Archives of Disease in Childhood, 1985, 60, 880-886

Current topic

Poverty and human development in the Third World*K CONNOLLY

Department of Psychology, University of Sheffield

A nation's policies with regard to children andfamilies give a fairly direct reflection of its econ-

omic, social, and political structure. Economic,social, and political beliefs are translated intoassumptions about the ideal relation of society to thefamily and the individual. The industrial, developedcountries with their relatively high standard of livingface an entirely different set of circumstances fromthose confronting underdeveloped countries whereresources are often grossly unevenly distributed;where malnutrition is often endemic; childhooddisease rife; and where survival is the first goal.The bulk of the world's children are in the

developing countries, and the largest number are inthe low income countries. In the past 35 years theworld's population has almost doubled, and thatgrowth has been largely concentrated in the de-veloping countries where it is now about 2% peryear. In a substantial proportion of the world's lowincome countries the number of children in the year2000 will be double what it was in 1975, and thisdespite an expected fall in the birth rate. Conse-quently, the age distribution of the populationdiffers between the developed and underdevelopedcountries (Table 1). On average just under 40% ofthe population of underdeveloped countries is belowthe age of 15 years.

Table 1 Age structures in developedcountries'9

and developing

Country group Percentage age distribution (years) Totalfertility

0-4 5-14 15-64 65+ All rate

Developedcountries 7-6 15-5 65-6 11-3 100 1-9

Developingcountries 13-4 25-6 57-0 4-0 100 4-2

The underdeveloped countries of the world are

very heterogeneous. The problems with which theymust cope are economic, political, demographic,climatic, and structural. Some are rich in naturalresources, other have almost none. Some are ineffect preliterate societies with a high degree ofsocial organisation, whereas others are largely sunkinto the 'culture of poverty'. There are some

accounts of an anthropological kind of the circum-tances of children in the Third World. Among thebest known is the work of Oscar Lewis' who madeimportant observations among Mexicans and PuertoRicans. One feature of the 'culture of poverty', as hecalled it, is that it tends to perpetuate itself, for themost part people are unable to take advantage ofopportunities that may occur. In these circum-stances, the family does not cherish childhood as aprolonged and especially protected stage in the lifecycle. The young have all too soon to do battle withtheir environment in order to maintain even a

marginal position. It is hardly surprising that a childgrowing up in such a culture has strong feelings offatalism, helplessness, dependency, and inferiority.A central feature of science is developing methods

of describing and measuring the variables that are ofconcern to us, and this is equally true of the lifesciences, the social sciences, and the physicalsciences. How do we measure the condition ofchildren? Our principal means is by the use of socialindicators. Social indicators are an attempt todevelop tools for monitoring patterns of change inpopulations.2 They provide us with information onthe conditions of children's lives and on the health,education, and well being of children themselves.Some basic social indicators are shown in Table 2 inrelation to the infant mortality rate. The construc-tion of social indicators followed the successeconomists had with measures such as gross national

*This paper is based on the sixth Greenwood Lecture given to the University of Exeter on February 14, 1985. The full text of the lecture isavailable from the Publications Office, University of Exeter.

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Poverty and human development in the Third World 881

Table 2 Some basic indicators in relation to the infant mortality rate'2

Very high infant High infantmortality mortalitycountries countries

Infant mortality rate (0-1 years)Child death rate (1-4 years)Life expectancy at birthPercentage immunised at 1 year

TuberculosisDiphtheria/pertussis/tetanusPolioMeasles

Percentage infants of low birthweightCrude birth rateGross national produce (US$)Percentage with access to drinking waterUrbanRural

Percentage adults literateMenWomen

Percentage population urbanised

product, but at the same time they are also a protestagainst the dominance of economic values in officialstatistics and political/social decision making.There are clear signs of improvement over the

past 30 years. Infant mortality rates have decreased,life expectancy has increased, primary school enrol-ment has gone up (especially among girls), and adultliteracy rates have improved. But although improve-ments are clearly discernible, there remain greatproblems-life and death problems-facing an enor-mous number of children around the world. Themanifestations of poverty vary between countriesand even different regions within - country, but fourprincipal concerns emerge from the statistical in-formation that has been collected. These relate topoor health, inadequate nutrition, high fertility, andlittle or no education.

