conditions of children of the poor. Here is what we found:

"Wherever we went and wherever we looked, whether it was the rural South, Appalachia, or an urban ghetto, we saw children in significant numbers who were hungry and sick, children for whom hunger was a daily fact of life and sickness in many forms, an inevitability. Many of these children were weak and in pain; their lives were being shortened; they were, in fact, visibly and predictably, losing their energy, their spirit and their health. They were suffering from hunger and disease, and directly or indirectly, many were dying."

Wherever we went the impact was the same. We saw countless families with large numbers of children isolated from the mainstream of American culture and opportunity, possessing none of the protections of health, life and job that other Americans take for granted as rights of citizenship.

What we saw on those trips and the conclusions we drew have been documented and substantiated over and over again. As a result, unprecedented publicity, surveys, reports, TV documentaries, Presidential messages, a select committee of the U.S. Senate on Nutrition and Human Needs, and even two White House conferences, occurred. The nation was shocked and in the years that followed Congress, responding to public pressures and public needs, enacted more than a dozen food aid laws and now appropriates more than 9 billion dollars annually to feed the poor.

There can be little doubt that this generous outpouring of money for food and medical care by our government and by concerned citizens over the past ten years has saved many lives and relieves great suffering. The statistics speak eloquently to this point.

There has been a decline in infant mortality of 33 percent from 1965 to 1975 with even more rapid decline in deaths of infants during the first month of life. Infant deaths from diarrhea, influenza, pneumonia, and immaturity, in any related directly to poverty and malnutrition, have declined 50 percent or more. These reductions in mortality have occurred more rapidly among Blacks and American Indians and in the ten states with the highest incidence of poverty and malnutrition.

The observations of the 1977 Medical Team sponsored by the Field Foundation support the accuracy of this information. From May to September, 1977, six teams of doctors fanned out across the country, carefully retracing steps many of us had taken ten years earlier into the worst poverty in America. "We went again into the delta of Mississippi, the tenements of the Bronx, the isolated mountain hollows of Appalachian Kentucky, the coastal regions of South Carolina and the migrant work camps of Central Florida. Our first and overwhelming impression was that there are far fewer grossly malnourished people in this country today than there were ten years ago."

When one visits the Head Start centers and examines the children, even cursorily, there can be little doubt that significant change has occurred since 1967. The children of the poor were healthy in appearance, lively and responsive in their interactions with each other and with their teachers. Nowhere did I see the gross evidence of malnutrition, the omnipresent evidence of acute respiratory illness, and the evidence of apathy and weakness that we saw in 1967. The teachers I questioned reported very few problems with illness among the children during the entire year.

The problem is not now primarily one of overt hunger and malnutrition, although unquestionably these conditions have not been eliminated. It is not possible to find so easily the bloated bellies, the shriveled infants, the gross evidences of vitamin and protein deficiencies in children that we identified in the late sixties.

Instead, my colleagues and I observed more subtle manifestations of malnutrition, especially among the poor in those areas where food-aid systems are functioning inadequately and are not reaching those who need help.

Undernutrition often masquerades as other kinds of problems. Many of these children already malnourished at birth, are born prematurely because malnutrition in the mother is the most common cause of prematurity and prematurity is directly linked to early infant mortality, birth defects and mental retardation.

Many undernourished infants die shortly after birth, killed by their unusual susceptibility to infections which are ordinarily benign in the well nourished child. Those children surviving infancy are more frequently ill, likely to be anemic and undersized for age, and they do less well in school than their counterparts in more affluent families.

They become slow learners, who wind up living in poverty and producing children who grow up in the vicious cycle which condemns them to lifetimes of marginal function.


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Their lives are characterized by behavioral disturbances, physical disability, high rates of failure in school and low levels of employability.

The social and economic consequences of this tragic sequence of events are enormous and devastating to the children and to the society in which they grow up. By not feeding children adequately, we may be negating our efforts to educate them and we are undoubtedly creating problems for the future.

It is important to understand that the effects of inadequate food, bad housing and poor medical care are not confined to the poor but directly determine the strength and vitality of our society, the amount of wealth and produce, and the incomes we enjoy. More than 10 years ago the Office of the Budget calculated that for every dollar we failed to spend feeding hungry people, it costs our government over three dollars in payment of sickness care, lower productivity, so-called "handouts" to the disabled. I suspect that the figures are equally or even more applicable today. As Robert Claiborne wrote recently "A balance sheet of the dollar costs of poverty versus dollar cost of ending it might well show that even in purely economic terms, humanity is the best policy."

I know that the health status of Southern people remains the worst in the nation, far below national averages in most of the parameters we use to judge health. But, I also know that the remedy for this situation lies not in more doctors, nurses, and hospitals. It lies in a rearrangement of the priorities of our society so that public policy addresses human needs.

