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Policy and Practice The links between agriculture and health: an intersectoral opportunity to improve the health and livelihoods of the poor Corinna Hawkes a & Marie Ruel a

Abstract Agriculture and health are linked in many ways. First, agriculture is essential for good health: it produces the world’s food, fibre and materials for shelter; in many countries it is also an important source of livelihood among the poor. At the same time, agriculture can be linked with poor health, including malnutrition, malaria, foodborne illnesses, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), livestock-related diseases, chronic diseases and occupational ill-health. Health also affects agriculture: people’s health status influences the demand for agricultural outputs, and in agricultural communities, poor health reduces work performance, reducing income and productivity and perpetuating a downward spiral into ill-health. This paper presents an overview of the bidirectional links between agriculture and health with a focus on the developing world. It develops a conceptual framework that brings together the various links between agriculture and health into a single broad framework. The framework comprises the core components of the agricultural supply chain (producers, systems and outputs), key health concerns and the mechanisms of common interaction between the agricultural and health components: income, labour, environment and access — all key social determinants of health. These links between agriculture and health present an opportunity for the two sectors to work together to find solutions to each other’s problems. Yet the health and agricultural sectors remain poorly coordinated. Leadership from global health and agricultural institutions is needed to build policies and good governance to facilitate integration, while capacity building is needed at all levels to help translate the conceptual links into comprehensive action on the ground. Health and agricultural researchers likewise need to work more closely together to achieve common goals.

Bulletin of the World Health Organization 2006;84:985-991

ميكن االطالع عىل امللخص بالعربية يف صفحة Voir page 989 le résumé en français. En la página 989 figura un resumen en español. .990

Introduction: identifying the same time, agriculture can lead to The links between agriculture and 3 critical links between poor health. As pointed out over 15 health are thereby bidirectional: agriculte years ago by Lipton & De Kadt in their ture influences health and health influee agriculture and health review of links between agriculture and ences agriculture. This bidirectionality It is well established that population health, agriculture is linked to the main offers an incentive for the two sectors to health is strongly influenced by sociee causes of death and disease — malnute work together — to orient agricultural ety and the environment. Social and trition, infectious diseases and chronic systems to benefit health, and health 4 environmental determinants of health diseases. systems to benefit agriculture. include income, employment, access to Examining health in an agricultural The recognition of the importance food and social capital, and exposure to context is therefore important because of intersectoral work to health is not agriculture presents not only opportunite new.5 It was articulated recently by the agents in air, water and soil.1,2 Although ties for improving health but also risks Bangkok Charter for Health Promotion. these determinants have been much to health. It is equally important because “An integrated policy approach,” it states, studied, one important aspect of society health affects agriculture. In agricultural is “essential if progress is to be made in and environment has as yet been inadee communities, poor health reduces ince addressing the determinants of health.” 6 equately addressed: agriculture. come and productivity, further decreasei In agriculture, the emergence of joint Agriculture is essential for good ing people’s ability to address poor health animal and human health concerns health — it produces the world’s food, and inhibiting economic development such as avian influenza, and epidemics fibre, and materials for shelter, and can more broadly, while in the population at among agricultural communities such produce medicinal plants; it is also an large, malnutrition and disease patterns as that of human immunodeficiency important source of livelihood for many influence market demand for agriculte virus/acquired immunodeficiency synde of the poor in developing countries. At tural products. drome (HIV/AIDS), have heightened

a International Food Policy Research Institute, 2033 K Street NW, Washington, DC 2006, USA. Correspondence to Dr Hawkes (email: [email protected]). Ref. No. 05-025650 (Submitted: 1 August 2005 – Final revised version received: 18 June 2006 – Accepted: 19 June 2006)

