Health Interaction with Farm Labor Productivity

HEALTH INTERACTION WITH FARM LABOR PRODUCTIVITY

FINAL REPORT

to the

BILL & MELINDA GATES FOUNDATION

INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE

October 2010

This paper was prepared by:

Kwadwo Asenso-Okyere

Catherine Aragon

Paul Thangata

Kwaw S. Andam

Table of Contents

Executive Summary ...... 1 1. Introduction ...... 6 2. Agriculture and Disease ...... 7 3. Disease and Health...... 8 4. Linkages between Agriculture and Health ...... 16 5. Linkages between Health and Nutrition, and Farm Labor Productivity ...... 23 6. Conceptual Framework for Analyzing the Impact of Illness/Disease on Agriculture ...31 7. Effects and Outcomes of Ill-health on Agriculture...... 34 8. Infectious and Parasitic Disease Projections ...... 53 9. Conclusions and Recommendations...... 56 10. References ...... 62

List of Tables

Table 1. Life expectancy with and without AIDS in selected African countries, 2000 ...... 10 Table 2. Leading infectious and parasitic disease causes of mortality (000s) for people aged 15 years and older in low-income countries, 2004 and 2030 ...... 53 Table 3. Leading infectious and parasitic causes of disease burden (DALYs) for people aged 15 years and older in low income countries, 2004 and 2030 ...... 54

List of Figures

Figure 1. Framework for linkages between agriculture and health ...... 17 Figure 2. Agriculture value added per worker by income group, 2000, and 2005 ...... 24 Figure 3. Conceptual framework for the impact of illness/disease on agriculture ...... 32 Figure 4. Projected agricultural labor force loss due to HIV and AIDS in the most affected countries of Africa, 2000 and 2020 ...... 55

List of Boxes

Box 1: Zoonotic Diseases ...... 15 Box 2: Pesticide Use and Farm Worker Health ...... 19 Box 3: Peri-Urban Agriculture and Malaria ...... 20 Box 4: Integrated Agriculture Aquaculture (IAA) Project for HIV-affected households ...... 28 Box 5: Impacts of Illness on Agricultural Productivity in Rural Kenya ...... 34 Box 6: HIV and AIDS and Absenteeism ...... 35 Box 7: Child Labor ...... 42 Box 8: Conservation Farming for Saving Labor ...... 44 Box 9: Home Gardens for Improving Household ...... 48 Box 10: Economic Burden of Illness to Households ...... 51 Box 11: Coping Strategies for Four States of Health ...... 53

Acknowledgments

We are grateful to the Bill & Melinda Gates Foundation for the chance to undertake this interesting study. We thank colleagues in IFPRI who undertook technical and editorial review of earlier drafts of the paper. We also appreciate useful comments we received from staff of the Bill & Melinda Gates Foundation. All these reviews have improved the paper.

We appreciate the assistance given by Daniel Ayalew Mekonnen in later drafts of the report.

iii

Executive Summary

As part of the Advisory Services of the International Food Policy Research Institute (IFPRI), the Bill & Melinda Gates Foundation asked IFPRI to carry out a desk study to throw more light on the interaction between health and farm labor productivity. The study was deemed important because health issues are increasingly affecting labor productivity and decision making in the household. The gender dimensions of health and the ensuing household adjustments seem to affect females disproportionally. Although agriculture provides the food and fiber that people need, agricultural development and practice can exacerbate the incidence of disease through an interaction with disease vectors and parasites. When disease (regardless of whether it is a direct result of farming) afflicts farmers, their productivity is reduced and they remain in poverty with an unacceptable standard of living. Understanding the interactions between health and agricultural development, and designing effective policy instruments to manage those interactions to minimize harmful impacts, are becoming more relevant for development practitioners. This report provides an overview of what is currently known about the impact of health issues on farm level productivity, and how health impacts household decision making related to farming; and the impact of agriculture on the health of people. Health is defined as absence of disease and good nutrition contributes to it. A cursory look is taken at cardiovascular diseases and some infectious and parasitic diseases that cause serious ill health in developing countries. The coping mechanisms that households adopt to deal with health shocks are discussed.

The approach used here is to follow two conceptual frameworks: (1) framework for understanding the two-way linkages between agriculture and health, and (2) framework for tracking the interaction of health and farm labor productivity by examining the pathway from the disease condition to its effects, outcomes on household decision making, and ultimately impacts on human livelihood. After a review of the literature to assess the state of knowledge on the subject with its ensuing discussion, conclusions and recommendations are made for further research, and policy actions and investments to tackle the issues raised.

Three-quarters of the world’s poor people live in rural areas, and they depend largely on agriculture for livelihood. Parasitic and infectious diseases abound in the rural areas, partly due to issues associated with poverty and with farming activities. However, long term projections point to a reduction in the incidence and general prevalence of various diseases (especially HIV/AIDS, TB and malaria) due to individual, household, national, and global efforts to control them.

Agriculture and health are generally linked by disease in a bidirectional manner: agricultural development projects may affect disease causation, and diseases may afflict farmers and negatively affect their productivity unless some adjustments are made in labor allocation to

the farm. Agricultural development affects health positively or negatively. Agriculture provides income that makes households resilient to health shocks, food to meet their nutrient and energy needs, and medicinal plants for treating ailments. On the other hand, agricultural development often leads to environmental change that has adverse effects on health (for example, irrigation dams or water storage receptacles create suitable conditions for the breeding of mosquitoes and therefore lead to increase incidence of malaria in the neighborhood). The use of agricultural inputs such as pesticides by untrained farm personnel often causes illness; improper food harvesting and storage practices allow mycotoxins toxic to humans and animals alike to flourish; lack of diet diversity and/or over-consumption of certain food items (oils, fats, etc) can lead to malnutrition which adversely affects health; some animal diseases also can infect humans, with grave consequences. Labor migration (including agricultural labor migration) can contribute to high incidence of HIV infections.

Poor health brings hardships to households including debilitation, substantial monetary expenditures, loss of labor, and sometimes death. The health and nutrition status of adults affect the duration of labor force participation and consequently the welfare of the household including the development of children. In this report, the effects of ill health on farm households are discussed with respect to absenteeism due to morbidity, and eventual death; family time diverted to caring for the sick; and loss of savings, and household and farm assets as disease afflicts a household. The outcomes of these poor health impacts include loss of farming knowledge, reduction of land under cultivation, planting of less labor-intensive crops, reduction of variety of crops planted, and fewer livestock. The ultimate impact of ill health is a decline in household income and possible food insecurity, that is, deterioration in household livelihood.

The literature reports of substantial amount of time lost to illness. For instance, average productive time lost to AIDS by infected persons in Tanzania over a one-year period was 198 days for men and 286 days for women. In Oyo State in Nigeria, the estimated average number of workdays lost per year due to malaria was 64 days in agrarian households. In the Leyte province in the Philippines, the total number of days lost to schistosomiasis was 45.4 days in a year. In southern Ghana, adult males untreated for guinea worm lost about 35 days per year, and in India the average number of days lost to tuberculosis (TB) was 83 days per year. In terms of care giving to people living with AIDS and other HIV-related diseases across households in the Free State province of South Africa, household members spend an average of about 2,700 hours a year which is equivalent to about 113 person days, and those in rural Zimbabwe spend an average of about 2,000 hours a year which is equivalent to 83 person days). Time lost per year in taking care of a child with malaria varied from 42 person days in Ethiopia, 17.5 person days in Ghana, and 14 person days in the Gambia. Often children are withdrawn from school for varying periods to help with care giving or household chores (especially girls). There is evidence from Uganda, South Africa and India that some households completely withdraw children from school because of high healthcare costs.

Some of the children take up employment to help support their families. Depriving children of their education in order to work is child labor and it is in contravention of the International Labor Organization (ILO) Convention 138 and 182.

Death of a household member implies permanent loss of labor and adjustments are more permanent than when a member falls sick. In Thailand, 35 percent of households with a member who died from AIDS suffered a decline of 48 percent in household income. In Zimbabwe, a death of a household head due to AIDS experienced a reduction of 61 percent in maize output. In Zambia, the effect of adult death on cotton production was a 15 percent decline in output. However, household production does not significantly change after the death of a member when households are able to replace the lost labor. Replacements are done by bringing external family members who may be unemployed or underemployed to the farm, withdrawing children from school to assist on the farm, or hiring labor if the household can afford this. Hired labor may be indigenes of the community who do not have farms of their own or may have farms but want to earn some extra income, or they may be migrants from other parts of the country or even outside the country who look for wage employment. In some patrilineal societies, women lose their farming lands when their husbands die. In households, the death of an adult household member leads to loss of indigenous knowledge and experience which are usually not recorded. However, not much empirical research has been conducted to measure the extent and degree to which the death of one or both parents affects the transfer of agricultural knowledge to younger generations.

Given the labor-intensive nature of developing country agriculture, disease and the associated loss of labor can have significant consequences. Farm households attempt to address the shortage of labor through various methods, such as reducing the area under cultivation or narrowing the range of varieties planted on the farm. The evidence reviewed in this paper from studies across Africa (Ethiopia, Ghana, Nigeria, Rwanda, South Africa, Sudan, Tanzania, and Zimbabwe) and in parts of Asia (India, the Philippines) indicates significant farm labor days lost to illnesses such as AIDS, malaria, guinea worm, and schistosomiasis. However, the effects of diseases on farm labor productivity are context-specific, varying by gender, nutritional status, age, and availability of medical care. Beyond the direct impacts due to loss of labor, illness undermines long-term agricultural productivity in a number of ways: when illness leads to long-term incapacitation households may respond through withdrawal of savings, the sale of important assets (such as jewelry, textiles, breeding animals, farm equipment, and land), withdrawing children from school, or reducing the nutritional value of their food consumption. All of these responses can have adverse effects on the long-term labor productivity of household members.

The report brings a few recommendations to the attention of researchers, policymakers, and development agents as follows:

Research-related recommendations 1. Studies should be commissioned to understand the disease-specific impacts on farm labor productivity to provide justification and guidance for financing disease control programs. 2. Research should be conducted to devise a methodology that can correctly capture farm labor productivity at the household level given the burden of disease.

3. Research should focus on the impacts of lesser known agriculture-related diseases such as food-borne diseases, pesticide poisoning, and zoonotic diseases. 4. Research on the so-called “paddies paradox”, where an increase in mosquito population does not correlate with increased malaria incidence, and implications for the agriculture as well as the health sector should be commissioned. 5. Research is needed to learn about the effects of climate change on human infectious diseases and the mitigation and adaptation policies and programs required.

6. Research and development on the availability of and access to nutritious (micronutrient-rich) staple foods through biofortification should be expanded.

7. A study for a broader and more systematic approach to understanding the interaction between health and nutrition, on the one hand, and agricultural labor productivity, on the other, should be conducted, and the knowledge used or adopted for the formulation and design of health and nutrition, and agricultural labor and sector policies and programs.

Policy-related recommendations

8. Programs to assist rural people should pay particular attention to women, who tend to be disadvantaged in many developing countries. 9. Policies and programs to support collective action and knowledge sharing for ecological restoration and maintenance should be enhanced. 10. Social protection and provision of social safety net interventions can be made part of rural development policy. Rural people facing insecurities in food, nutrition, health, shelter, and education, among others, can be assisted through public-supported programs (particularly those linked to specific development goals), with an exit strategy based on time or specific objectives and/or results. 11. Policies that encourage education on the use of protective clothes against harmful effects of pesticides should be supported and where necessary legislation to enforce their safe use should be enacted. Additionally, regulation over the testing, production, formulation, transportation, marketing, disposal, and use of pesticides in conformity with international standards should be encouraged.

12. Education targeting rural people on sources and the negative impacts of aflatoxins, and optimal ways of drying food commodities, should be promoted. 13. Intersectoral partnerships between agriculture and health should be promoted for synergistic rural development. This will require regular monitoring of the situation and occasional impact assessments to assess the effectiveness of these partnerships. 14. Regional cooperation on animal disease surveillance, diagnosis, and treatment should be promoted. 15. To tackle zoonoses, “The One Health” concept, based on the understanding that human health and animal health are inextricably linked and that a holistic approach is needed to understand, to protect, and to promote the health of all species, should be adopted by all countries and development organizations. For instance, recent global development initiatives such as joint veterinary and human health surveillance, and control of zoonotic and pandemic diseases such as SARS and avian influenza should be expanded in the context of the One Health principle.