Health

In Birmingham in 1906, the infant mortality rate was200 per 1000, higher than in all but about threecountries of the world today. In 1906 the maincauses of infant death in Birmingham were much thesame as in the Third World today-malnutrition,diarrhoeal diseases, whooping cough, and respira-tory infections. By 1946 the rate in Birmingham was46. The precipitate decline from 200 to 46 per 1000was achieved very largely by rising living standards(food, housing, sanitation, clean water, education,and increased income) supported by maternal andchild care services and by medical advances. In mostdeveloping countries the changes have followed adifferent pattern. The major impact has been madeby medical and biological technology-by insecti-cides, antibiotics and immunisation. Rising living

standards have played a supporting role rather thanacting as a prime mover.

In general terms, the determinants of health are

known. Income gives access to goods and services;climate is often an important factor as is theavailability of public sanitation. Given that thesocioeconomic correlates of childhood mortality indeveloping countries are known, the problem is oneof moving from correlations to an understanding ofthe causal matrix. For example, maternal educationcorrelates with reduced infant mortality but it is alsoassociated with other socioeconomic variables suchas income. From an examination of factors associ-ated with infant mortality in rural Peru, Young et al3identified three classes of factors; the physicalecology, intervention programmes, and the socialstructure. All of them correlated with infant mortal-ity, but when all the other relevant variables were

controlled for only the educational level of womensignificantly predicted reduced infant and childmortality. The observation does not mean that otherfactors, such as intervention programmes, may besafely ignored or that they are unimportant, butwhat it does do is focus our attention on theimmediate context of the child. Many factorscontribute to the causes of ill heath and they can beattacked in various ways.

Let me take a specific example. Water is anessential commodity we take for granted in Britain,but it is well to remember that without water therecan be no life. Large numbers of people living inrural areas, and some city slums, in the developingcountries do not have access to a regular supply ofclean water. Women and children devote a gooddeal of time and energy to fetching water; waterwhich is often contaminated. Not all disease is life

1402647

321710171646320

6920

421921

901157

513537341444870

8521

685541

Middle infantmortalitycountries

402

69

705667521029

1770

9150

908551

Low infantmortalitycountries

11(.)74

908592706-414

9110

969476

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882 Connolly

threatening, some debilitates but rarely kills. One ofthe widespread diseases of the Third World trans-mitted by water is schistosomiasis. The WorldHealth Organisation estimated in 1965 that between180 and 200 million people were infected, and thenumber has probably increased as irrigation pro-grammes have been implemented. Infection ratesare usually highest in children because of the patternof water contact that they have. Infection is knownto affect their activity level and their involvement inplay-they are debilitated by the disease.4 It seemslikely that mental function may also be affected butno satisfactory investigation has so far been made,and the evidence relating to this important questionis equivocal.

Malnutrition

The effects of disease are compounded by malnutri-tion. For the most part malnutrition is invisible. Thesickening consequences of famine that we havegrown used to seeing on our television screensaccount for less than 2% of the cases of malnutri-tion. In 1981, it was estimated that 40 000 childrendied each day from malnutrition, and for everydeath many more children cling to a debilitated lifein hunger. A simple answer to malnutrition is toprovide food, but it is more complicated than thatand we need to understand better both the causesand consequences of malnutrition.