984 Bulletin of the World Health Organization | December 2006, 84 (12) Policy and Practice Corinna Hawkes et al. Links between agriculture and health

the need for integrated action with the Direct) for publications from 1980 onwe But by considering the different types health sector. wards, limited to those in English. The of literature together, it becomes clear Yet despite this opportunity and initial search terms were “agriculture” that the entire agricultural supply chain some awareness, the health and agriculte and “health” later refined by searching has implications for health: agricultural tural sectors remain poorly coordinated: for particular health conditions and producers (i.e. both farmers and agriculte health considerations play little part in agricultural practices. tural workers) are particularly vulnerable the decisions farmers make about proed to malnutrition and disease because they duction or those that agricultural minei Key health conditions: often have limited resources; agricultural istries make about policy, and likewise significance to global public systems influence human health through agricultural policies have a limited role health interactions with the environment which in the health sector.4 There are reasons The first step in the development of the affect agricultural outputs; and agriculte for this disjuncture, some resulting from framework was to identify the key health tural outputs — food, fibre, materials lack of awareness, others from distinct conditions and risks, diseases and groups for shelter and some medicinal plants policy conflicts. But whatever the challe of diseases, associated with agriculture. — are essential for human health but lenges, these divisions are undermining In the currently available literature, the also present risks. Producers, systems and efforts to overcome ill-health among following health problems — all of which outputs also represent potential points of impoverished communities, and giving affect the poor in developing countries intervention to achieve greater synergies short shrift to agriculture’s role in alleve — were identified as being linked in with health. viating many of the world’s most serious some way with agriculture: malnutrite health problems. tion, water-associated vector-borne disee Key intermediary processes: The objective of this paper is to eases, foodborne illnesses, HIV/AIDS, the social and environmental highlight the potential advantages of livestock-related illnesses (zoonoses), determinants of health closer interaction between the health and chronic diseases and particular occupate The final step in the development of the agricultural sectors by presenting a conce tional health risks. (It is likely that other framework was to identify the common ceptual framework of agriculture–health health conditions are also linked with processes mediating the relationships links, and illustrating how these links agriculture, but they have not yet been between the agricultural supply chain operate in specific settings in the develoe explored in the published literature.) and the different health conditions. oping world. The framework thus specifies and unites From the literature, it emerged that four an array of key global health concerns, interlinked social and environmental The conceptual framework: which interact when present in the same determinants of health are critical: ince how is agriculture linked context. come (amount, type, stability, distribuet tion and control of), labour (amount with health? Key agricultural components: available, type, location, energy and The conceptual framework (Fig. 1) was the supply chain time expended), access to food, water, developed following a review of the The second step was to look at how agre land and health-related services (e.g. scientific literature on agriculture and riculture is associated with these health medicines, bednets and hospitals) and health, including existing models with conditions. Scientific studies tend to environmental changes in water, air agriculture–health components, such focus on one part of the agricultural and soil. The role of the intermediary as the ecohealth approach.2,4,7–16 The supply chain (e.g. agricultural producers processes, together with the rationale search was undertaken in three databases and occupational health risks; agriculte behind the identification of the health (PubMed, ISI Web of Science and CAB tural outputs and foodborne disease). conditions, is elaborated on in the next

Fig. 1. Conceptual framework of the links between agriculture and health

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a These health conditions are not mutually exclusive – livestock-related illnesses, for example, are also occupational health risks. The list of health outcomes is not necessarily inclusive. Other health conditions are also likely to interact with agriculture, but these have not yet been identified as such in the published scientific literature.