1. Introduction Poor people in developing countries struggle continually to fight hunger, malnutrition, ill health, and deepening poverty. Agriculture continues to be one of the most important drivers of poverty reduction and bedrock for economic growth, especially for the billions of people in developing countries.1 Three-quarters of the world’s poor live in rural areas, particularly in Asia and Africa,2 and depend on agriculture as their primary source of livelihood. Thus, policies and programs that would improve agricultural incomes tend to have poverty reduction effects. The global significance of agriculture means that it is vital for achieving the Millennium Development Goals (MDGs), especially that of poverty reduction.3 The mid-term report for the MDGs indicates that Sub-Saharan Africa (SSA) significantly lags behind all the other regions of the world in meeting these goals, several of which are directly linked to health.4

Agriculture’s role in human livelihood also means that agricultural development has strong linkages with other fields of development practice and research, including land and water resource management, infrastructure development, gender, health and nutrition, and social services. The importance of good health is summarized in a popular saying, “The wealth of a nation is the health of its people.” When people are ill themselves or must care for sick children, they are less productive. Better health also has the potential to reduce poverty because healthy people are able to work to the best of their abilities and maximize their outputs or earnings. Therefore the success of agricultural livelihoods depends on the health of its workforce. At the same time, different agricultural production systems have different impacts on health, nutrition, and well-being of the people. Households can use income from agricultural production for improved access to health products and services, and agriculture provides food and nutrients for energy and maintenance of good health; but on the other hand, agriculture-associated infections affect nutrient absorption and people’s nutritional status. Knowledge of these interactions and their consequences will be useful in planning development programs in agriculture and health.

This review focuses on the interaction between health and farm labor productivity. The review is motivated by the fact that in low-income countries, work often relies more heavily on strength and endurance and, therefore on good health. The labor market consequences of poor health are likely to be more serious for the poor, who are more likely to suffer from severe health problems and to be working in jobs for which strength (and therefore good health) has payoff.5 In many developing countries publicly supported social protection programs are not available and so illness can completely devastate and impoverish

1 World Bank (2007) 2 Ravallion, Chen, and Sangraula (2007) 3 United Nations (2005) 4 Johansen (2007) 5 Strauss and Thomas (1998)

households. The approach used here is to follow two conceptual frameworks: the first is a framework developed by Hawkes and Ruel (2006a) for understanding the two-way linkages between agriculture and health, and the second tracks the interaction of disease with agriculture by examining the pathway from the disease condition to effects, outcomes, and ultimately impacts on agricultural development. The coping mechanisms adopted by households to deal with health shocks are also discussed. The rest of the paper is structured as follows. The second section briefly describes agricultural practices and disease. Section 3 presents selected diseases that afflict farmers in the developing areas, including cardiovascular diseases which hitherto mainly affected developed countries but has become an important disease also in the developing countries. Section 4 looks at the linkages between agriculture and health. Section 5 examines the linkages between health, nutrition, and farm labor productivity. In Section 6, a conceptual framework for analyzing the impact of illness/disease on agriculture is presented, and Section 7 discusses loss of productivity due to ill health. Infectious and parasitic disease projections are discussed in Section 8. Conclusions and recommendations are presented in section 9.

2. Agriculture and Disease Agriculture is a source of economic development, rural livelihoods, and environmental services. Three-quarters of the world’s poor live in rural areas, and agriculture provides employment for most of these rural dwellers.

Agriculture occupies about half of the world’s land and uses more than two-thirds of the world’s fresh water.6 Increasing population and rural-urban migration, increasing incomes, and changes in dietary requirements have given rise to new demands for food and raw materials which have led to expansion in agricultural production. Between now and 2050 the world’s population will increase by a third, but demand for agricultural goods will rise by 70 percent and demand for meat will double.7 Changes in land and soil management practices, production systems, and post-harvest practices have brought unprecedented growth in agricultural output. In the 21st century, agriculture remains fundamental to economic growth, poverty alleviation, improvement to rural livelihood, and environmental sustainability.8 It must contribute to the general growth of the macro economy and provide adequate incomes to the people who work in it so that they can make improvements in their livelihoods. However, work in agriculture is being threatened by many factors, including diseases which affect the health of the actors in the agricultural value chain and therefore reduce their optimal performance. Agriculture has to adapt to climate change while mitigating its own contribution to it.

6 Horrigan, Lawrence, and Walker (2002) 7 The Economist (2009) 8 World Bank (2007)

In many developing countries, the supply response to the increasing demand for food and fiber has been expansion in areas devoted to crop farming and ranching, which has resulted in massive deforestation and promoted the breeding of disease-carrying vectors, especially mosquitoes. Given the high population growth rate in Africa, extensification in agricultural production is not sustainable as parcels of land become smaller and smaller. Intensification, on the other hand, requires increased use of production inputs including water.

Water for agriculture is critical for food security. However, in many parts of the world agricultural production is threatened by water scarcity. Projects aimed at providing water for agriculture through dams, wells, dugouts, and bunds have also led to increased breeding of disease-carrying vectors. Fish ponds also have been found to contribute to malaria transmission, as evidenced by a study in the Peruvian Amazon9 and Côte d’Ivoire.10 In Burundi, malaria parasite prevalence was estimated at 24–69 percent in irrigated rice fields compared with 5–30 percent in nearby non-irrigated fields.11 Similar findings were obtained from studies in East and West Africa.12 Surprisingly, increased mosquito numbers on irrigated rice fields do not necessarily result in increased prevalence of malaria. This is the so-called “paddies paradox.” It is speculated but not proven that higher income and improved livelihoods in irrigated areas, which tend to improve access to malaria treatment and may support an increased use of malaria preventive devices, are key factors.13

Improperly managed agricultural systems have resulted in water pollution and food contamination and their associated human diseases. Water pollution arises from dumping or seepage of waste, including agricultural waste and agrochemical effluents, into standing or flowing water, and food contamination results from lapses in agricultural production and post-harvest management. The contamination can result in health problems, even acute diseases with high mortality rates at young ages and early onset of chronic diseases at middle ages. Agriculture-related accidents can also result in temporary or permanent disability or death.

3. Disease and Health The World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.14 Economists define health as an asset which can be invested in as well as consumed.15 In his attempt to construct a model of the demand for the commodity “good health,” Grossman (1972) viewed health as a durable capital stock that produces an output of healthy time. The stock of health

9 Maheu-Giroux et al. (2010) 10 Matthys et al. (2006) 11 Mutera et al. (2006) 12 Mutero et al. (2004) 13 Van der Hoek (2004) 14 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19-22, 1946 and came into force on April 7, 1948. 15 Zweifel et al. (2009); Grossman (1972)

depreciates with age and illness, and it is therefore important to invest in health (including disease prevention, healthcare, adequate food, and good nutrition) to continue to obtain quality healthy time. In this review ill health is assumed to have been caused by the contraction of disease or by malnutrition.

Disease causes ill health and prevents people from fully engaging in their work activities or education and training or recreation. Depending upon the severity of disease, these interruptions can seriously affect the livelihood of these people if the necessary adjustments are not made to replace lost time due to illness. Ill health can lead to death, and the labor contribution of the dead person to household production is permanently lost. Without adjustments in the household’s labor pool, this could alter the standard of living of household members left behind. This section discusses some common diseases which have pronounced effect on agricultural productivity and production in low-income developing countries. More specifically, this section covers AIDS, malaria, TB, soil-transmitted helminth infections and schistosomiasis, mycotoxins, cardiovascular diseases, and zoonotic diseases.

HIV and AIDS Globally, the number of people living with HIV16 continued to grow in 2008, estimated at 31.1–35.8 million of which 50.2 percent were women.17 This is about 20 percent higher than the number in 2000 and about threefold higher than 1990. There were about 2 million AIDS- related deaths in 2008 of which Sub-Saharan Africa accounted for 72 percent. It is also the most heavily HIV-affected region worldwide representing 67 percent of infections, 68 percent of new HIV infections among adults, and 91 percent of new infections among children. Women and girls continue to be disproportionately affected by HIV in the region, with women accounting for approximately 60 percent of all estimated HIV infections.18,19

The effects of HIV and AIDS are reflected in the changes in life expectancy. HIV infection in Sub-Saharan Africa has resulted in the substantial decrease in life expectancy (Table 1). It is disappointing that after several years of investments to control HIV and AIDS in Africa, life expectancy among people living with AIDS is expected to fall from 2000 to 2010. This is not surprising since more people in many African countries are getting infected and dying, and apparently AIDS control programs have not been adequate or effective. However, reversal of the situation is expected in later years as anti-retroviral drugs become increasingly available (see Section 8). For instance, the latest seroprevalence data in Mozambique indicate that one in six persons is infected with the AIDS virus. According to the Government, this means that over three million people are infected, that is over 25 percent of the population in some areas,

16These estimates include all people with HIV infection, whether or not they have developed symptoms of AIDS. 17 UNAIDS and WHO (2009) 18 UNAIDS (2008) 19 Garcia-Calleja, Gouws, Ghys (2006)

with 500 new persons contracting the virus every day in certain regions (Radio ONU, Maputo).20 According to official 2008 data, out of the 300,000 or so AIDS patients requiring urgent treatment in rural areas of Mozambique, fewer than 90,000 were able to benefit from anti-retroviral drug treatment, owing to lack of information and poor access (Radio UNU, Maputo).21 AIDS threatens households, community, and national food security and poverty reduction efforts and so effective control measures should be put in place.

Table 1. Life expectancy with and without AIDS in selected African countries, 2000

Country 2000 2010 With Without AIDS Years Lost With AIDS Without Years Lost Botswana AIDS39.3 70.5 31.2 29.0 AIDS73.2 44.2 Ethiopia 45.2 56.1 10.9 42.1 60.0 18.0 Kenya 48.0 64.9 16.9 44.3 68.4 24.1 Nigeria 53.6 57.8 4.2 38.9 64.0 26.0 South Africa 51.1 65.7 14.6 35.5 68.3 32.8 Swaziland 40.4 57.7 17.3 29.7 61.5 31.8 Zimbabwe 37.8 69.9 32.1 32.5 72.8 40.3 Zambia 37.2 58.7 21.5 38.9 72.8 33.9 Source: U.S. Bureau of the Census, International Data Base, 2010

Malaria Malaria is one of the most prevalent and challenging infectious diseases affecting developing countries. The disease is geographically specific with its extent and severity largely determined by climate and ecology.22 Intensive malaria is confined to the tropical and subtropical zones, and poverty may promote its transmission. In 2006, malaria was present in 109 countries and territories.23 It is endemic in 91 countries whose population makes up 40 percent of the world’s population, and is responsible for more than 1 million deaths per year, mostly children.24 Clearly, such deaths affect the short- and long-term supply of labor. While malaria is non-fatal in the majority of cases, particularly among adults who participate in the labor force, it results in frequent recurrent debilitating bouts of illness which prevents individuals from supplying their labor productively.25 Because malaria mostly affects children, a significant amount of adult (women) time is used in taking care of the sick children instead of doing productive work. Repeated bouts of malaria in agrarian households cause a decline in farm output and farm income, and cause food insecurity and an increase in

20 CTA (2010) 21 CTA (2010) 22 Gallup and Sachs (2001) 23 WHO (2009a) 24 McCarthy et al. (2000) 25 Cole and Neumayer (2006)

poverty.26 For example, while about 50 percent of Nigerian population experience at least one episode per year, official estimates suggest that there are as many as four bouts per person per year on average.27

The world is now facing an increasing disease burden with respect to malaria as a result of increasing population movements into malarious regions, changing agricultural practices including the building of dams and irrigation schemes, deforestation, the weakening of public health systems in poor countries, increasing resistance of the parasite to drug treatment, and more speculatively, long-term climate changes such as more pronounced El Niño cycles and global warming.28

It is heartwarming to know that the use of derivatives of artemisinin (extract of the ancient medicinal plant Artemisia annua) combined with other drugs (artemisinin-based combination therapies – ACTs) have shown good efficiency in parasite resistance. This has led to efforts to increase cultivated production of Artemisinin in the short run and to develop, through biological and chemical research, synthetic substitutes in the long run.29 Scientists are developing a biological control method for malaria that uses larvae-eating fish to control mosquito populations in rain-fed pools. Tanzania’s Tropical Pesticide Research Institute is working with the US-based Poseidon Science Foundation to investigate the best way to mass produce and distribute the fish embryos for use in the areas where malaria is endemic.30

Tuberculosis According to the World Health Organization (WHO),31 tuberculosis (TB) threatens one-third of the world’s population. TB was declared a global health emergency in 1993. One in ten people infected with TB bacilli will become sick with active TB in their lifetime. WHO estimates that the largest number of TB cases in 2007 occurred in the Asia region32, which accounted for 63 percent of the cases globally. However, the estimated incidence rate in the African region, at 363 cases per 100,000 populations, is greater than that of the Asia region (289 cases per 100,000 populations). TB prevalence and death rates per 100,000 populations declined from 296 in 1990 to 206 in 2007 for the former, and from 28 in 1990 to 25 in 2006 for the latter 33 which indicates an improvement in disease control. The Africa region has the highest mortality rate. The TB mortality rate for the region was 45 per 100,000 individuals who were HIV-negative and 47.6 per 100,000 individuals with HIV.

