When I was a small boy, the traditional thing for a mother to say to a child who would not eat his vegetables was that he should “remember the starving Armenians” and be ashamed of himself for wasting food. I would gladly have donated any amount of broccoli to the starving Armenians or to anyone else who was suffering even mild discomfort, but there seemed to be no practical way to do so.
When I picked up Hunger and Public Action my first thought was to look in the index under Armenia, but the entries go nonstop from Angola to Australia. On reflection, that is not surprising. The starving Armenians of my childhood were the victims of the Turkish oppression and massacres of 1915. That story may contain a lesson for today about the capacity of useless ethnic hostility to elicit violence and cruelty, although it is evidently not a lesson anyone has taken to heart. But there is nothing analytically interesting or practically significant in the fact that deliberate attacks on an ethnic minority can produce mass starvation. Nor is there much to do about it afterward except, whenever possible, to provide food from the outside and distribute it effectively and—what is often harder—equitably.
Drèze and Sen raise much bigger intellectual and practical issues. They want to understand how mass hunger comes about in the modern, relatively food-rich, world. And they want to tell the world how best to prevent it and, if that fails, to relieve it. Hunger itself has two quite different forms. The simpler and more obvious is famine, the episodic and localized, but large-scale, occurrence of death and near-death by starvation. The other form, less visible, easier for people elsewhere to forget, but more costly in human life and human functioning, is endemic undernourishment, the fact that millions of people live inadequate lives because they rarely, if ever, have enough to eat, and their physical and mental health suffers for that reason.
The two authors are clearer and more decisive on the subject of famine, perhaps because the problem is less deeply embedded in the rest of the social and economic structure, than its counterpart. Nevertheless what they have to say about famine is arresting, and not at all what the ordinary good-hearted donor to relief efforts has come to expect.
Their conclusions about endemic undernourishment are more tentative and less programmatic; and that is probably inevitable. There was a time when economists and government officials could get away with being casually Malthusian about widespread hunger—too many people, not enough food—and shrug their shoulders. Certainly there are too many people in some parts of the world, but there is hardly any doubt that modern agricultural technology could make it possible for all of them to be adequately fed. Drèze and Sen are withering about the spectacle of endemic hunger in part of the world while millions of people in rich countries eat too much for their own good and know it.
It is even possible that the relief of hunger could work to reduce birth rates. To the extent that surviving children are treated as a last-ditch source of subsistence in their parents’ old age, a reliable supply of food would diminish the need for them. The policy of the current US government, which is not very generous about supplying food and actively tries to deprive poor countries of the means to limit their own population, is morally and intellectually bankrupt, if that is not too kind a description. Drèze and Sen direct their recommendations more to the indigenous governments, and they make some useful points.
The key to understanding famine, according to Drèze and Sen, is to realize that it has little to do with shortages of food. That is a deliberately paradoxical claim, of course, but it catches the attention. Sometimes, needless to say, drought or flood or crop failure can cause famine in a local economy that is already near the edge. Then there is not enough food to go around and starvation strikes the poor, or the powerless, or the losers in the struggle for what food there is. But Drèze and Sen show convincingly that contemporary famine may happen even when the overall supply of food is better than average and improving.
The Bangladesh famine occurred in 1974 when the available supply of rice and other food grains per person—local production plus net imports—was 4 percent higher than in 1972 or 1973 and 7 percent higher than in 1971 (and also 7 percent higher than in 1975 and 1976). Nor is this an isolated case. The point is that famine is more a social than a natural event.
The authors like to put their analysis in terms of “entitlements.” A person’s or a family’s entitlement consists of the various “bundles” of commodities, including food and other things, to any one of which he or it has legitimate access. How an entitlement is constituted may differ from social system to social system. In an exchange economy, each household starts with an “endowment”—meaning whatever it owns initially and is allowed to use or sell, often mainly its members’ labor—and its entitlement consists of any commodities it can buy with the proceeds of those sales. Obviously there are other sources of entitlement. Even in a market economy most households have some enforceable claims against the government in the form of health care, housing assistance, unemployment compensation payments and so on. In some economic systems such nonmarket entitlements can be extensive; in others they may be meager.