Malnutrition reduces resistance to infection, andinfection often precipitates malnutrition-and so thetwo reinforce each other. Where the sequences ofmalnutrition and disease are rapid, death results;where they are slowed down, the children endureserious developmental disadvantage. The conse-quences of mild to moderate malnutrition aredifficult to investigate because of the confounding ofbiological and social factors. Gradually, evidence isaccumulating that shows the effects on mental andbehavioural development.5 Malnutrition has con-sequences on an infant's level of activity, explora-tory behaviour, and social interaction. Apathyreduces the child's physical and social transactionswith the environment. Other consequences may bemediated by adults. A child may fail to evoke fromthe mother adequate stimulation, sensitive caring,or the necessary encouragement for development.Better nourished infants are seen by parents as moredemanding, and greater activity on the part of thechild increases parental pleasure.6 Malnutritiontherefore has more than one route of action. Severemalnutrition may have a primarily physiologicalroute whereas less severe cases may have their effectlargely via the child's reduced contact with hisphysical and social world. Specific nutritional

deficits also have effects. For example, iodine de-ficiency, which is common in many of the under-developed countries, especially those in mountain-ous regions of the world, is known to have con-sequences on the behavioural development ofchildren.7 8Any investigation of behavioural mediation on

the dynamics of nutritional deficit requires carefulattention to the pattern of caretaking because weneed to understand the contextual mechanisms ofearly development. Super et al,9 in a carefullydesigned intervention experiment among poor fam-ilies in the barrios of Bogota, have shown thatnutritional supplements and a maternal trainingprogramme have effects, separately and in concert,on the behavioural development of infants. Thesefindings do not fit easily with some of our earlierideas but they are intuitively plausible, and so wemust look to our theories and models of develop-ment.As I have said, an important feature of science is

measurement. When a variable can be identifiedand measured it becomes possible to study theeffects of experimental manipulations, therapeutictreatments, educational programmes, and so forth.An important step in combating malnutrition is itsearly detection and measurement, and a simple,reliable method is available. By systematicallyweighing infants and plotting weight changes on agrowth chart it is possible to detect early signs ofmalnutrition.10 11 An early warning alerts mothersto the need for action whether it be supplementaryfeeding or getting medical aid. The use of growthcharts is one of the spearheads of what the UnitedNations International Children's Emergency Fund(UNICEF) has called the 'Children's Revolution'.12A very important function which the growth chartserves is as a means of educating mothers abouttheir children, and perhaps most importantly of all,it shows them that they do have some control overevents.One of the most effective means of combating

early malnutrition is to bring about a change ininfant feeding practices. Winston Churchill oncesaid, in one of those famous wartime broadcasts ofhis, 'There can be no finer investment for anycommunity than putting milk into babies.' Wouldthat he had said mothers' milk. The shift from breastto bottle feeding has been massive and disastrous.For example, in Recife, a large city in the poor northeastern region of Brazil, all babies were breastfed in1940. By the 1970s the proportion had fallen to lessthan 10%. In 1975 a survey in Port Moresby, thecapital of Papua New Guinea, found 35% of babiesbeing artificially fed and two thirds of them weremalnourished. A vigorous government campaign

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Poverty and human development in the Third World 883

succeeded in reversing this trend and by 1979 theproportion of seriously undernourished infants fellsignificantly. In addition to nutritional advantages,breast feeding also leads to a reduction in infectionamong babies (mothers' milk offers some protectionand the danger of food being made up withcontaminated water is removed) and it has conse-quences on fertility.

Fertility and conditions for children

For some there is a moral issue in whether govern-ments should seek to influence fertility as well asmortality. I believe it to be imperative that theyshould. Fertility and population growth contributeconsiderably to the problems of children in theThird World. More effective family planning is anurgent necessity; but what are the links betweenhigh mortality, impoverished living conditions, il-literacy, poor health, and the practice of havinglarge families. Why do the poor have so manychildren? Children are of course an investment-biologically, socially, and economically. In manycountries, as in Europe not so long ago, childrencontribute in cash or kind to the family income. Forsome families having more children makes goodeconomic sense, and to the very poor the economiccosts of children are relatively small. This is inmarked contrast to the position in the developedcountries, where children are a major cost to parentsboth in time and money. In many countries,especially in Asia, parents are reliant on theirchildren to take care of them in old age. For anindividual family, rather than a society therefore,more children means greater security, and the needfor support in old age outweighs the immediatecosts. A further factor is the family structure in somesocieties. The age of marriage and the woman'sposition in the family and in the wider society meanthat for some the way to a satisfactory adulthoodand relatively secure old age is to have many sons.We know that high fertility is associated with high