26 ESPD (2005) 27 Alaba and Olumuyiwa (2009) 28 Sachs and Melaney (2002) 29 Dalrymple (2009) 30 CTA (2009) 31 WHO (2009b) 32 Asia here means the WHO regions of South-East Asia and the Western Pacific according to the WHO 33 WHO (2009c)

The economic impact of TB comes from the size of the problem and from the fact that in developing countries the majority of those affected are in the economically active segment of the population. Moreover, the value of activities such as cooking, house cleaning and childcare, which are traditionally considered chores for women, are rarely looked at in studies that attempt to estimate the costs of tuberculosis, even though they may be considerable. In the state of Tamil Nadu, India, for example, female TB patients reported a 50 percent reduction in household work and only one-third reported that they were able to attend adequately to the needs of their children.34

Soil-transmitted Helminth infections and Schistosomiasis Helminth infections (roundworm, whipworm, hookworm), caused by soil-transmitted helminths (STHs) and schistosomes, are among the most prevalent afflictions of humans who live in areas of poverty in the developing world. STH infections rarely cause death. Instead, the burden of disease is related to chronic and insidious effects on the hosts’ health and nutritional status.35,36

The transmission of these diseases depends on environments contaminated with egg-carrying feces associated with poverty, poor sanitation, and lack of clean water. Approximately 300 million people suffer from severe morbidity as a result of these diseases.37,38 The greatest numbers of STH infections occur in the Americas, China and East Asia, and Sub-Saharan Africa. In these regions together (excluding the Americas), the prevalence of roundworm, whipworm, and hookworm are 1.222 billion, 795 million, and 750 million, respectively39.

Schistosomiasis, also known as Bilharziasis, is a water-borne parasitic disease caused by trematode flatworms of the genus Schistosoma.40 An estimated 200 million people in 74 countries are infected with the disease.41 About 100 million of the infected are in Africa, many of whom rely on agriculture as their livelihood. While schistosomiasis has a relatively low mortality rate, it has a high morbidity rate, causing severe debilitating illness in millions of people. The disease causes chronic illness that can damage internal organs and, in children, impair growth and cognitive development, which can negatively affect their productivity and income earning ability during adulthood. Schistosomiasis is often associated with water resource development projects, such as dams and irrigation schemes, and rivers where the snail intermediate hosts of the parasite breed. The parasite then spreads to people and causes disease as farmers collect water to irrigate their fields, women and children collect water or

34 Ahlburg (2000) 35 Stephenson et al. (2000) 36 Stolzfus et al. (1997) 37 Crompton (1999) 38 Montresor et al. (2002) 39 de Silva et al. 2003. 40 WHO (2009d) 41 Carter Center (2009)

stand in the water to wash clothes, people wade through the water to cross from one bank to another, or children swim in the water for recreation. Schistosomiasis is second to malaria as the most devastating parasitic disease in tropical countries.

Mycotoxins Mycotoxins are toxic secondary metabolites of fungal origin and contaminate agricultural commodities before or under post-harvest conditions. When ingested, inhaled, or absorbed through the skin, mycotoxins cause lowered performance, sickness, or death of humans and animals.42 Over 300 mycotoxins have been reported,43 but the five agriculturally important toxins from fungi are aflatoxins, fumonisins, ochratoxin A, zearalenone and deoxynivanelol.44 High on the list of mycotoxins is aflatoxins, which pose serious health, economic and agricultural problems in developing countries.45 Aflatoxin chemical poisons are produced mainly by the fungus Aspergillus flavus and are found as contaminants in foods such as cassava, peanuts, corn, rice, cottonseed, and other grains that underwent stress factors during plant growth, late harvesting of crops, high ambient humidity preventing thorough drying and poor storage conditions.

There is a high level of aflatoxin exposure in countries in Sub-Saharan Africa and Southeast Asia.46 Data from several West African countries show that more than 98 percent of children and adults have detectable amounts of aflatoxin in their blood.47 Aflatoxin contaminated diet has been linked with the high incidence of liver cancer in Africa.48 Gong and others demonstrated that children in Togo and Benin who ate foods contaminated with aflatoxins exhibited stunted growth and underweight, which are symptoms normally associated with malnutrition.49 Turner and others also concluded that aflatoxin exposure in West Africa at the time of weaning has been associated with impaired child growth and with a decreased immune response.50 According to Miller, 40 percent of the productivity lost to diseases in developing countries is due to diseases exacerbated by aflatoxins.51

The good news is that scientists at the African Agricultural Technology Foundation, Kenya and the United States Department of Agriculture, and International Institute for Tropical Agriculture have collaboratively demonstrated the ability of a natural fungus (atoxigenic strains) found in Nigeria to significantly reduce concentration of aflatoxins in maize.52 This

42 Wagacha and Muthomi (2008) 43 Coker (1979) 44 Bankole and Adebanjo (2003) 45 Bankole and Adebanjo (2003) 46 Jolly et al. (2007) 47 Montesano et al (1997); Wild and Turner (2002) 48 Oettle (1964); Bababunni et al. (1978) 49 Gong et al. (2002) 50 Turner et al. (2003) 51 Millier (1996) 52 Rural21, (2009)

biological control strategy offers a viable option for mitigating the negative effects of aflatoxins on human health. It is suggested that the strategy of using food additives to protect farm animals from aflatoxin may also provide effective and economical new approaches to protecting human populations.53

Cardiovascular diseases Cardiovascular diseases (CVD) are becoming an important health hazard in developing countries, especially in urban areas, after a long period of low prevalence. By 2001, CVD had become the leading cause of death in the developing world, except Sub-Saharan Africa where it is HIV-related disease.54,55 Many factors have contributed to this, including changing diets from coarse grains, fruits, and vegetables to more fine grains, meat, oil, fat and sugar, disappointedly even in some rural households, along with increasingly sedentary lifestyles that are sometimes accompanied by smoking and heavy consumption of alcohol. The resulting heart disease, high cholesterol, hypertension and diabetes require the administration of daily medication which can push even relatively well-to-do households into poverty in the absence of health insurance. Because working-age adults account for a high proportion of the CVD burden, impact of cardiovascular diseases in developing economies is large. Conservative estimates in Brazil, China, India, Mexico, and South Africa indicate that each year at least 21 million years of future productive life are lost because of CVD.56

Zoonotic diseases The health of farmers and farm workers may be at risk if they work with animals. Essentially, zoonotic diseases are defined as all those human diseases that are acquired from or transmitted to any other vertebrate (Box 1). Zoonotic diseases are common throughout the world, and in developing countries they constitute an important threat to human health. More than three-quarters of the human diseases that are new, emerging, or re-emerging at the beginning of the 21st century are caused by pathogens originating from animals or from products of animal origin.57 Disease ecology shows that disease spread and the emergence of zoonotics are largely the product of human activity, and, therefore, of human choices. Increased migration and incomes lead to increased intensification and market-oriented smallholder livestock systems and adaptive agro-pastoral and pastoral systems which supply large local and regional markets. These intensive production systems are less profound in Africa, except for poultry, close to large urban markets. Intensification of animal production tends to increase disease risk.

53 Williams et al. (2004) 54 Mathers et al. (2006) 55 WHO (2002) 56 Mathers et al. (2006) 57 FAO/WHO/OIE (2004)

The consequences of animal diseases range from direct economic costs, such as the loss of animal production and products, to indirect costs related to a disease outbreak, such as the loss of trade, markets and jobs.58,59 In the 1980s, a foot and mouth outbreak caused the Kenyan dairy farming sector to suffer a 30 percent loss of milk production.60 In 1997−1998, abortion by cows caused by Rift Valley fever virus undermined birth of calves and milk production, and milk exports declined by 75 percent in East Africa.61 The 2003−2004 outbreak of highly pathogenic avian influenza in Southeast Asia resulted in more than 140 million dead or destroyed birds and losses exceeding US$10 billion.62 Since late 2003, the H5N1 strain of avian influenza has been responsible for 4,544 documented outbreaks in poultry farms in 36 countries. These outbreaks have been associated with 269 human cases and 163 fatalities (as of January 2007).63

Avian influenza has generally been dealt with by culling birds, but health authorities are now trying to look up the supply chain to identify possible sources of infection, according to David Nabarro, the United Nations senior coordinator for avian and pandemic flu. “We are finding that if we have a much clearer understanding of the patterns of movement of the virus, and in particular build-up points, we can then do much more sophisticated control strategies that have less economic damage for poorer people and more impact”, said Nabarro.64

Box 1: Zoonotic Diseases

The World Health Organization defines zoonoses as diseases caused by infectious agents that are naturally transmitted between animals and humans. Some well-known zoonoses are salmonellosis, swineherd’s disease (caused by Leptospira spp), brucellosis, hepatitis E, HIV, bovine spongiform, encephalopathy (BSE) and its zoonotic form the variant Cretzfeldt-Jakob disease (vCJD), Rift Valley fever (RVF), anthrax, adult meningitis (caused by Streptococcus suis), and influenza.

Of most interest today are the so-called emerging zoonoses, which include SARS, West Nile virus, and highly pathogenic avian influenza. Increasing population, globalization, trade in exotic pets, and the close intermingling of animals and humans in urban settings have all contributed to outbreaks of emerging zoonoses. The diseases especially pose serious threat to the fragile economies of Sub-Saharan Africa where livestock, dairy, and poultry industries are just emerging and could be seriously affected. In Africa, movements of domestic and wild animal populations are important in the spread of the diseases. A very serious emerging zoonotic disease in South Asia is Nipah Virus Disease, which is transmitted by Pteropus bats. The disease causes high levels of fatality in humans and in pigs.

Source: National Research Council (2008)

58 OIE (1999) 59 Le Gall (2006) 60 Ibid. 61 Ibid. 62 OIE/FAO/WHO (2007) 63 World Bank (2007) 64 The Daily Monitor (2010)

4. Linkages between Agriculture and Health Agriculture and health are linked in various ways. These links are bidirectional: agriculture influences health and health influences agriculture. Figure 1 presents a framework, developed by Hawkes and Ruel (2006a), for understanding the linkages between agriculture and health. In the framework, the entire agricultural supply chain—agricultural producers, agricultural systems, and agricultural outputs—has implications for health through critical intermediary processes, which are the labor process, environmental change, income generation, and access to food, water, land, and health-related services. Poor agricultural households tend to be vulnerable to malnutrition and poor health; agricultural systems interact with the environment, and by so doing affect human health; and agriculture produces foods, fibers, and plants with medicinal properties essential for human life and health.

Figure 1. Framework for linkages between agriculture and health

Source: Hawkes and Ruel (2006a) Agricultural production is a determinant of health, primarily through the consumption of food produced and through intermediary processes related to income and labor. In addition to providing some or all of the household’s food needs, agriculture provides income for farmers and farm laborers. Income enables them to purchase and gain access to food, water, land, information and education, and health-related services which in turn determine their overall nutrition and health status. On the other hand, agricultural labor, which is relatively intensively utilized, can affect nutritional status due to high energy expenditure and by usurping time that could be otherwise spent on child care, food preparation, and other nutrition-related activities. Farm labor, particularly when inefficiently utilized, can also detract from time that could be productively spent on income-generating activities, educational, or other endeavors. Labor exposes producers to a range of occupational health hazards, such as accidents, diseases, and poisoning from pesticides as well.