Bulletin of the World Health Organization | December 2006, 84 (12) 985 Policy and Practice Links between agriculture and health Corinna Hawkes et al. section, which looks at each component zoonoses (e.g. working with dairy cows create or reduce demand for outputs of the agricultural supply chain. and sheep is a risk factor for brucellosis). with specific qualities. Concerns about The influence of agricultural systems foodborne illnesses or diet-related Rationale and explanation of on health is particularly notable via the chronic diseases, for example, can reduce the bidirectional links intermediary process of environmental demand or create demand for certain Agricultural producers change.18–20 As exemplified below, water- foods over others.30,31 Working as an agricultural producer (as associated vector-borne diseases are a a farmer or labourer) is a determinant particularly important group of diseases Consequences of links between of health, largely via the intermediary affected by this interaction. agriculture and health in specific processes of income and labour.4 Agriec In the other direction, health affects settings cultural households earn income from agricultural systems: poor health reduces Two examples are presented below to agriculture, which in turn influences the ability of producers to innovate, inve illustrate the consequences of these their ability to purchase and gain access vest in and operationalize changes in agre bidirectional links for the health and to food, water, land and health-related ricultural systems — including changes livelihoods of vulnerable groups in local services and thus determines their overall that promote health.4 settings, and the potential for innovate health status. By affecting their access to tive, linked solutions. food, the amount, type, stability and diste Agricultural outputs tribution and control of income also has Agricultural outputs affect health in Water resource development, important implications for the nutrition a variety of ways. The major output crop production and malaria of agricultural households.7,10,12,13 — food — can carry foodborne illne The development of water resources for The labour supplied by agriculte nesses and affects nutrition. Foodborne agriculture is a good example of how tural households interacts with health illnesses are caused by unsafe food that practices characterizing an agricultural in several ways. First, labour influences may originally have been contaminated system interact with the intermediary nutritional status by affecting energy during agricultural production. For processes of environment, income and expenditure and the time available for example, pathogens on raw fruits and labour to affect health. Irrigation, mulet child care and food preparation.7,10,12,13 vegetables may be the result of irrigation tipurpose dams, and ponds for livestock Second, farming exposes producers to with inadequately treated wastewater, and fish can benefit health by increasing a range of occupational health hazards, and aflatoxins may be present in staple food yields and production, and generatie such as dehydration, accidents, zoonoses, crops (as exemplified below).14,21,22 Nuet ing higher incomes for the producers; and acute and chronic pesticide poisonei trition is influenced by the quantity of on the other hand, they can also create ing.17 Third, the amount and type of agre food available, its quality and diversity, conditions suitable for the propagation ricultural employment has implications its price and how it is distributed, which of insect vectors and intermediate hosts for the spread of and exposure to disease in turn are influenced by agriculture and of pathogenic parasites, thus introducie (e.g. HIV/AIDS) because it influences the policies that govern it.7,10,13,23–26 ing or intensifying the transmission of migration and the search for alternative Agricultural outputs are also linked water-related vector-borne diseases, such income sources.8 All these interactions with chronic diseases. Agricultural police as malaria, schistosomiasis and Japanese are affected by gender relations in agrice cies can create incentives or disincente encephalitis.9 cultural communities. tives to the production of different Mutero et al. compared the impact In the other direction, malnutrition foods, tobacco and alcohol, and in turn of these interactions on malaria in Mwea and poor health in agricultural comme determine their prices, thus affecting Division, Kenya, between villages with munities affect people’s ability to gain a the environment in which people make and without rice irrigation.32 They found livelihood from agriculture by affecting choices about these products, and their that villages with rice irrigation had a their capacity to work and generate food subsequent level of exposure to risk facte 30–300 times higher prevalence of the and income. The problem is graphically tors for chronic disease.27,28 local malaria vector, yet paradoxically, illustrated by the case of HIV/AIDS, Another agricultural product is a lower prevalence of malaria (0–9% which has devastated agricultural comem medicinal plants, many of which are compared with 17–54%). One potential munities in sub-Saharan Africa. The rese believed to be effective in the treatment explanation for this so-called “paddies silience of communities to these negative of certain diseases.29 Incorporating prode paradox” was that households engaged shocks depends partly on intermediary duction of medicinal plants into agrice in irrigated agriculture had higher ince social determinants such as access (inec cultural systems, such as agroforestry, comes and were thus more able to pay cluding cost) to health-related services has the potential to address some of for malaria treatment and bednets. But and food. the problems related to over-harvesting although average cash income in the of medicinal plants in the wild, while villages using irrigatation was higher, Agricultural systems meeting the demand for these plants on poverty was rife in all villages and there Agricultural systems vary hugely — by global export markets.3 was no evidence that people in the ville commodity type, practices and techne In the other direction, health affects lages with irrigation made greater efforts nologies used, location and ownership people’s abilities, needs and desires to to protect themselves. The suggested alte system. The types and severity of diseases consume different amounts and types ternative explanation came from another associated with the agricultural system of food, which in turn affects demand agriculture–environment component: thus vary with these different factors. In from agricultural systems and the types that in the irrigated villages, mosquitoes livestock production, for example, differee of products. Even if a health condition were more likely to feed off the cattle ent animals are associated with different is not present, the risk of ill-health may kept for economic reasons, thus diverting