infant mortality, and although the evidence islimited, it is widely believed that infant mortalityitself contributes to high fertility. Expressed in crudeform the 'child survival hypothesis' is simply thatparents feel the need to have more children in orderto ensure that a few survive. How improved infantsurvival actually serves to reduce fertility is probablyquite complicated. Broadly speaking there seem tobe two routes, one physiological the other psycholo-gical. Early and frequent child bearing contributessubstantially to the illness and death of infants,children, and mothers in developing countries.Maternal age, birth order, and birth spacing all haveeffects on infant mortality. 13 Mortality is higher

among babies born to young (less than 20) and old(over 40) mothers, it rises steadily as the number ofchildren increases, and it falls steadily as the intervalbetween births increases (Figure). Breast feeding isalso linked to fertility since the likelihood of awoman conceiving while lactating is reduced by thesecretion of prolactin. 14 Breast feeding a babytherefore serves to delay the arrival of the next, andin so doing improves the chances of survival forboth.We know little of psychological factors associated

with the child survival hypothesis, but there isevidence indicating that the ideal number of births isjudged to be larger by parents who have lost a child.Similarly couples who have lost children tend toadopt the use of contraceptives later, and theexpressed approval of couples for contraceptiondeclines with the rise of child deaths in the family.'5Much remains to be discovered about how couplesdecide on the size of their family, and what factorsare important in reaching decisions about fertility.What we can say is that increased survival ratescontribute to an increased motivation to limit familysize.

Spacinginterval(years)

<2

2-3

4+

I

2-3Birth oader

4-6

7+

Mother'sage(years)

<20

20-29

30-39

40 +0 50 100 150

Mortality rate (per 1000)

Figure Infant mortality per 1000 live births in Peru inrelation to spactlg interval between births, birth order, andmaternal age. 9 20

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Education of women Children in the recession

There are grounds for believing that there are somecommon features among people afflicted withpoverty irrespective of the culture in which they live.There is a feeling of powerlessness, of being lockedinto circumstances over which one can exert noinfluence. Feeling that one has no control over one'sdestiny is only a short step from despair, and theconsequences which that has upon the care anddevelopment of children can be catastrophic. Weknow from research in America and Europe overthe past 20 years that various forms of interventioncan lead to changes in the pattern and style of copingboth of children and families. Mothers are central,we have to work with them not compensate forthem.From the investigations that have been under-

taken we can confidently assert that educatingmothers is good for children. Hobcraft et all'analysed five socioeconomic correlates of infant andchild mortality in 28 developing countries and foundlevels of maternal education strongly associated withmortality during a child's first 5 years. The mother'slevel of education affects her access to informationthat will influence her decisions on medical care forherself and her children, on whether she knows ofthe advantages of breast feeding, on how to weanand feed her child, and so on. The relation shown inTable 3 is thus hardly surprising.

Educating women has other consequences. Ittends to delay the age of marriage, which in turnreduces fertility. In general, education increasesemployment prospects, and in some circumstancesthe employment of women outside the home isassociated with lowered fertility. Education andliteracy act like a passport by giving access to greatresources, and one sure way to improve the lot ofchildren in the Third World is to educate women.