A person or a family is in danger of starvation when her or its entitlement does not include commodities that provide enough calories and nutrients to sustain life. Famine can threaten from any of a number of directions. Mass unemployment of landless laborers, or a substantial fall in their wages, can shrink their entitlement even if enough food is locally available. The same thing can happen if food prices rise because demand increases faster than supply. Then some part of the population may be barred from buying enough food to stay alive, no matter how much food is stored for sale by farmers or merchants.
Drèze and Sen make the interesting point that even food producers can fall victim to a shrinking entitlement in a similar way. Some small landowning farmers may make a living by producing not very nutritious specialty foods for sale to richer consumers, with the proceeds spent in buying calories. A rise in the price of calories or a fall in the price of their own product can leave such producers face to face with starvation, unable to live on their own production.
The merit of this slightly abstract way of putting the problem is that it suggests a range of things to do, not just one. Demands that food be directly provided from the outside and distributed quickly to the hungry are the obvious and standard response to news of a famine in some out-of-the-way place. The extra food may come from elsewhere in the country or from international agencies or from gifts through organizations like Oxfam. But the authors argue persuasively that direct provision of food may very well not be the best thing to do, unless perhaps there is an overall food shortage of large magnitude.
One of the problems with direct provision of food is that it may be administratively difficult to bring the additional food directly to the needy. To put people in camps, often far from home, is surely not an attractive solution to the administrative problem. There may be pilfering or embezzlement. In many instances harassed bureaucrats give up trying to allocate food where it is most needed and settle for passing out a uniform ration. Then some of the food will go to those who do not need it, and some who need more than the average—especially pregnant and lactating women—may not get enough. Even the quite well fed are not above accepting a free ration of food. Families that can scrape by have been known to keep one child undernourished as a way of maintaining eligibility for donated food. One attraction of direct provision of food is that it gives the donors a feeling of benevolence. That is not all bad: benevolence is a scarce commodity and needs cultivating.
The authors favor a quite different approach. They advocate most strongly the creation of local public works that will employ people for cash wages. The extra income is then available for purchase of food in the market. Consider the advantages: (a) Food prices will rise—less if the government brings in some extra food—but not enough to wipe out the added purchasing power of those who work. (b) The higher prices will elicit additional food: shipments will arrive from less affected regions; the inventories of suppliers who have held onto food in anticipation of higher prices will be reduced, as will consumption by the relatively well-off; and local production may even be increased. (c) The well-off are less likely to take part in a program if it involves the inconvenience and indignity of common labor. (d) Families will not be dispersed by the need of some member to go far away either to seek work to receive donated food. (e) If women are eligible for employment, they will be less discriminated against in the allocation of food within the family. (f) The public works themselves—roads, irrigation, sewage disposal, construction—can be valuable to the local community. (g) On the whole, good social habits and attitudes are encouraged by doing work that is both useful to the community and sustaining of family life. (h) Private channels of food distribution can be used. It is of course necessary that such a program be supplemented by freely supplied relief for those who are unable to work and are without relatives able to work. But inability to work is fairly easily recognized, and so it is not difficult to administer such relief. The authors give examples of this system working very well indeed. When the drought of the 1970s in the Indian district of Maharashtra caused food production there—which was already low even by Indian standards—to drop sharply, famine was averted mainly by large-scale cash support supplemented by the distribution of free food.
The authors make a powerful and convincing argument for their approach to famine relief, and it is perhaps the most important argument in a generally powerful and convincing book. It has changed the way I will think about famine relief from now on. We are all aware of failed efforts to relieve famine in the Sudan and in Ethiopia. The book includes brief sketches of some African successes in doing so, for example, in the Cape Verde Islands, in Kenya, Zimbabwe, and Botswana. The cases are not all alike and involve different degrees of reliance on direct distribution of food as well as cash support. They point up the importance of a preexisting system that protects entitlements. India too, for all its economic failures, has succeeded in avoiding famine since independence in 1947. The main source of this success is not higher and more reliable production of food. In fact population growth has kept the per capita production of food down to nineteenth-century levels. The key seems to be the adoption of a systematic and accepted program of protecting entitlements, a program based on the two principles of employment for cash and relief for the unemployable.