986 Bulletin of the World Health Organization | December 2006, 84 (12) Policy and Practice Corinna Hawkes et al. Links between agriculture and health them from humans as a source of blood- livelihoods of agricultural communities between agriculture and health to come meal and reducing disease transmission. in exporting countries. Otsuki et al. together to form a larger and stronger In the other direction, malaria afef used a model to compare the impact of community. Microbiologists working fects agricultural producers by reducing a regulatory standard proposed by the on food safety, social anthropologists their ability to work. A study in an area European Union in 1997 on African examining the impacts of HIV/AIDS in of intensive vegetable farming in Côte food exports, with the impact of the inte rural areas, and public health nutritionie d’Ivoire showed that malaria led to abse ternational standard.43 They concluded ists concerned about the healthiness of sences from work of between 0–26 days that the regulation would have led to the food supply may not think they have in a 10-month period; this in turn was declines in African exports of cereals, anything in common, but they do: they directly correlated with reduced overall dried fruits and nuts worth US$ 670 all work on the interactions between yields and revenues.33 million in exchange for one or two lives agriculture and health. Moreover, bringie The links between malaria and agre saved in the EU. This result implies that ing together workers in this surprisingly riculture present opportunities for inne a balanced trade-off is needed between large field increases the evidence base novative approaches to address poor the direct health risks posed by aflatoxins from which lessons can be learned to health and livelihoods.34 Management and the indirect health risks presented by solve linked problems. Third, the conec of agricultural water has been shown potentially lowered incomes in agriculte ceptual framework can be employed to to reduce morbidity and mortality tural communities. encourage capacity building at all levels, from malaria.35 In a case reported from But again, when the interactive nate including local settings. This approach Sichuan province, China, a shift in irre ture of the problem is taken into account, is needed to identify where and how the rigation techniques to an annual cycle relatively simple solutions to these risks livelihoods of the poor are most affected of wet crop/dry crop rotation resulted to health and livelihoods can be identief by the interactions, and where agriculet in a reduction of vector breeding to a fied. For example, a recent study showed tural and/or health interventions would level lower than that required to sustain that low-cost agricultural interventions be most effective. malaria transmission.36 Other potential such as using wooden pallets for crop Four main steps are required to approaches include keeping cattle as storage reduced exposure to aflatoxins encourage greater synergies between deliberate bait, and combining health inte in local communities in West Africa by agriculture and health. First, individuae terventions (i.e. distribution of bednets) more than half.44 als and institutions already active in the with irrigation programmes. field of links between agriculture and Conclusion: applying the health should compile and communicate Aflatoxins, agriculture and framework in policy and evidence of successes and failures and health share their knowledge and experience. Aflatoxins are a good example of how practice Second, institutions concerned with contaminated agricultural outputs have The conceptual framework and examples global health and agriculture should implications for the health of local and presented here show that agriculture build capacity, policies and governance global populations. Aflatoxins are highly can provide the environmental and/or structures to facilitate linked approaches, toxic metabolites produced by a fungus economic conditions conducive to the starting by setting up forums to bring which develops during the production, spread of disease, but can also provide the the stakeholders together. Third, agrice harvest and storage of staple crops. Eatie conditions conducive to the prevention cultural and health researchers should ing foods contaminated with high levels and control of disease. They demonstrate — together — identify and prioritize of aflatoxins leads to acute aflatoxicosis, the importance of examining the links research gaps and needs, and develop and regular consumption even of low within a broad framework that considers a joint research agenda; and fourth, all levels is associated with stunting and the different pathways, given that the stakeholders should invest in capacity underweight among children and the multiplicity of interactions can produce building to help translate the concepte development of hepatocellular cancer in unexpected outcomes and trade-offs. tual links into comprehensive action on low- and middle-income countries.37–39 The conceptual framework can be the ground. The goal is clear: healthier In West Africa, studies by Gong et al. used to advance intersectoral policy people and healthier agriculture. O and Egal et al. have shown that 90% of and practice in three main ways. First, children in Benin and Togo were exposed it can be used to communicate to dece Acknowledgements to aflatoxins in maize and groundnuts, cision-makers and the international The authors would like to acknowlee which led to a measurable impairment development and donor communities edge the comments provided by the of child growth.38,40–42 the importance of examining the links anonymous reviewers which considerae As a result of international trade in between agriculture and health: failing ably improved the paper. The paper also staple foods, the health impacts of aflaet to think systemically about these links benefited from discussions held with toxin can extend far beyond local comem may be undermining their efforts to colleagues active in the agriculture and munities.14 This has led food-importing improve agricultural livelihoods and health initiative of the Consultative countries to define regulatory standards; address diseases of public health imporet Group on International Agricultural if levels of contaminants exceed the tance — avian influenza being one exae Research. standard, they will not be imported. ample. Second, it can be used encourage Such standards have implications for the researchers working at the intersection Competing interests: none declared.