Pesticide use has been increasing in developing countries and so has pesticide poisoning in farmers (Box 2). In addition to increase in quantity of pesticide used, farmers use stronger concentrations of pesticides, they have adopted increased frequency of pesticide applications, and they increasingly mix several pesticides together to combat pesticide resistance by pests.65,66 Due to lack of training in pest management or in safe methods of storage, handling, and application, many farmers contract pesticide-related diseases.67 Farm workers who do not wear protective clothes or equipment (because they are not aware of the dangers, the clothes are not available or are unaffordable, or there are no regulations to enforce wearing them) are in danger of inhaling the fumes from chemicals and damaging their skin and eyes. Many of the negative health impacts resulting from pesticide use can be mitigated if protective measures are taken or recommended methods are followed when mixing and applying the chemicals. For instance, anecdotal information indicates that many

65 Chandrasekera et al. (1985) 66 WRI (1998) 67 Antle and Pingali (1994)

young men in the tomato-growing communities in Ghana have complained of reduced libido and impotence in sexual relations because many of them test the strength of the chemicals they spray on the tomato plants by tasting them after mixing with water instead of following the instructions of the manufacturer.

Consequences of large-scale pesticide use include hormone disruption and immune suppression.68 Prolonged exposure to pesticides could cause one or more of the following chronic effects: cardiopulmonary problems, neurological and hematological symptoms, and adverse dermal effects.69,70 Deaths resulting from exposure to pesticides are not uncommon. Estimates from Food and Agriculture Organization (FAO)71 in 2000 show that approximately 3 million people are poisoned and 200,000 die from pesticide use each year. A more recent estimate by the World Bank puts annual deaths caused by pesticide poisoning to 355,000 (see Box 2). Evidence also points to negative health and productivity impacts resulting from pesticide use. For example, in Tanzania, a study of vegetable farmers reported that 68 percent of farmers who used pesticides reported having felt sick after routine pesticide application.72 In Zimbabwe, it was found that pesticide acute symptoms significantly increased the direct cost of illness in cotton growers.73 The time spent recuperating from illnesses attributed to pesticides average 2-4 days during the growing season. Combining production data from a farm-level survey and health data from the same population of farmers in two rice-producing regions of the Philippines, Antle and Pingali74 found that pesticide use has a negative effect on farmer health, while good farmer health has a significant positive effect on productivity. A study of potato production in Ecuador showed similar results.75 In that study, results indicate that despite the role that insecticides play in controlling the Andean weevil insect pest, a reduction in the use of the principal insecticide (carbofuran) used to control the pest could raise productivity of potato production and also improve farmers’ health.

68 Straube et al. (1999) 69 Davies, Freed and Whittermore (undated) 70 Spear (1991) 71 FAO (2000) 72 Ngowi et al. (2007) 73 Maumbe and Swinton (2003) 74 Antle and Pingali (1994) 75 Antle et al. (1998)

Box 2: Pesticide Use and Farm Worker Health

Pesticides can increase agricultural productivity but there is growing concern on the health impacts of its use. When handled improperly, agricultural chemical use is toxic to humans and other species. Deaths due to unintentional poisoning from exposure to pesticides are estimated at 355,000 people yearly, two-thirds of whom are in developing countries.

In Ecuador, Carchi had the highest level of pesticide poisoning as reported by the Ecuadorian Ministry of Public Health. Pesticide poisoning was the second leading cause of death for men (19 percent) and women (14 percent). Research results of a potato farming community in the area revealed a rate of 171 pesticide poisonings per 100,000 people during 1991−1992, which was 10 times the number of poisoning cases reported by the Ministry of Health. Days of recuperation following a typical poisoning equated to 11 days of lost labor wages. Hospital records showed numerous cases of poisoning of women and children besides the main pesticide applicators. Using fluorescent tracers to confirm the presence of pesticides on farm family members and in the household, pesticide residues showed on the hands, back and legs of the applicators after spraying and clean up. Residues were also found on workers applying the pesticides, and children who had been to the field to run errands like fetching water for mixing the chemicals, and on various surfaces inside the farm household.

About 50 cases of pesticide poisoning were formally reported during the year of surveillance for the research, with an average of 4 cases of poisoning reported for each month. Of the 50 pesticide poisoning cases, 32 occurred among male agricultural workers, and 1 occurred in a female agricultural worker. Nine involved accidental poisoning in agricultural settings, eight of which occurred among children. Voluntary ingestion of pesticides (suicidal intent) occurred in the remaining eight cases. With the exchange rate at that time, median costs associated with the poisonings in the area were estimated as follows: public and social security healthcare direct costs of $9.85/case and private health costs of $8.33/case. Among the 29 follow-up cases, 23 youth and adults lost a total of 99 workdays (mean 4.5 days/case), estimated to be an overall wage/income loss of approximately US$249.88. Median lost-time indirect cost was thus $8.33/case. These costs were considered substantial, as local agricultural wage was about $1.50 per day.

Negative health and economic impacts of pesticides can be minimized through training and information campaigns on pesticide use. In Nicaragua, farmers trained in appropriate pesticide use suffered lower exposure after two years and had higher net returns than those who had not been trained.

Source: Cole, et al. (2000), Yanggen et al. (2004), World Bank (2007)

Rola and Pingali76 assert that the positive production benefits of applying insecticides in rice production are overwhelmed by the insecticide-related health costs. They conclude that the value of crop loss to pests is invariably lower than the cost of pesticide-related illness and the associated loss in farmer productivity. It is therefore important to consider health effects in the economic analysis of pesticide adoption in agricultural production. Failure to do this may result in the overstatement of the economic effect of pesticides or underestimation of the economic effect of pest-resistant crops or organic farming (biological control of pests/non- use of pesticides).

76 Rola and Pingali (1993)

Pesticides also contaminate drinking water and food crops, especially fruits and vegetables receiving higher doses of pesticides, thus posing serious health hazards to consumers.77 According to the U.S. Food and Drug Administration, approximately 35 percent of the foods purchased by consumers have detectable levels of pesticide residues and 1−3 percent of the foods have pesticide residue levels above the legal tolerant levels.

Agricultural income generation in terms of the amount and type of agricultural Box 3: Peri-Urban Agriculture and Malaria activities of producers influences Urbanization is increasing in most developing countries. migration and the search for alternative To feed the increasing population, urban and peri-urban income sources, which has implications agriculture, including fish ponds, has intensified, for the spread of and exposure to especially in Africa. Farmers cultivate undeveloped land around the cities to produce and supply vegetables to the diseases such as HIV. Migrants have city dwellers. Since cultivation is done all year round been at the center of cocoa production in availability of water is vital for the success of the West Africa. Farmers in Ghana and Côte venture. However, water is scarce in most of the cities d’Ivoire have moved from one area to and so it becomes a constraining factor for urban and peri-urban agriculture. Most farmers construct wells or another to acquire land for cocoa harvest water and store it in dugouts and bunds. These farming. During the long dry season in water storage receptacles provide favorable aquatic the Sahel region of West Africa, people habitats for mosquitoes. People who live around these migrate to the cocoa-growing areas to gardens easily contract malaria throughout the year if they are not properly protected by bednets, pesticides, or find jobs as farm laborers and take their other control measures. A study in Kumasi, Ghana to earnings back to invest in their farming assess the impact of irrigated urban agriculture on ventures at home. This movement of malaria transmission revealed higher adult anopheline people includes women who provide mosquito densities in peri-urban and urban agricultural locations, with more reported malaria episodes than in sexual services to the migrants. When the non-agricultural locations in the city. The study migrant laborers contract diseases, found high levels of parasitemia among children living especially sexually transmitted diseases, in communities closer to agricultural sites. It is therefore they risk infecting others when they important for policymakers in agriculture and health to be cognizant of this relationship when devising return home, including spouses they left agricultural development and disease control policies behind. In the other direction linking and strategies. Due to scanty information, more research health to production, poor health and is needed to provide detailed information on the health malnutrition of agricultural producers impacts of urban agriculture. reduce their work performance, thereby Source: Afrane (2003) reducing productivity and income and bringing about even more ill health.78,79

Inadequate labor availability to meet production needs is one aspect underlying the use of child labor on family cocoa farms in West Africa (see Box 7), a practice that affects

77 Pimental et al. (1992) 78 Hawkes and Ruel (2006a) 79 Hawkes and Ruel (2006b)

children’s health and education.80 However, child labor should be distinguished from child work which involves a child accompanying a parent to undertake light farm work that does not affect his or her schooling.81

Agriculture in terms of the agricultural systems chain also influences health. Agricultural systems affect human health via the intermediary process of environmental changes in water, soil, and air. For instance, characteristics of agricultural production systems, such as crop rotation, the presence of livestock, and the proximity of villages to fields and water sources, create conditions for contracting water-borne vector diseases.82 Agricultural development has increased the need for crop irrigation, which creates conditions that favor the breeding of parasitic vectors and facilitate disease transmission. For instance, an increase in the soil moisture associated with irrigation development in the southern Nile Delta after the construction of the Aswan Dam caused a rapid rise in the mosquito population and the consequential increase in the disease Bancroftian filariasis.83,84 In Ethiopia, a study reported that the introduction of microdams for irrigation resulted in a seven-fold increase in the incidence of malaria.85 Onchocerciasis and trypanosomiasis, which cause river blindness and sleeping sickness, respectively, are vector-borne parasitic diseases that can emerge in an area by changing land-use and water management practices. Research in Malaysia reported that expansion and changes in agricultural practices were intimately associated with the emergence of Nipah virus in the country.86 Also, ponds used to collect water for irrigation in peri-urban agriculture breed mosquitoes which increase the incidence of malaria for residents around the farms (Box 3). To reduce the impact of these health conditions linked to agricultural development, projects should recognize and address the potential consequences with appropriate intervention activities. Discussions between agriculture and health policymakers and professionals can help to tackle the externalities of these projects and minimize their negative impacts.

Conversely, poor health also affects agricultural systems. Poor health lessens the farmer’s ability to innovate, experiment, and operationalize changes in agricultural systems. A farmer who is ill cannot attend a farmer field school or interact with an extension officer to learn about new technologies and improved practices, and so may lack the knowledge to innovate. Most often, innovation requires the purchase of improved seed, fertilizer, or other inputs, or use of machinery, and this may not be affordable for poor farmers after spending their money on healthcare. When the innovation involves additional labor (for example, farming practices like planting in lines), it is difficult for households with sick members to adopt the practice.

80 Barrientos et al. (2008) 81 Asuming-Brempong et al. (2007) 82 World Bank (2007) 83 Harb el al. (1993) 84 Thompson et al. (1996) 85 Ghebreyesus et al. (1999) 86 Chua et al. (1999)

Experimentation on technology adoption and improved practices would be too costly for a farm household that is spending a lot of money on healthcare and is losing labor to illness.

Agriculture’s major output, food, carries diseases caused by contamination by pathogens during agricultural production. Consumption of milk contaminated by Mycobacterium bovis, which is present in animals in most developing countries, has long been regarded as the principal mode of TB transmission from animals to humans.87 M. bovis and M. tuberculosis have been found in milk samples in Ethiopia, Nigeria, and Egypt, highlighting the serious public health implications of potentially contaminated milk and milk products in developing countries where proper food hygiene practices are lacking.88,89,90 One way of reducing the effects of the contaminants is to boil the milk before consumption, but in many milk- producing communities, milk is consumed fresh.

Agricultural output also affects health through availability of quality food. Quality and diversity of food produced influence access to micronutrients and dietary diversity. Food that is poor in micronutrients cannot provide adequate nutrition for people, making them susceptible to disease. Certain types of food, like fats and oils, and others which contain dangerous substances like aflatoxins, have given rise to diet-related chronic diseases.

Agriculture also contributes medicinal plants which help treat diseases. In areas where orthodox medicine is not available or where they are available but the people cannot afford it, they seek disease treatment from traditional herbalists who use medicinal plants. For instance, because of the high treatment costs and difficulties with access, only a small percentage of households with people living with HIV or AIDS are currently using pharmaceuticals and supplements and instead depend on local capacities and resources, including plant-based medicine sourced from the forest.91,92 Examples of medicinal plants include the bark of Prunus africana tree which is used in the treatment of prostrate disorders; Artemisia annua (sweet wormwood) used in treating malaria; and the African tree Melaleuca alternifolia (tea tree) which contains an antifungal substance that combats Candida albicans, the bacteria responsible for fungal skin problems and mycosis (a condition that commonly affects the eyes of AIDS patients).

The WHO estimates that about two-thirds of the world’s population, and 80 percent of Africa’s population, sometimes use herbal or traditional medicine. Therefore, medicinal plants constitute a fundamental component of traditional healthcare systems in rural communities throughout Africa.

87 Acha and Szyfres (1987) 88 WHO (1994) 89 Idrisu and Schnurrenberger (1977) 90 Nafeh et al. (1992) 91 Willumsen and Kettaneh (2005) 92 FAO (2003)

Health also affects agricultural output, particularly its demand. Malnutrition and disease patterns influence market demand for food quantity, quality, diversity, and the price people are able or willing to pay.