I wish that Drèze and Sen had taken the trouble to study the Irish famine of the 1840s and comment on it from their point of view. They merely mention it once or twice, mainly to remark on the fact that food was shipped from Ireland to better markets in England even during the worst of times, and with little or no lapse of public order. That observation dramatically confirms their argument that famine need not be synonymous with an overall shortage of food. Famine depends on who has access to what food there is. So far so good. But they missed the opportunity to analyze the last European famine ever, one that still affects the municipal politics and foreign policy of the United States, and one that was observed and discussed by some major figures in the history of political economic thought. Am I right to harbor the thought that only, Victorian England could let the Irish starve with the comforting thought that it was for their own good?
Endemic undernourishment is an altogether more complex social phenomenon than famine. Economists are no longer tempted to classify long-term mass hunger as something to do with drought or flood. It is, they say, “just” one aspect of endemic poverty. If the entire society is quite poor, and hunger is the lot of “the poorest of the poor,” we file the case under “Economic Development, Lack of.” If the entire society is rather better off but there is a layer of the population that goes to bed hungry every night, we file the case under “Income Distribution, Inequality of.”
What is so special about hunger that it deserves special treatment? One possibility is the feeling that the need for food is so elemental, so clearly a part of the right to be treated decently as a human being, that it cannot simply be pigeonholed under “Poverty.” Moreover, the dice are loaded against the mental and physical development of inadequately fed children, so that early hunger takes away life’s chances in a way that even early ignorance does not. Both sentiment and social responsibility make hunger harder to ignore than poor housing.
Drèze and Sen insist that endemic undernourishment is best thought about as a case of severely limited entitlement. Their view has the advantage of emphasizing that it is not so much hunger itself that matters as its effect on human functioning generally, including the ability to work. And it enables them to keep saying—maybe a little too often—that relief of elementary hunger may not be enough to rescue human functioning from being deeply impaired. Access to health care, clean drinking water, and sanitation, among other goods and services, has to be part of the group of entitlements that defines the infrastructure of a decent life.
The authors distinguish three broad strategies through which poor countries can try to meet these basic needs. One they call “growth-mediated security.” This is the strategy that concentrates first on economic growth, on increasing the national income rapidly to provide the resources with which to make a later direct attack on the provision of basic needs. It is important to understand that this need not be a laissez faire strategy even at the beginning. The prize examples of economic success along these lines, Hong Kong, Singapore, and South Korea, are also among the ten countries that were most successful in lowering the mortality rate of children under five, between 1960 and 1985. (Kuwait and the United Arab Emirates have rather special characteristics, but are classified similarly.) These are not weak governments, either in their direct involvement in encouraging national economic growth or in providing citizens with the benefits of growth.
The second approach the authors call “support-led security.” This is the strategy by which the public authorities intervene at the very beginning to look after the elementary needs for food, health care, and related goods, without waiting for economic growth to provide the wherewithal. It is certainly an interventionist strategy. It has been practiced by Chile, Costa Rica, Cuba, China, and Jamaica, the other five among the top ten countries in reducing mortality rates among children under five. That is evidently a mixed bag of “cases.” The very variety of political systems—one right-wing dictatorship, two Communist dictatorship, two Communist dictatorships, and two representative democracies—allows Drèze and Sen to argue that support-led security is, so to speak, a strategy available to anyone.
They take pains to distinguish growth-mediated security from what they call a strategy of “unaimed opulence.” The latter is the policy of encouraging growth without any serious public intervention to secure basic needs, It is the policy imputed to Brazil, South Africa, and Oman, none of which has provided any significant improvement in the quality of life of people at the bottom of the heap, although all have grown fairly rapidly in aggregate terms. This would presumably be the policy that the Bush administration, so far as it cares at all, and does not merely simper about an ineffective “safety net,” would adopt for itself and recommend to poor countries. Drèze and Sen are concerned only with poor countries, and they regard this strategy simply as a proved failure.