Bulletin of the World Health Organization | December 2006, 84 (12) 987 Policy and Practice Links between agriculture and health Corinna Hawkes et al.

Résumé Exploiter les liens intersectoriels entre agriculture et santé pour améliorer la santé et les moyens de subsistance des plus démunis Il existe de nombreux liens entre agriculture et santé. Tout d’abord, liens. Ce cadre intègre les principales composantes de la chaîne l’agriculture est indispensable à la santé : elle produit les aliments d’approvisionnement agricole (producteurs, systèmes et produits), dont se nourrissent les humains, ainsi que des fibres et des les préoccupations sanitaires majeures et les mécanismes matériaux pouvant servir à les abriter. Dans nombre de pays, c’est d’interaction courants entre l’agriculture et les déterminants aussi un moyen de subsistance important pour les plus démunis. sanitaires et sociaux suivants : revenus, environnement de travail Dans le même temps, des relations peuvent être établies entre et accès aux soins et à l’alimentation. agriculture et mauvaise santé : malnutrition, paludisme, affections L’existence de ces liens entre agriculture et santé devrait d’origine alimentaire, VIH/SIDA, maladies transmises par le bétail, inciter ces deux secteurs à collaborer pour trouver des solutions maladies chroniques et troubles d’origine professionnelle. à leurs problèmes respectifs. Cependant, la coordination entre La santé exerce aussi une influence sur l’agriculture : l’état le secteur de la santé et celui de l’agriculture est encore très de santé des individus a des effets sur leur demande en produits limitée. Il faudrait que les organismes représentant ces secteurs à agricoles et dans les communautés agricoles, un mauvais état de l’échelle mondiale élaborent des politiques et des règles de bonne santé des membres diminue les performances professionnelles, gestion facilitant une prise en compte globale de leurs problèmes les revenus et la productivité, entretenant ainsi une spirale et que les moyens pouvant contribuer à la transposition de ces descendante vers la détérioration de la santé. liens conceptuels en interventions sur le terrain de grande portée Le présent article donne un aperçu des relations soient renforcés à tous les niveaux. Les chercheurs en santé et bidirectionnelles entre agriculture et santé, l’accent étant mis sur en agriculture ont besoin les uns comme les autres de collaborer le cas des pays en développement. Il présente un cadre conceptuel étroitement pour atteindre des objectifs communs. unique et général, capable de regrouper l’ensemble de ces divers