Deforestation resulting from road construction, logging, and farming has also opened up opportunities for increased consumption of bush meat with its associated contraction of zoonoses.93 Farmers lay traps to catch animals which roam about in the forest, or hunters kill animals with guns. For many people in some parts of west and central Africa’s farming areas, bush meat is the main source of meat for their households, and through that some of them contract diseases.94 In Ghana, for example, people turn to bush meat when fish yields are low and some people treat bush meat as a delicacy. The handling of freshly butchered bush meat, in particular primates, brings about a risk of transmission of new zoonoses. Pathogens that do not cause disease in their natural hosts can do so in their new hosts, or evolve to do so. Some of the African examples are: (i) the Simian Immunodeficiency Virus (SIV) and Human Immunodeficiency Virus (HIV) thought to have separately crossed over from African monkeys and apes into humans and, after a long incubation period, evolved into HIV, (ii) the Simian Foamy Virus (SFV), a retrovirus like SIV and HIV. Antibodies to SFV have recently been found in Cameroonians who have had exposure to fresh bush meat, but it has yet to prove pathogenic to humans, and the Ebola haemorrhagic fever, lethal both to gorillas and chimpanzees as well as humans.95.

Very often diseases can be treated if people get access to appropriate healthcare on time. The unfortunate situation is that many rural areas do not have clinics, and the sick are sometimes carried on the backs of young men or on bicycles to nearby clinics. Delays in conveying sick persons to clinics sometimes result in death. Clinics in rural areas often lack adequate equipment or trained health personnel. In the absence of health insurance, rural people are not able to access healthcare, even when it is available, because of the “cash and carry” policy (or pay before you receive service) in healthcare in many countries. Some people are put off in seeking healthcare because of the indirect cost of travel time, waiting at the health facility, and searching for drugs to purchase. The result is self-medication with its attendant repercussions.

5. Linkages between Health and Nutrition, and Farm Labor Productivity Of the 960 million hectares of land under cultivation (arable and permanent crops) in Africa, Asia and Latin America, 10-15 percent is managed by traditional farmers.96 Africa has approximately 33 million small farms (less than 2 hectares per farm), representing 80 percent of all farms in the region. In Asia, the majority of more than 200 million rice farmers cultivate around 2 hectares of land each, making up the bulk of the rice produced by Asian farmers. Farms of less than 2 hectares constituted 78 percent of the total number of farms in

93 Patz et al. (2004) 94 Nasi (August 2007) 95 POST, UK-Parliamentary Office of Science and Technology (2005). 96 Altieri ( 2008)

India but contributed 41 percent of the national grain production.97 Due to the small sizes of farms and low incomes, the sector depends largely on manual labor which is invariably obtained from household members or hired from the local community. The farms are therefore vulnerable to household labor disruptions.

Apart from the farm owner and the spouse, additional farm labor is generally supplied by hired workers. When these people become ill, either their labor is no longer available or they cannot work at full strength and their productivity and output dwindle. This situation often causes farm labor shortages and disrupts scheduled farm activities. Thus, low labor productivity has become a distinguishing characteristic of developing country agriculture. As shown in Figure 2, labor productivity, measured in terms of agriculture value added per worker, is quite low in low income countries or developing countries compared to high income countries and middle income countries, which rely more on farm machinery than labor. Rampant poor health among the most active population in developing countries is one of the reasons for explaining the differences.

Figure 2. Agriculture value added per worker by income group, 2000, and 2005

25000 20000 15000 10000 2000 5000 2005 0

Low income Lower middle Upper middle High income AgricultureValue Added per Worker(Constant US$) 2000 income income Income Group of Countries

Source: World Bank, World Development Indicators (2008)

Nutrition affects people’s health and is an important factor in farm labor productivity. Past nutritional status predicts the probability of developing chronic diseases and consequently influences labor force participation.98 The nutrition and health status of adults affect the duration of labor force participation and the intensity of work effort. Poor health will result in a loss of days worked or in reduced worker capacity, and is likely to reduce output. 99 Limited access to food may occur in a household if individuals are too ill or overburdened to produce or earn money to buy food.100 A study in Brazil simultaneously explored the effect of

97 Greenland (1997) 98 Sur and Senauer (1999) 99 Antle and Pingali (1994) 100 Keverenge-Ettyang et al. (2010)

four separate dimensions of health on urban wages.101 The relationship among wages, per capita calories, per capita protein, body mass index (BMI),102 and height were examined. Research results revealed that height is associated with higher wages for both self-employed men and those who work in the market sector. Moreover, being taller and having a higher BMI is compensated most in self-employment. It was noted that many of the self-employed in urban Brazil work as manual laborers and returns to strength are large in such vocations in which a lot of energy is required. Based on the premise that wages reflect the marginal productivity of labor, Sur and Senauer (1999) looked at the link among nutrition, health and labor productivity by estimating wage equations from individuals participating in the wage labor force in rural Bangladesh. Height, which was used as an indicator of long-term health status, was found to be a significant determinant of labor force participation in agricultural wage labor but not for non-agricultural wage labor. Good nutrition has been found to be crucial for both children’s physical and cognitive development and for their productivity and earnings as adults. The Lancet103 reported that boys who benefited from a randomized nutrition intervention during conception and in their first two years of life earned 50 percent more wages than those of non-participants, when both groups became adults.104

Because they reduce the productivity and the potential of the workforce, policymakers need to be as concerned with micronutrient deficiencies and the quality of food consumed as they are with broader issues of hunger and the quantity of food consumed.105 Vitamin A, iron, and zinc are considered to be deficient in diets in developing countries.106 The World Health Organization (WHO) estimates that 190 million children of pre-school age and 19.1 million pregnant women are affected by vitamin A deficiency.107 Some 5.2 million children of pre- school age and 9.8 million pregnant women suffer from night blindness, the principal cause of which is lack of vitamin A. In the school feeding program in Kenya, the children are served a cup of maize and beans and for many of them that may be the only meal of the day.108 It is recognized that food security refers not merely to adequate energy intakes, but also to ensuring sufficient intakes of essential micronutrients. Vitamin-enriched maize could help raise the intake of essential nutrients for the Kenyan school children and many others in the developing world. Biofortification is increasingly seen as additional tool to combat micronutrient malnutrition and provides a cost-effective way of enriching staple foods with essential micronutrients for poor people.109 A team of Spanish and German scientists have genetically modified maize to contain beta carotene (precursor to vitamin A), vitamin C, and

101 Thomas and Strauss (1997) 102 BMI is measured as weight in kilogram divided by height in meters squared (kg/m2) 103 Hoddinott et al. (2008) 104 Hoddinott et al. (2008) 105 Benson (2004) 106 Meenakshi et al. (2009) 107 http://whqlibdoc.who.int/publication/2009/0789241598019_eng.pdf 108 CTA (2009) 109 Meenakshi et al (2009)

folic acid (Golden maize).110 The HarvestPlus Challenge Program of the Consultative Group on International Agricultural Research (CGIAR) has a program to biofortify selected staple crops (sweet potato, bean, pearl millet, cassava, maize, rice and wheat) with micronutrients (pro-vitamin A, iron and zinc) for release in some countries in Africa and Asia, as a means of improving the diets of the poor in those countries.111

One condition taking place as a result of rapid economic growth is characterized by a shift from staple diets to increased consumption of processed energy-dense (micronutrient-poor) foods and greater intake of saturated fats, refined sugar and salt, augmented by more sedentary life. The result is rapid rises in obesity (Body Mass Index>30) which predispose people to chronic diseases (especially cardiovascular diseases). Although more of an urban phenomenon now, obesity becomes important in rural areas as farming becomes intensive or uses more machinery, and requires less labor input and rural non-farm agricultural activities (for example, agro-processing) become more sedentary. The obesity epidemic is a problem for all countries, including low-income countries.112 Evidence from Latin America and Asia, points toward a situation where the rates of change in the structure of diet and activity, are such that the burden of a high energy-dense diet and low activity pattern are going to be found as much, if not more, among the poor.113 Obese people cannot cope with the drudgery of hard work and long hours, such as demanded by farming. The WHO in 1998 declared obesity a global epidemic and called for coordinated effort in the management and prevention of the condition.114

A common mechanism households adopt to cope with the burden of high medical costs is reducing consumption of basic needs, including food.115 A survey in Côte d’Ivoire found that per capita consumption of AIDS-afflicted households to be half that of other households.116 Using household vulnerability index (HVI), a study of 300 households from two districts in Zimbabwe in 2007, categorized 23 of them as coping level households117 and the rest (277) as acute level households118. The study found that only 23 percent of the acutely affected households had three meals per day compared to HIV/AIDS coping level households who had about 57 percent of them that ate three meals per day. Moreover, the acute level households had less diversity in their diets than coping level households.119 In Malawi, HIV-

110 http:www.pnas.org/content/early/2009/04/27/0901412106 111 HarvestPlus (2004-2009) 112 Abubakari et al. (2007) 113 Popkin (2001) 114 WHO (2008c) 115 Pitayanon et al. (1997) 116 Bechu (1998) 117 HVI: Coping level household was defined as a household in a vulnerable situation but still able to cope; a household is considered coping level if HVI > 0.33 (Food Security Network of Zimbabwe 2007) 118 HVI: Acute level household was defined as a household that has been hit so hard it badly needs assistance to the degree of an acute health care; a household is considered acute level if HVI is greater than or equal to 0.33 and less than or equal to 0.66 (Food Security Network of Zimbabwe 2007). 119 Food Security Network of Zimbabwe (2007)

affected households had to reduce their consumption by 30 percent.120 If consumption reduction is substantial, this can lead to malnutrition which increases susceptibility to opportunistic diseases for AIDS patients. Malnutrition weakens the immune system, increasing the risk of ill-health, which in turn can aggravate malnutrition. The World Health Organization identifies malnutrition as "the single most important risk factor for disease." In developing countries, poor nutrition is a massive problem making people more susceptible to diseases. Box 4 shows options for increasing household nutrition, which would particularly be advantageous to communities affected by HIV.

A study on the effect of nutrition on labor productivity in rural Sierra Leone was one of the first attempts to test the nutrition-productivity relationship using total farm output as the measure of productivity. A Cobb-Douglas production function was estimated to test the hypothesis that farm output is influenced by effective family and hired labor hours, variable non-labor inputs, fixed capital, and land. It was found that calorie intake had a significant positive effect on farm labor productivity with a calorie-output elasticity of 0.34 at the sample mean.121 The results depend upon the number of hours worked (which vary considerably) and therefore the elasticity should measure the percentage increase in output per hour worked (and not just output) for one percentage increase in calorie intake. Using household survey data in India, Deolalikar122 estimated both a wage equation and a farm production function to examine the empirical relationship between nutrition and productivity. It was found that calorie intake or short-term nutrition status was not a significant determinant of wages and farm output, but that weight-for-height, which was used as a medium-term indicator of health and nutritional status (measured in kg/cm), significantly influenced both the wage and production function equations. The study concluded that the medium-term effects of better nutrition are quite large and positive although the short-term effects are insignificant. The study has the same defect of measuring productivity as output and not output per unit time. The medium-term used in the study depends on the length of the period. Weight-for-height is a short-term measure for nutritional status and not a medium-term measure. For farms where the workers are adults, a better measure of nutritional status is body mass index. In a Sri Lankan study that analyzed the effect of nutrition status on rural wages, it was found that per capita calorie intake had a positive significant effect on productivity for men but not for women.123 The different result may be due to differences in the work done by men and women on farms.

120 Thangata et al. (2007) 121 Strauss (1986) 122 Deolalikar (1988) 123 Sahn and Alderman (1988)

Box 4: Integrated Agriculture Aquaculture (IAA) Project for HIV-affected households Among other sources, fish is often the only accessible and affordable source of animal protein for poor households, especially those affected by HIV. It offers fats (macronutrients) and micronutrients such as iron, iodine, zinc, calcium, and vitamins A and B. In Malawi, 70% of protein source comes from fish. However, per capita fish consumption has decreased from 14 kg per person per year in the 1970s to about 4 kg today (FAO, 2009). Many agricultural technologies and economic investments have so far not adequately and sufficiently responded to the needs and strengths of vulnerable households such as those with members who have HIV (Nagoli, et al., 2009). HIV-affected households are among the worst affected by food and nutrition insecurity and reduced income levels. This is due to increased demands by agricultural technologies in terms of labor, capital investment, time, institutional support, and planning skills. In addition, HIV-affected households spend more time, labor, and other resources to care for their sick members who no longer participate in economic activities (Gillespie 2006). Fish, and in particular cultured fish (in small ponds), can play a mitigating role in the combined crisis of HIV and food insecurity in Malawi (Bene and Heck 2005), especially through technological innovations that can account for the requirements of the affected households.