While much has been said and written about the economic resurgence of the South since 1945 and especially in the decades of the 60s and 70s, we are not as prosperous as we appear. We are still behind significantly (17 percent) in per capita income. A large proportion of the nation's poor live in the South. We have 25 percent of the population of the U.S. and 40 percent of its poor. Sixty percent of the nation's rural poor live in the South and one in five Southerners is poor, double the national rate. Both our industrial wages and our per child expenditures for education are the lowest in the nation.

Our position at the bottom of the ladder is equally solid when we examine health statistics as one would expect for health care and economic development are integrally related.

General death rates are 22 percent higher in the rural South than in the nation. The life expectancy of migrant farmers is 49 years, 23 years less than the national average. Infant mortality rates are higher than the national average for Black and White Southerners as are the rates for premature births, but in the rural South Blacks have 65 percent higher rates than their White neighbors.

The existing institutions for the delivery of medical care, no matter how they are restructured or paid for, may be irrelevant to the central health issue. All things considered, even acknowledging the remarkable benefits from recent advances in medical science and technology, the health services of the twentieth century that have been most influential for improving health have had to do with sanitation, water supply, and food distribution. The main reason we enjoy longer and healthier lives than our ancestors is not that we possess more effective ways of treating our sicknesses, though in many cases we do. We are more healthy and longer living because we get sick less often thanks to prevention of infectious disease, the provision of pure water and sanitary sewage disposal systems, and the greater availability of food.

Perhaps the most important public health measure in our history has been the gradual evolution of a society in which people - most people - are living better. There is more money for food, family sizes are smaller, work hours are shorter and work less exhausting.

Associated with these advances have been major advances in the processing, storage, and distribution of food. These overall benefits have done more to reduce morbidity and


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mortality rates and to extend life expectancy than perhaps any other societal endeavor including those directly related to coping with illness. It is likely that the greatest promise for improved health for most populations, including the South's, in the foreseeable future continues to be related to the possibilities for improved nutrition.

There are many initiatives that might improve nutrition. They include the regulation of a advertising, improvement of housing, and public education about diet and nutrition. None of these will be effective in the absence of an effort to increase the availability of food. Local and privately initiated efforts of this kind are desirable and praiseworthy, but success on a meaningful scale demands a public policy dedicated to a more equitable distribution of food to poor people and to particularly vulnerable groups such as pregnant women, children, and the elderly. Hunger is the problem; food is the remedy.

An important first step in making available food assistance to all who needed it when, in 1974, Congress extended the Food Stamp Program to cover all those eligible for help in the entire U.S. Other programs have been added and liberalized. They have made a significant difference in the nutritional and health status of people they have reached. We can document decreases in illnesses, in infant and maternal deaths, and in the incidence of iron deficiency and anemia. Carefully controlled studies in a poor population have revealed that a 15 percent increase in dietary energy during pregnancy and the early months of infancy produced larger children who demonstrated improved learning ability over a population who had not received dietary supplement. The children evidenced improved growth, increased head circumference, and a decreased incidence of nutritional anemia. These are important measures of improved health.

Unfortunately, none of the existing food programs, either singly or together, has proved sufficient to deal with the problem of hunger. 'Me programs are administratively clumsy, often demean people, and have never reached more than 60 percent of the people in need of help. Due to bureaucratic ineptness, hostility to the programs by local political leadership, and the lack of will on the part of the U.S.D.A. to see that the programs serve all who are eligible, - participation in these programs is actually decreasing all over the nation during a time when food prices are rising and the need for the program is greater than ever. What is needed is a system that will deliver food in adequate amounts to people who need it. I know of no proposal that will accomplish that objective short of a full employment program that guarantees a job with adequate pay to every person who wants to work and this must be supplemented by financial assistance at a realistic and humane level to those who, for a variety of reasons, cannot work and do not have money to buy enough food.

In the absence of a national policy of full employment, the new Food Stamp law, now being implemented, represents an unparalleled opportunity to assure an adequate diet for all needy Americans. There is no necessity for apology or defensiveness, for the program does more to lengthen and strengthen the lives of disadvantaged Americans than any other noncategorical social program. It is virtually the only government aid offered to the working poor.

This is a matter of self-interest. The social costs of 30 million poor and near poor in our midst are enormous, primarily in terms of the loss of human potential, lost forever to malnutrition and secondarily, in terms of operating expenses wasted in the support of battalions of caretakers.

But there is another side to this coin. In this overfed country, it is almost foolish to ask whether hunger has serious consequences. Surely, even a negative answer would not lead us to conclude that it is all right for people to remain unnecessarily hungry. The reason for feeding disadvantaged children and their families in the richest country the world has ever know is because they are hungry.

Arnold Toynbee once said "I do not believe the greatest threat to our civilization is from bombs or guided missiles. I don't think our civilization will die that way. I think it will die when we no longer care."

My assumption is that we do care and my hope is that we shall find the wisdom and the will to eliminate poverty from this nation and there will no longer exist the necessity for a food stamp program.

Raymond Wheeler is a physician in Charlotte, N.C. and past president of the Southern Regional Council.