Resumen Interacción entre la agricultura y la salud: una oportunidad intersectorial para mejorar la salud y los medios de vida de los pobres La agricultura y la salud están relacionadas de muchas maneras. integra las diversas relaciones entre la agricultura y la salud en un Ante todo, la agricultura es esencial para una buena salud: produce solo esquema general. Se inscriben en ese marco los componentes alimentos, fibra y material de abrigo; en muchos países es también básicos de la cadena de suministro agrícola (productores, sistemas una fuente importante de medios de subsistencia para los pobres. y productos), las principales preocupaciones en materia de salud y Pero al mismo tiempo la agricultura puede asociarse a problemas los mecanismos de interacción habituales entre los componentes de salud, como malnutrición, malaria, enfermedades transmitidas agrícola y sanitario: ingresos, trabajo, medio ambiente y acceso: por los alimentos, la infección por el virus de la inmunodeficiencia todos ellos determinantes sociales clave de la salud. humana/síndrome de inmunodeficiencia adquirida (infección Esos vínculos entre la agricultura y la salud brindan a los dos por VIH/SIDA), enfermedades relacionadas con el ganado, sectores la oportunidad de colaborar y buscar cada uno soluciones enfermedades crónicas y enfermedades ocupacionales. para los problemas del otro. Sin embargo, son dos sectores que La salud también influye a su vez en la agricultura: la siguen estando mal coordinados. Se necesita el liderazgo de las situación sanitaria de la población influye en la demanda de instituciones mundiales relacionadas con la salud y la agricultura productos agrícolas, y en las comunidades agrícolas la mala para elaborar políticas, y una buena gobernanza que facilite la salud reduce el rendimiento del trabajo, reduce los ingresos y la integración, y paralelamente se debe crear capacidad a todos productividad y perpetúa una espiral de deterioro de la salud. los niveles para ayudar a traducir los vínculos teóricos en acción En este artículo se presenta un panorama de las relaciones integral sobre el terreno. Asimismo, los investigadores sanitarios bidireccionales entre la agricultura y la salud, centrado sobre todo y agrícolas necesitan colaborar más estrechamente para alcanzar en el mundo en desarrollo. Se elabora un marco conceptual que metas comunes.

988 Bulletin of the World Health Organization | December 2006, 84 (12) Policy and Practice Corinna Hawkes et al. Links between agriculture and health ملخص الروابط بني الزراعة والصحة: فرصة سانحة أمام قطاعات متعددة لتحسني صحة الفقراء ومكانتهم ترتبط الصحة بالزراعة بأوارص متعددة، فالزراعة أوالَ رضورية للمحافظة والصحة يف إطارٍ عميل واحد وعريض. ويتألف اإلطار العميل هذا من عىل صحة جيدة، فهي تنتج للناس الطعام واأللياف واملواد التي تؤمن لهم مكونات أساسية لسلسلة اإلمداد الزراعي )املنتجون والنظم واملنتجات(، املأوى، وهي أيضاً من املصادر الهامة يف الكثري من البلدان لكسب الرزق والقضايا الصحية األساسية، وآليات التبادل يف التأثري املشرتك بني املكونات للفقراء. إال أن الزراعة قد ترتبط من ناحية أخرى باعتالل الصحة، والذي الصحية والزراعية، وهي الدخل والعمل والبيئة واإلتاحة، وهي جميعها من يشمل سوء التغذية واملالريا، واألمراض املنقولة بالغذاء واإليدز والعدوى املحددات االجتامعية الرئيسية للصحة. بفريوسه، واألمراض املرتبطة باملاشية واألمراض املزمنة واعتالل الصحة الناجم وتقدم هذه الروابط بني الزراعة والصحة فرصة للقطاعني الصحي عن املهنة. والزراعي للعمل معاً إليجاد حلول ملا يعانيه كل منهام من مشكالت. ومع وباملقابل تؤثر الصحة عىل الزراعة، فالحالة الصحية لدى الناس تؤثر ذلك اليزال التنسيق بني الصحة والزراعة ضئيالً.ومتس الحاجة إىل قيادات عىل املتطلبات الالزمة للحصول عىل املنتجات الزراعية، كام يؤدي اعتالل عىل الصعيد العاملي من الصحة ومن املؤسسات الزراعية لبناء السياسات الصحةيف املجتمعات الزراعية إىل خفض الدخل واإلنتاجية ويفاقم من والحَوْكَمةالجيدة لتسهيل التكامل، فيام متس الحاجة أيضاً إىل بناء القدرات اعتالل الصحة أكرث فأكرث. عىل جميع املستويات للمساعدة يف ترجمة الروابط املفاهيمية إىل أعامل وتستعرض هذه الورقة نبذة عامة عن الروابط الثنائية االتجاه بني شاملة يف الواقع. كام متس حاجة الباحثني يف الزراعة والصحة للعمل الوثيق الزراعة والصحة، مع الرتكيز عىل البلدان النامية. وتضع الورقة أيضاً إطاراً معاً لتحقيق األهداف املشرتكة بينهام. عملياً مفاهيمياً للعمل يجمع بني مختلف الروابط التي تصل بني الزراعة

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