Realizing the importance of deliberate targeting of households affected by HIV with new projects, the WorldFish Center, in collaboration with the World Vision Malawi, carried out a one year (July 2005 to June 2006) World Bank funded project in Chingale - Zomba district, covering 37 villages (in Traditional Authority Mlumbe). The aim of Integrated Agriculture Aquaculture (IAA) project was to identify constraints that limit HIV-affected households’ adoption of fish farming, and adapt technologies and practices for the affected beneficiaries to boost fish production and utilization. The IAA project introduced 134,000 fingerlings of Tilapia rendall in new and rehabilitated ponds. Tilapia rendallii feeds on rice or maize bran as supplementary feed and on large amounts of vegetation. This fish species grows to market size (100 grams) in 4−6 months (Nagoli et al., 2009) The yield from the ponds averaged 1500kg/hectare that translated to a production of 21 tonnes of fresh fish. The local per capita supply of fresh fish was estimated to have increased by 150% from about one kilogram of fresh fish per person. In total, about 1,200 households benefited, of which 60% were women-headed households affected by HIV. Women contribute substantially to agricultural production and related household income. At the same time, they bear the brunt of the HIV epidemic. The IAA project also succeeded because the investment in farm inputs was minimal because farmers were encouraged to use farm wastes and crop by-products to feed their fish. The provision of additional water from the ponds in the dry season expanded crop and vegetable production. This allowed farmers to grow additional valuable crops like bananas and guava on the perimeter of their ponds. These results have shown that developing customized technologies to suit HIV-affected households is a critical component in setting an all-inclusive strategy for their economic growth. The results also indicate that IAA can dramatically improve the ability of families to cope with the effects of HIV and AIDS. The technology ensures nutritional benefits for the sick and improves household income and food security. The reduction of labor from the multiple benefits (fish, vegetables) is another crucial incentive for HIV-affected households.

Source: Nagoli et al. (2009)

Re-examining the nutrition-productivity relationship taking seasonal variability into consideration using data from India, Behrman and Deolalikar124 found that calorie intake is an important determinant of wages in peak seasons, while weight-for-height is a more important determinant during lean months. During lean seasons energy is required to carry out strenuous and time consuming work and so calorie intake becomes very important. Again, it would have been more appropriate to use body mass index as the measure for nutritional status. Examining the link between nutrition and productivity in the Philippines with height as the predictor of long-term nutritional status, Haddad and Bouis125 found that while height is a significant determinant of wages, energy intake as determined from a 24- hour food recall survey was not a significant predictor of wages. However, energy requirement depends on the farm activity being carried out, so it can be misleading to make a general statement that energy intake has nothing to do with wages or productivity.

Research carried out in Ethiopia estimated the impact of health and nutritional status on the efficiency and productivity of cereal growing farmers.126 Results showed that the distance to the source of water as well as nutrition and morbidity status affects agricultural productivity. Ulimwengu127 used a stochastic production function to analyze the relationship between farmers’ health impediments and agricultural production efficiency in Ethiopia. Healthy farmers were found to produce more per unit of inputs, earn more income, and supply more labor than farmers affected by sickness. As expected, the model results show that production inefficiency increases significantly with the number of days lost to sickness. Using a quasi- experimental design along with a generalized linear model (GLM) for longitudinal data, Audibert and Etard128 estimated the worker productivity benefits of health in Mali. They assumed that the family members and the hired labor who are working in the fields are imperfect substitutes because of the cost of hired labor and the low agricultural yield. This is an unnecessary assumption because a well-supervised hired labor is as good as family labor and cost is not a relevant factor in determining productivity. Results showed an increase of 26 percent in the production per family labor person-day in the experimental group who received treatment for schistosomiasis relative to the control group who received a placebo. Unlike other studies which looked at health indicators related to past and time-invariant health (e.g., such as height due to investment during childhood), current health and changes in health caused by unexpected illness or external input were considered in their study.

Thus, across these different studies, the general conclusion is that poor health (defined broadly in terms of nutritional and health status) has significant impacts on farm productivity. The studies used different definitions for nutritional status and it is not clear how health status was measured. Severity of illness determines whether a farm worker stays away from the

124 Behrman and Deolalikar (1989) 125 Haddad and Bouis (1991) 126 Croppenstedt and Muller (2000) 127 Ulimwengu (2009) 128 Audibert and Etard (2003)

farm or the extent of effort exerted at the farm, both of which affect labor productivity and the adjustment used to cope with the situation.

High labor productivity is essential because it can play a significant role in the economic well-being of a nation. As workers’ productivity increases, they will be able to earn higher incomes; otherwise any attempt to increase their wages will be inflationary. In order to have economic growth that would result in an increase in standard of living, it is necessary for output to grow faster than the labor force participation. This implies that labor productivity should grow faster to attain high economic growth.129 As such, improvement in agriculture labor productivity is needed in developing countries where labor is abundant and agriculture provides a major source of employment and livelihood for the people.

Many studies have measured farm labor productivity as the output per unit time per farm worker. It can also be measured as value of goods and services produced in a period of time, divided by the hours of labor used to produce the goods and services. Note that labor productivity may not completely capture efficiency. For instance, a farm can boost output per worker by introducing machinery or adopting a new technology. Similarly, a farm can lose output per worker if a disease strikes the workforce. A more comprehensive measure of an economy’s (or farm’s) use of resources is “total factor productivity” (TFP), which tries to assess the efficiency with which both capital (land) and labor are used. It is calculated as the percentage increase in output that is not accounted for by changes in the volume of inputs of capital (land) and labor. Thus, TFP can be lowered if disease decreases the efficiency of labor, holding other factors constant. Although TFP is a more comprehensive measure of resource allocation, the analysis of TFP is best done at the macroeconomic level, not at the microeconomic level of analysis (households). Thus, this review focuses on “farm labor productivity,” which has been widely used in the empirical literature. However, it must be pointed out that productivity is difficult to measure because people infected with disease may have lower physical capacity even on days they go to work, even though their work may be diminished by illness. Therefore the full cost of these diseases on productivity is only partially captured by days of work missed. It will be useful if future research looks at devising methodology that can correctly capture farm labor productivity at the household level given the burden of disease.

Empirical studies on the relationship between nutritional and/or health status on farm labor productivity have used wages for agricultural laborers and/or own-farm output as the measure. Labor productivity has been analyzed either by estimating wage equations or production functions. The problem with wage equations is uncertainty about whether the wage is competitively determined and therefore equates with the value of the output of the workers. In cases where labor unions are able to bid up the wage rate or where labor is very scarce, the price of labor may not necessarily equate with the value of the workers’ output.

129 Ukoha (2000)

For smallholder agriculture, unions may be absent but labor may be scarce in the rural areas due to migration to the urban areas by many young men and women after they complete basic education. Young people would want to live in the cities for a lower wage and enjoy social amenities than to live in the villages where the amenities do not exist and there is a lot of deprivation. The scarcity of labor in rural areas often leads to uneconomic rural wage rates which tend to be higher than the national minimum wage or the urban wage for manual non- specialized work, when hours of work and perquisites like food provided for farm laborers are taken into consideration. For instance, the average daily wage for weeding on cocoa farm in Ghana in 2006 was $3.25 with most people (mode) paying $2.65. These rates, which included provision of lunch, were higher than the official minimum wage of $2.00.130

6. Conceptual Framework for Analyzing the Impact of Illness/Disease on Agriculture To examine the impacts of the disease aspect of health on agriculture, this paper adapts the conceptual framework used by Negin (2005) in the study on the impact of HIV and AIDS on agriculture and by Asenso-Okyere et al. (2009) on the linkages between malaria and agriculture (Figure 3). Microeconomic explanation of individual and household poverty revolves around the understanding that an individual’s labor (health and energy), human capital (education and skills), and physical and social assets (such as land and access to a social network) determine the individual’s ability to generate income both today and in the future.131 A study exploring welfare dynamics in rural Kenya and Madagascar found that every poor household interviewed could ultimately trace its poverty to an unexpected loss of assets or health.132 Similarly, in 74 percent of the households that had fallen into poverty in the Indian state of Andhra Pradesh, serious illness was discovered to be one of the causes.133

130 Barrientos et al. (2008) 131 Von Braun et al. (2009) 132 Barrett et al. (2006) 133 Krishna (2004)

Figure 3. Conceptual framework for the impact of illness/disease on agriculture

Ill health in the agricultural household sector Condition (poor health)

Death of Absenteeism Family members’ Loss of savings, workers due to time diverted to household, and Effect malaria caregiving farm assets

Loss of farming knowledge Outcome

Less land under Less labor-intensive Less crop variety Reduced labor cultivation crops efficiency

Low crop and livestock production Impact

Decline in income Food insecurity Decline in farm from wage labor, income and off-farm activities Source: Adapted from Negin (2005) and Asenso-Okyere et al (2009)

Illness results in morbidity and sometimes mortality. These reduce labor availability through absenteeism or death of agricultural producers/workers (Figure 3). Through morbidity the quantity and quality of labor to the household is also affected because the sick may abstain completely or partially from work during the period of illness. Labor availability is also indirectly affected when labor of productive members of the household is diverted from the farm to caring for the sick. When sick persons die, the knowledge that they acquired through learning and experience is no longer available for others to use and considerable agricultural knowledge is lost. However, it must be pointed out that although chronic illness results in a net decrease in household labor (the ill and the caretaker), the death of a chronically ill person who had a full-time caretaker can result in increased household labor when the caretaker returns to the workforce. The cost of healthcare for sick persons and of funerals drive many

households into debt, and they resort to using their savings and remittances they receive or even sell household and farm assets to defray the costs. For instance, due to costs of treatment and other expenses as well as due to lower incomes from loss of labor, AIDS affected households usually draw on assets. After the onset of AIDS, savings and financial assets are usually the first to be depleted. Then, non-productive assets, such as furniture, cooking utensils and clothes follow. Finally households may have to sell off productive assets such as tools, draught animals, and land. 134 The outcomes of these effects include reduction of farm sizes, cultivation of less-intensive crops, reduction in variety of crops planted, and reduction in livestock numbers. These outcomes affect livelihoods in terms of reduction in farm outputs and income, decline in income from wage labor and off-farm activities, and food insecurity. The impact of illness on agricultural productivity is illustrated in Box 5 for a study conducted on HIV and AIDS in rural Kenya.

134 Slater and Wiggins (2005)

Box 5: Impacts of Illness on Agricultural Productivity in Rural Kenya

In Kenya, a country with one of the highest HIV infection rates, the effects of illness on agricultural households is clearly illustrated in a study by Yamano and Jayne (2004). Data from 22 districts in rural Kenya showed that HIV-related deaths led to changes in household size, size of cultivated land, agricultural output (in terms of crop production levels), household assets, and off-farm income.

Households tend to lose some of their members to migration or off-farm activities in the locality or outside following the death of the household head (whether male or female), but there are no such effects in the event of the death of other adult household members. The death of household heads leads to a reduction in the amount of crop land devoted to high-value crops as well as reduced crop output. This is especially so in the case of the death of male heads of households, who tend to have the knowledge of high-value crop production. Apart from absence of knowledge to undertake high-value crops, the possible splitting of farms due to inheritance may explain the reduction in size of farms. As might be expected, household assets tend to decline following the death of household members, possibly due to the sale of such assets or through inheritance.

One of the key findings was that there are gender differences in the effects of mortality on agricultural productivity. The death of male household heads has a more severe impact on crop output. Households turn to low-value crops when they lose a male household head, and they also lose some farm labor due to the departure of other household members.

Source: Yamano and Jayne (2004)

7. Effects and Outcomes of Ill-health on Agriculture This section relies on Figure 3 and expands on the issues raised in section 6. Generally, the gravity of the impact of illness on agricultural production depends on the severity of the illness, and labor requirements of a particular farming system or farm activity, and the extent to which a farm household can augment or substitute for lost labor. The opportunities that households possess for labor substitution will crucially affect whether disease leads to output and income losses. However, empirical evidence on the extent of labor substitution and, in

particular, its impact on output per unit time of labor and other activities for all diseases (except HIV) is limited.