Table 3 Maternal education and infant mortality. Deathsof children under 2 years (per 1000) as function of mother'seducation'2

Country Years of schooling

None 1-3 4-6 7-J 10+

Paraguay 1972 104 80 61 45 27Costa Rica 1973 125 98 70 51 33Columbia 1973 126 95 63 42 32Chile 1970 131 108 92 66 46Dominican Rep. 1975 172 13(0 10)6 81 54Ecuador 1974 176 134 1()I 61 46El Salvador 1971 158 142 111 98 30)Bolivia 1975 245 209 176 11(

The world is experiencing the worst recession in 50years. For the most part, governments and otheragencies have been preoccupied with narrowlyeconomic issues-inflation, interest rates, tradedeficits, and the like. But what has the recessiondone to children?Over the past 40 years child welfare has improved

greatly in developed and developing countries alikebut there are still great differences. The effects ofrecession depend among other things on the positionfrom which people start. Because of its economicand human resources one family may be wellbuffered against the effects of recession. Anothermay be so poor that it is hardly touched by thechanges-too poor you might say to have access tothe world crisis. Different regions and social groupsare affected differently and countries have re-sponded in various ways to the crisis. Some have cutback on social services, others have accelerated theirdevelopment, yet others have concentrated theirresources into particular areas of social welfare. Thecountries of Africa seem to have suffered the mostsevere setbacks, while South East Asian countrieshave withstood the worst effects with only minordislocations. A series of case studies commissionedby UNICEF'7 has examined the effects of recessionon children from countries in South America,Africa, Asia, North America, and Europe. Thepicture that emerges is limited by the availability ofreliable and useful data. Also it is important toappreciate that there is widespread lack of informa-tion about the condition of children in the poorestcountries.To speak of child welfare implies that there is

general agreement on what it is, on its maindeterminants, and on the indicators appropriate toassess its level. Cornia'8 has outlined a scheme ofthe production of child welfare that illustrates theroute by which international economic events con-tribute to changes in the situation of children. Three2classes of variables exert a direct effect. First thefamily and community: these determine a child'sphysical, social, cultural and psychological environ-ment, and I have already stressed the importance ofmaternal education. The second is household in-come, whether in cash or in kind. Income givesaccess to food, clothing, housing, and in somecountries education and health services. A suddensharp decline will have predictable effects. The thirdsource of influence is government expenditure onsocial services (including health and education).These services are usually paid for by taxes. Ifrevenues fall so expenditure must be adjusted, cutsbecome inevitable, and as we know from the British

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Poverty and human development in the Third World 885

experience, painful decisions on priorities must betaken. The three sets of variables influencing thewelfare of children are not equivalent but they arelinked and they will interact to compound theireffects.The recession has slowed down and threatens

even to reverse the improvements in economic andsocial conditions which have been taking place over30 years. In Zambia there has been a decline inheight for age (a measure of long term growth), andthe number of child health clinics has been reduced.In Costa Rica, between 1981 and 1982, the numberof children treated for malnutrition just aboutdoubled. In Brazil there has been an increase in thenumber of low birthweight babies, and an increasein the number of children given up by their parentswas also recorded. In the plantation sector in SriLanka between 1979 and 1982 there is clear evi-dence of an upward trend in the infant mortalityrate. It is up also in the states of Michigan andAlabama (1981-82), where unemployment has beenrising and incomes falling.

Behavioural indicators are also showing warningsigns. Delinquency among the young has risensharply in Italy, and in some sectors of the youth ofthe USA suicide and homicide rates are up. Overallinfant mortality rates and other social indicatorshave continued to improve, though at a reducedrate. The picture is not encouraging, however, and ifthe process of slowing down is not halted andreversed there is every likelihood that the deteriora-tion will be reflected in the cruellest of statistics-areal increase in the infant mortality rate.

Conclusions

What stands out from the variety of issues, prob-lems, and data that I have touched upon is that tounderstand and influence the welfare of children wemust take an ecological perspective. A view frommedicine, education, economics, psychology, orbiology is necessarily a partial perspective. We needa model of the child and his development that takesproper account of the richness and diversity ofcontributing factors. The welfare of children and anunderstanding of the conditions that affect theirdevelopment is not the preserve of any one disci-pline.A clear lesson that emerges from an examination

of the effects of poverty on children is that the bestway of combating these is to provide the childrenand their families with the means to influence andcontrol their own destiny. It is the individualsthemselves who will right matters if we help them todo so. Fatalism and despair, apathy and lethargy are