The notion of the authors that growth-mediated support and supportled security are alternative strategies, in the sense that a country might choose deliberately to adopt one or the other, seems to me a little unrealistic. More likely some national economies grow rapidly and others do not for reasons very little related to their choices of social policy. Some of the countries that grow fast use a considerable part of their resources to meet basic needs for diet, health care, and housing. Others do not. The choice is primarily political; quite often the governments of the countries in question are not shy about taking a strong hand in the economy. My guess is that none of the governments sees itself as having the option of explicitly accepting perceptibly slower economic growth in exchange for earlier and more intense devotion to a social policy that would meet the needs of the poor.
On support-led security, however, Drèze and Sen come to convincing and important conclusions. First of all, as I have already noted, this strategy has succeeded in a variety of political environments that have little in common other than that they have not achieved high per capita income. So it will not do to say—as has often been said to explain the contrast between India and China—that only an authoritarian society can achieve low infant mortality at a low level of income per person. Costa Rica and Jamaica, rather different in their political cultures, reduced their mortality rates for children under five by 81 and 72 percent between 1960 and 1985. During that time Costa Rica had slow growth of GNP per capita and Jamaica’s GNP fell by almost 1 percent a year. Sri Lanka, a much poorer country still, was one of the first poor countries to follow the same pattern. Its rapid increase in life expectancy, no doubt connected with the expansion of basic public health services and the provision of free or heavily subsidized rice, goes back to the 1940s.
The political will and capacity to carry out such policies has to be mustered in some way. For example, there is much debate about why the Pinochet dictatorship, while presiding in its early years over a collapse of real wages and employment, bothered to preserve and perhaps even extend a successful policy of providing food and health care to poor families. Drèze and Sen claim that the continuance of these policies testifies to “the power of adversarial politics even under authoritarian systems,” i.e., to persisting pressures from opposition forces. Whatever the precise reasons may have been, Drèze and Sen do establish beyond serious doubt that a similar approach could be taken by many poor countries and is not incompatible with liberal politics. The central importance of “political will” is worth underlining as a second conclusion of Drèze and Sen about the basic needs strategy.
Third, the authors insist that the key to ending endemic deprivation is not simply food but a package of complementary goods and services. Undernourishment does more than reduce body weight; it impairs human functioning in many other ways. More food is not a sufficient response; it needs to be accompanied by basic health care, education, sanitation, clean drinking water, and other family services in cultures where inequality within the family is also endemic, with girls and women among the main victims. The point here is not just that each of the components of the package of entitlements is important for its own sake, as of course is the case. Health care and education must also be understood as complementary to food: parasitic diseases make the absorption of nutrients difficult; and education makes it possible for public health services to be used more effectively and widely.
The fourth point is in many ways the most interesting, because it uncovers an easy, lazy error. One may be tempted to skepticism about the support-led startegy by the thought that it is too costly to undertake programs of nutrition, public health, and basic education that are specifically addressed to the people who most need them. Poor countries, some experts would say, cannot afford to look after basic needs. Their only choice is to stake everything on initial gains in productivity and income; they also serve who only sit and starve.
To this Drèze and Sen reply that the services in question generally make intensive use of labor. In poor countries they are therefore generally cheap. It is the barefoot doctor, the elementary school teacher, and the rudiments of sewage disposal that are needed, not the capital-intensive hospital or universities or elaborate capital cities that make large demands on human capital. This argument rings true.
It poses in any case a central issue. If the trade-off between immediate basic support and future productivity is such that future productivity would seriously suffer, then the best possible result can emerge only from difficult calculation involving a great many imponderables. Since a solution will not be clearly indicated, the policies chosen are bound to be determined by the political balance of power within the country in question, not by the balance of costs and benefits. Drèze and Sen claim—a little too tacitly for my taste—that the resources required for the provision of basic needs will not interfere much with the normal pursuit of income growth. I hope they are right.
December 5, 1991