Absenteeism Illness causes pain and weakness, leading to absenteeism and lost labor time to economic activities like farming. Through morbidity, the quantity and quality of labor to the household is also affected because the sick may abstain completely or partially from work during the period of illness (see Box 6). A number of studies estimated labor time lost as a result of illness. A Tanzanian study on AIDS found that males with AIDS lost an average of 198 days of productive work over a one-year period and women with AIDS lost 286 days over the same period.135 Meanwhile, research in Rwanda revealed that for those who died, the average period of illness before death was 23 months during which care had to be provided.136

Box 6: HIV and AIDS and Absenteeism

Dick Huck Farm in Mt. Darwin, Zimbabwe was once a prosperous sweet potato farm employing more than 500 workers. But a few years ago, labor problems set in. “We started witnessing most of our specialized workers developing full blown AIDS and skipping work, and our cash flows dropped drastically,” said farm manager Josphat Jonga. In South Africa, voluntary testing of 1,500 employees on 18 commercial farms recently revealed 28.5% are infected with HIV. One quarter of Swaziland’s workforce is absent because of HIV and AIDS, according to the International Monetary Fund. Elsewhere in Africa, farmers are having to source migrant workers as their own staff fall sick and many are reporting a serious loss of agricultural skills.

Source: CTA (2009) Compared to HIV infection, which generally causes steadily deteriorating health, lost labor time due to malaria is lesser, because malaria affects children more than adults, whereas it is the opposite for HIV. Studies have shown that per malarial attack, depending on the severity, typically entail a loss of four working days, followed by additional days with reduced capacity for about four episodes per year.137,138 This means about 16 working days are lost in a year. Another study found that a bout of non-fatal malaria will typically last for 10–14 days, including 4–6 days of total incapacitation with the remainder characterized by headaches, fatigue and nausea.139 In Oyo State of Nigeria, the estimated average number of workdays lost per malaria episode by productive adults in agrarian households was 16 days for an average of 4 bouts per year which is about 64 days per year.140 Meanwhile, farmers engaged

135 Rugalema (1998) 136 Donovan et al. (2003) 137 Brohult et al. (1981) 138 Picard and Mills (1992) 139 Hempel and Najera (1996) 140 Alaba and Alaba (2009)

in intensive vegetable production in Côte d’Ivoire suffering from malaria were absent from work for up to 26 days in a 10-month period or about 31 days per year.141 In rural households of Nigeria, farmers lost an average of 22 days of farm labor to malaria illness in a year.142 Time lost per year143 to take care of a child with malaria varied from 42 days144 in Ethiopia, to 17.5 days in Ghana145 and 14 days in The Gambia.146 Variations in number of productive days lost to malaria depend on the severity of the malaria episode, a person’s general health and nutritional status, proximity to health facilities, and ability to seek healthcare during malaria episodes.147,148,149

A study of schistosomiasis in the northern and southern portions of Leyte province in the Philippines found that total days lost per person per year was 45.4 days.150 In southern Ghana, adult male farmers untreated for guinea worm disease were estimated to lose about 35 days per year,151,152 while people infected with the same disease in Nigeria were estimated to lose an average of 117 days (3.9 person months) per year. A study in urban Zambia found that before treatment, about 46 percent of TB patients and 30 percent of caregivers were absent from work due to illness, missing an average of 48 days of work in a year. About 31 percent had to cease work completely.153A study in India looking at rural and urban areas found that the number of work days lost to TB depended on age, literacy, type of income and region. The average number of work days lost per year was 83 days (82 days for females and 85 days for males), with 48 days before treatment and 35 days during treatment.154 Patients in rural areas who were between 15–25 years old had the lowest number of mean days lost (61 days) in a year. For those aged 26–45 years, about 94 workdays were lost in a year. And it was highest for individuals aged 46 or more, at 105 days in a year. In the same study, the impact on children of tuberculous patients was examined. It was found that about 8 percent of schoolchildren in rural areas of parents with TB discontinued their studies due to the burden caused by their parent’s illness. Also, about 8 percent sought employment to help support the family. The study also found that caregiving activities of female patients decreased

141 Girardin et al. (2004) 142 Ajani and Ashagidigbi (2008) 143 Studies reported number of days lost per episode to take care of a child with malaria. These varied from 12 days in Ethiopia, to 5 days in Ghana and 4 days in The Gambia. WHO estimates that an African child has on average between 1.6 and 5.4 episodes of malaria fever each year. Using the average of the two (3.5 episodes), number of lost days per episode was converted to number of lost days per year. 144 Cropper et al (1999) 145 Asenso-Okyere and Dzator (1997) 146 Aikins (1995) 147 Brinkmann and Brinkmann (1991) 148 Chima et al. (2003) 149 Asenso-Okyere et al. (2009) 150 Blas et al. (2006) 151 Belcher et al. (1975) 152 Five weeks of work time per year as reported in the study but we converted to days per year which is 35 days. 153 Needham et al. (1998) 154 Rajeswari et al. (1999)

significantly from 64 percent to 35 percent of rural patients. About 58 percent of female patients indicated inability to feed their children or take care of their daily activities and education.

Absenteeism also occurs as a result of time reallocated to care for an ill household member, including children. A household impact study of HIV and AIDS on families in the Free State province of South Africa found that household members spend 7.5 hours a day or about 2700 hours per year which is equivalent to 113 person days a year taking care of the ill.155 In rural Zimbabwe, the average time spent in taking care of bed-bound AIDS patients is 38.5 hours per week or about 2,000 hours per year which is equivalent to 83 person days a year.

As quantity and quality of labor are affected during duration of an illness, capacity to produce agricultural output often is reduced, resulting in lower labor productivity. Empirical evaluation of morbidity impacts on individual labor productivity has been limited to a few diseases. Available literature seems to show that not all types of diseases have significant negative labor productivity effects. One study in Santa Lucia examined the productivity effects of five parasitic diseases (schistosomiasis, ascariasis, trichuriasis, strongyloidiasis, and hookworm infection) using earnings per week as a measure of productivity and the parasite load as measure of disease morbidity.156 Results show that parasitic infections, except schistosomiasis, appear to cause few statistically significant adverse effects on agricultural labor productivity. A follow-up study three years later still found that schistosomiasis negatively influences productivity but its estimated impact was lower than the earlier study (a loss of 14 percent of the daily earnings of male workers) compared to the previous study of 30 percent).157 Looking at schistosomiasis disease alone, an experimental study of sugarcane workers in an irrigated estate in Tanzania found a significant difference in economic productivity of about 3 to 5 percent between uninfected and infected schistosomiasis workers.158

From Africa, two studies in a coffee plantation in southwest Ethiopia found similar results that disease has negative labor productivity effect.159,160 Male workers suffered significant losses in economic productivity (in the form of lower daily wages earned) as a result of onchocercal skin disease (OSD). Specifically, it was found that depending on the severity of OSD (and controlling for such factors as age), daily wages were 10 to 15 percent lower than workers without OSD.161 A study in western Kenya that examined the impact of HIV and AIDS on labor productivity had also similar findings. The study found that HIV-positive workers plucked 4 to 8 kg/day less tea in the last year and a half before they died compared to

155 Booysen and Bachman (2002) 156 Baldwin and Weisbrod (1974) 157 Weisbrod and Helminiak (1977) 158 Fenwick and Figenshou (1971) 159 Workneh et al. (1993) 160 Kim et al. (1997) 161 Kim et al. (1997)

HIV-negative workers.162 Another research in the Ondo state of Nigeria in 1997 involving 500 cocoa farmers infected with guinea worm, found that on average, a cocoa farmer infected with guinea worm disease lost 19 bags of potential harvest due to disease morbidity, which was valued at about 4,884 naira at that time (about US$ 64 in present value terms).163 This would be substantial amount of loss of (9,566 bags) of potential harvest for the 500 farmers worth about 2,442,000 naira at that time (or US$31,845 in present value terms).

As suggested by theoretical literature, household farm production will decline (and shift to less labor-intensive crops) because of loss of productive labor due to illness. While numerous studies have focused more on estimating the economic burden of illnesses (direct and indirect164 costs), the available empirical literature165 evaluating effect of morbidity on agricultural production has shown varying results. A study in Rwanda indicated that reduced labor time as a result of HIV related illness among women and increased time women devote to caregiving to members living with AIDS resulted in a decline in production of beer bananas (a cash crop), a source of income for women. While beer banana production decreased, sweet potato (food crop) production increased because it allowed a more flexible labor schedule.166 A survey in Zambia found that heads of HIV-affected households reduced their cultivated land area by 53 percent, resulting in reduced crop production.167 A study of farmers engaged in intensive vegetable production in Côte d’Ivoire showed that those suffering from malaria produced about half the yields and received half the incomes of healthy farmers.168 A survey in Uganda on subsistence farmers found that 95 percent of them reported a decline in production due to reduced capacity to work due to TB.169

In contrast, a study in Mexico found that malaria did not have any effect on farmers’ production due to coping processes170 in which intra-household labor is reallocated.171 Similarly, research on sugarcane workers in Cameroon found that due to reallocation of intra- household labor, production was not affected from either malaria or schistosomiasis.172 Another study found a similar effect among female cotton pickers in Sudan, where

162 Fox et al. (2004) 163 Adewale et al. (1997) 164 Direct costs refer to household expenditure linked with seeking treatment, including non-medical expenses such as transport or special foods. Indirect costs refer to the loss of household productive labor time for patients and caregivers valued using the going wage rate. 165 For literature on HIV, impacts for the illness period have been rarely evaluated (Donovan and Bailey, 2006). Studies on HIV focused more on the impact of adult death. Production impacts during the illness period as compared to those in the postdeath period have received little attention. HIV studies that examined the impact of adult death on agricultural production are mentioned in the next section. 166 Donovan and Bailey (2006) 167 ILO (2000) 168 Girardin et al.(2004) 169 Saunderson (1995) 170 The coping process is the process by which the household succeeds in compensating for the loss of family worker productivity due to ill health. 171 Conly (1975) 172 Gateff et al (1971)

schistosomiasis did not reduce farm production because healthy family members increased their working hours to compensate for reduced farm production so as to cope with the reduction of labor productivity.173 Research on the impact of schistosomiasis in rice-growing households in Mali found that “changes in health have no direct effect on rice production”, implying that contraction of schistosomiasis does not incapacitate workers in rice fields.174 A Côte d’Ivoire research on coffee and cocoa found that malaria infection seems to have no effect on coffee and cocoa crops, neither directly through the production nor indirectly, through a coping process such as the resort to hired labor. Authors posed that this may be due to the fact that coffee and cocoa crops are less labor consuming than rice or cotton crops.175

As some of the literature has shown, a number of factors can limit the extent to which lost labor time due to illness will reduce farm output, such as the nature of crop and whether the farmer can fully replace lost labor. When family and hired labor are not perfect substitutes or when there are liquidity constraints, it is likely to reduce output.176 In cases of temporary disability of a farmer, the household workforce may provide a cushion for the period of absence of the disabled member, limiting the loss of output. For instance, a Sudan study found that 62 percent of the loss of work hours in all sectors due to malaria and schistosomiasis was compensated for by family members, and malaria labor hours lost to agriculture were fully compensated for. Noteworthy though is that the study found withdrawal of labor by men was primarily replaced by women and children, who had to put in 20 percent more time than was lost to reach the same output.177 This puts an extra burden on women who are already commonly responsible for other household tasks. Furthermore, the involvement of children in farming activities may disrupt their development or contribute to child labor178 (see Box 7). Moreover, even if labor hours lost to agriculture can be completely compensated for, there may be costs associated with labor substitution (opportunity cost), depending on the value of the activities from which the substituting labor is withdrawn.179

While illness can affect a farmer’s/agricultural worker’s performance, studies have pointed out that variations in number of productive days lost due to different diseases can be affected by a person’s age, gender, general health and nutritional status, and ability to seek healthcare. While labor is lost due to sickness, the cumulative results of impact studies caution against unwarranted generalizations on the effect of morbidity on agricultural production. A better understanding about interactions and responses will shed light on how context-specific many

173 Parker (1992) 174 Audibert and Etard (1998) 175 Audibert et al. (2009) 176 Antle and Pingali (1994) 177 Nur et al. (1988) 178 Child labor is defined as any work performed by a person below 18 years of age, which deprives the person of the basic human rights, and is abusive, hazardous, exploitative, and harmful to the health, safety, morals, and total development of the child. 179 Over et al. (1992)

of them are. Although morbidity may not automatically affect household agricultural production, future agricultural output of households and nutrition of members may be negatively affected given regressive cost burdens that chronic and long-term illnesses such as TB and AIDS impose, particularly on poor agricultural households.