what we must help to drive out by using sciencerather than resorting to mere political exhortation.You may consider the picture I have sketched out

so fearfully complicated that any prospect of solu-tion is remote. That would be an understandablereaction for we are certainly not dealing with asingle problem that has a single means of solution.Paradoxically, I take some comfort in the complex-ity because it permits a multiplicity of ways wherebywe can enter the matrix that determines childwelfare. Were it the case that we could improve thelot of children only by spending huge sums of moneythen in the latter half of the 1980s I should feelpessimistic. But we can improve matters by anynumber of actions, some of which as UNICEF hasshown are relatively cheap. I fancy William Blake'sedict is a good guide, 'He who would do good toanother, must do it in minute particulars, GeneralGood is the plea of the scoundrel hypocrite andflatterer.' We must use our skills to their utmost inanalysing problems and determining ways to bringabout improvements.

References

'Lewis 0. The culture of poverty. Sci Am 1966;215:19-25.2 Miles 1. Social indicators from human development. London:Franics Pinter, 1985.

3Young FE, Edmonston B, Andes N. Community level determi-nants of infant and child mortality in Peru. Social IndicatorsResearch 1983;12:65-81.

4Kvalsvig JD. The effects of schistosomiasis on spontaneous playactivity in black schoolchildren in endemic areas. S Afr Med J1981 ;60:61-4.

5Joos SK, Pollitt E, Mueller WH, Albright DL. The Bacon Chowstudy: maternal nutritional supplementation and infant be-havioural development. Child Dev 1983;54:669-76.

" Chavez A, Martinez C, Yaschine T. The importance of nutritionand stimuli on child mental and social development. In:Ciavioto J, Hambraens L, Vahlquist B, eds. Early malnutritionand mental development. Stockholm: Almqvist and Wiksell,1974.

7Connolly KJ, Pharoah POD, Hetzel BS. Fctal iodine deficiencyand motor performance during childhood. Lancet 1979;ii:1149-51.Pharoah POD, Connolly KJ, Ekins RP, Harding AG. Maternalthyroid hormone levels in pregnancy and the subsequentcognitive and motor performance of the children. Clin Endocri-nol 1984;21:265-70.

9Super CM, Clement J, Vuori L, et al. Infant and caretakerbehaviour as mediators of nutritional and social intervention inthe Barrios of Bogota. In: Field TM, Sostek AM, Vletze P,Lciderman PH, eds. Culture and early interactions. Hillsdale,Ncw Jcrscy: Erlbaum, 1981.Moricy D, Woodland M. See how they grow. London: Mac-millan, 1979.Tremlett G, Lovel H, Morley D. Guidelines for the design ofnational weight-for-age growth charts. Assignment Children1983;61/2:143-75.

12 Grant JP. The state ofthe world's children 1984. London: OxfordUniversity Press, 1983.

3 Santow G, Bracher MD. Child death and time to next birth incentral Java. Population Studies 1984;38:241-53.

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4 Short RV. The evolution of human reproduction. Proc R SocLond /Bioll 1976;195:3-24.

5 Taylor CE, Ncwman JS, Kelly NU. The child survival hypo-thesis. Population Studies 1976;30:263-78.Hobcraft JN, McDonald JW, Rutstein SO. Socioeconomicfactors in infant and child mortality. Population Studies1984;38:193-223.

7 Jolly R, Cornia GA. The impact of the world recession otnchildren. Oxford: Pergamon Press, 1984.

18 Cornia GA. A summary and interpretation of the evidence. In:

Jolly R, Cornia GA, eds. The impact of the world recession onchildren. Oxford: Pergamon Press, 1984.

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21' Rutstein SO. Infant and child mortality: levels, trends anddemographic differentials. World fertility survey comparativestudy no 24. London: 1982.

Correspondence to Professor K Connolly, Department of Psy-chology, University of Sheffield, Sheffield S1O 2TN.

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