Death of workers When illness of a productive household member results in death, this leads to a permanent loss of one source of labor in the farm household. A household death further affects labor availability as healthy individuals divert their time and energy from the farm to mourn and attend to the funeral and related matters. All these have an impact on agricultural production. Due to the permanent labor loss, area cultivated and crop variety may decline. Cropping patterns may also change from more labor-intensive systems to less intensive ones. Through coping mechanisms within the family labor pool and the extra intra-family substitution of labor, however, labor loss may be compensated for.

In empirical literature, most studies on the agricultural consequences of disease-related death focus on HIV and AIDS while mortality impacts from other diseases have received very little attention. A study in Uganda found that reductions in labor supply due to AIDS death resulted in reduced variety of crops planted by households.180 Most of the reduction was more common in female-headed households (77.3 percent), particularly where the woman was widowed. Such households experienced a reduction in the production of food and cash crops. Similarly, in Rwanda households with a recently deceased adult male from AIDS suffered a decline in the production of cash crops; while production increased for cassava and sweet potato, which are less-labor intensive crops, there was a decline in these crops if the female died.181 These findings are consistent with the fact that, in Africa, men are more involved in cash crop production while women are more involved in food crop production. In Thailand, 35 percent of households with an AIDS death felt a serious impact on agricultural production, leading to a 48 percent reduction in family income.182 In Zimbabwe, a study conducted by the Zimbabwe Farmers Union showed that death of a household head due to AIDS will lead to a reduction in maize production in the small-scale farming sector and communal areas of 61 percent where family labor is mostly used. A study in Zambia that examined the effects of adult mortality on smallholder agriculture in cotton and maize producing areas concluded that afflicted households suffer relatively large crop output declines of about 15 percent.183 A recent study from Zambia found that when an adult male household head died, households already in the lowest half of income level experienced a decline of nearly 20 percent in crop output.184 Poor households cannot afford to hire labor to replace the household head

180 Asingwire (1996) 181 Donovan et al. (2003) 182 Pitayanon et al. (1997) 183 Larson et al. (2004) 184 Chapoto (2006)

(especially if the head is a male). Therefore, the death leads to permanent loss of labor and output declines.

In contrast, some studies found that household agriculture production did not significantly change after incurring AIDS-related death. A study in the Kagera District of Tanzania found only short-term and temporary effects of AIDS-related deaths on households’ agricultural activities.185 There was little or no impact on labor devoted to agricultural activities because households brought extended family members to the farm, a finding highlighted in other empirical studies.186,187,188,189 Similarly, a Mozambique study found that households that experienced an adult death compensated by bringing in new members.190 For instance, a surviving male would likely remarry. Research in Kenya indicates that demographics of the household and gender and the deceased’s role in the household strongly condition outcome on agricultural production. Households suffering the death of an adult (other than the head or spouse) were largely able to attract new household members but those suffering death of household head or spouse were largely unable to replace the labor lost through the death. With regard to the overall effect on agricultural production, the Kenya study found that the impact was only statistically significant in the case of male head-of-household death, where a decline in the value of the per capita household crop production was observed particularly for cash crops. Based on the findings above and as reiterated in the literature,191 there is heterogeneity of household response strategies and the impacts of adult mortality on agriculture. Its impacts appear to be conditioned by household characteristics such as age, gender and position of the deceased in the household, post death household composition, and ability to replace labor.

As mentioned, some households cope with labor loss through labor replacement. In some cases, farm labor is replaced by children. In Mozambique, it was found that death of a household head increased the likelihood of the use of child labor. 192 In Zambia, increased involvement of children in farming activities in households with an AIDS death was observed.193 This may disrupt the development of the children or contribute to problems associated with child labor. Using children for farm activities is considered to be child labor and violates the United Nations Convention on the Rights of the Child (ILO Convention 138, and 182) (Box 7).

185 Beegle (2005) 186 Ainsworth et al. (1995) 187 Menon et al. (1998) 188 Mather et al. (2004a) 189 Jayne et al. (2004) 190 Mather et al. (2004b) 191 See Yamano and Jayne (2004); Chapoto and Jayne (2005); Jayne et al. ( 2005); Gillespie and Kadiyala (2005); Chapoto and Jayne (2008); Rau et al. ( 2008) 192 Mather et al. (2004a) 193 FASAZ/FAO (2003)

Box 7: Child Labor

Child labor is any work performed by a person below 18 years of age, a deprivation of basic human rights that is abusive, hazardous, exploitative, and harmful to the health, safety, morals as well as the total development of the child. This definition is derived from the United Nations Convention on the Rights of the Child, ILO Convention 138 and 182. It is all work that is harmful and hazardous to a child’s health, safety and development, taking into account the age of the child, the conditions under which the work takes place, and the time at which the work is done. According to UNICEF, child labor refers to all “children below 12 years of age working in any economic activities, those aged 12 to 14 years engaged in harmful work, and all children engaged in the worst forms of child labor.” The worst form of child labor (WFCL) is described as involving children being enslaved, forcibly recruited, prostituted, trafficked, forced into illegal activities, and exposed to hazardous work.

A study conducted in four West African countries (Cameroon, Côte d’Ivoire, Ghana, and Nigeria) by International Institute of Tropical Agriculture (IITA) in 2002 estimated that there were about 284,000 child laborers working in hazardous conditions on cocoa farms, 200,000 of whom were based in Côte d’Ivoire and Nigeria. A study conducted by the Ghana Statistical Service (GSS) in 2001 estimated that out of the estimated 6,361,111 children in Ghana, some 1,273,294, or 20%, were engaged in various forms of child labor, including 242,074 (3.8%) who were engaged in activities classified as hazardous work, such as head porterage, child domestic work, commercial or ritual servitude, small scale mining and quarrying, fishing, commercial agriculture, and commercial sex.

Sources: UNICEF (2010), IITA (2002), Ghana Statistical Service (2003)

The literature194 reports of the negative impacts of death due to AIDS on children’s schooling. Research in Tanzania found the impact on school enrollment depended on whether death in the family is male or female.195 Death of women aged 15−50 in a household was found to be negatively related to enrollments in the last 12 months of children in that household, while there was no relationship between enrollments and death of men aged 15−50. The author concludes that upon death of a woman, children are likely to replace that woman’s domestic roles in the short run, which was also found in a study in Zimbabwe.196 Girls rather than boys are most commonly withdrawn from school. In Swaziland, school enrollment is reported to have fallen by 36 percent due to AIDS-related deaths, with girls accounting for most of this decline.197 In Kenya, girls were nearly 20 percent more likely than boys to drop out of school following the death of a parent.198 Withdrawing children from school further erodes human capital in years to come as it compromises their future earning power.

194 See Case et al. (2004); Oni (2002); Yamano and Jayne (2005) 195 Ainsworth and Koda (1993) 196 Mutangadura (2000) 197 UNAIDS (2004) 198 Desmond et al. (2000)

The demand for farm labor can be reduced with the adoption of labor-saving technology (see Box 8). For instance, biotechnology has been used to breed varieties that require less weeding and limited use of pesticides and therefore reduces use of labor on farms. The use of crop residues such as maize and sunflower, and cover crops (dolichos, lablab, crotalaria, mucuna and canavalia), dead weeds, and mulch are known to suppress weeds and therefore reduce labor for weeding. The practice also increases water-retention capacity of soils and maintains soil moisture, helping to improve yields in dry years. Equipment and draft animals like donkeys have reduced the use of labor on farms and for transporting agricultural produce to the market or inputs to the farm.

Box 8: Conservation Farming for Saving Labor

Conservation farming techniques that shift land preparation labor to the dry season may be particularly attractive in many areas. In other areas, strategies to rapidly increase the stock and health of animal assets within the small-scale farm sector as well as the stock of animal and draft equipment such as ploughs and harrows may be important. Enhancing farmers’ incentives and ability to acquire draft animals and equipment will help alleviate the crucial labor burden of land preparation (Jayne et al., 2005). Under conservation farming, in Siavonga, Zambia, the “basin planting,” method, a water harvesting technology and cover crop production have been introduced to smallholder farmers without access to draught animal power (DAP) for land preparation. The basins are made by hand hoe during the dry season before the rains start; this way the labor is spread and shifted to a time where labor is available. The labor amount for making the potholes is similar to digging the field for cultivation. Cover crops are good at maintaining soil moisture, reduce runoff, increase infiltration, reduce erosion, and increase or maintain organic matter throughout the year. The use of crop residues such as maize and sunflower, and cover crops (Dolichos lablab, crotalaria, mucuna and canavalia), dead weeds, and mulch have been documented in Karatu, Tanzania as technologies that suppress weeds and thereby reduce labor demand for weeding (Shetto and Owenya, 2007). Additionally, because the cover crops, such as mucuna, are leguminous, they fix nitrogen, hence improving soil fertility without additional labor input. Further, in increasing water retention capacity of soils this technology also helps to improve yields in dry years. However, the wider adoptions of these technologies both in Zambia and Tanzania have been minimal.

Within the same concept of conservation agriculture, the use of a Hand Jab Planter (HJP) (hand tool to plant into soil cover) is widely in use in Brazil and Paraguay. The HJP reduces labor energy demand after a period of learning how to best use it. It requires only one person for planting instead of three (digging hole, planting, closing hoe). It has been estimated to cost approximately $10 if made in Arusha, Tanzania or can be imported from Brazil. However, its uptake in Africa has been minimal (Shetto, and Owenya, 2007).

Sources: Jayne et al (2005), Shetto and Owenya (2007)

Deaths are generally associated with substantial expenses, including funeral ceremonies, burials, and even travel and support costs for mourners.199,200 Death further increases demands for cash and erodes remaining household income, inducing sales of livestock, farm 201,202 203 equipment, and land. Various studies in Africa found that households sell their land to cope with these expenses. In Kenya, cattle and productive farm equipment were sold in response to severe cash requirements after incurring a male death in the household.204 Sale of such assets compromises the household’s ability to sustainably generate income in the long run because these are needed for agricultural production.

Some households respond to financial strain due to death in the family by reducing food consumption. In the Kagera region of Tanzania, a study found that prime-age death results in a 7 percent reduction in consumption in the first five years after the death.205 Empirical research by Gertler et al. (2003) found that in Indonesia, a prime-age male death was associated with a 27 percent decline in mean per capita household consumption, while the death of a female had no significant effect. This happens when the household consumption expenditures are paid for by the male. In Mexico, they found no gender differences, which may be explained by higher income earning opportunities for Mexican women than Indonesian women. In the Rungwe district of Tanzania, households that experienced an AIDS death had significantly lower food expenses than other households.206 Various studies207 have shown that households experiencing adult death are likely not to recover pre-shock levels of consumption. This has implications for household nutrition and health status.

As household heads succumb to death due to disease, future agricultural production is also affected through tenure rights. Differences in the impact to surviving households exist among and within countries based on variations in tenure systems, the availability of land, and inheritance patterns. Widows’ tenure rights are especially tenuous upon death of the husband in customary systems that are patrilineal and patriarchal, which is common in many communities in East and Southern Africa,208 As household’s access to land are frequently dependent on the presence of an able-bodied male adult in patriarchal systems, the ability of the household to access and retain the land cannot be guaranteed in instances where the household headship passes from a male to a female upon death of the male. Widows and orphans therefore often lose rights to land, with the dead husband’s extended family claiming

199 Beegle (2005) 200 Onyango et al. (2005) 201 Du Guerny (1999) 202 Jayne et al. (2005) 203 See Drimie (2003); Mbaya (2002); Rehmtulla (1999); Rugalema et al. (1999) 204 Yamano and Jayne (2004) 205 Beegle et al. (2006) 206 Mwakalobo (2003) 207 See Yamano and Jayne (2004); Gertler et al. (2003); Bechu (1998) 208 Drimie (2003)

land and other assets.209,210 While land is frequently intended to be held in trust for male orphans by male caretakers from the extended family land, it is seldom returned to oldest sons when they come of age. Sometimes widows are forced to marry a surviving brother of the deceased husband to be able to cultivate the household piece of land.

In Central Kenya, where ancestral land is still distinctly inherited through patrilineal patterns, widows and orphans are increasingly losing inheritance rights. In Bondo and Nyeri district in Kenya, cases were reported of women being dispossessed of their right to use land after their husbands’ death.211 Widows in cases where the deceased husband died as a result of AIDS were often condemned as the ones who infected their husbands and were subsequently under great pressure to leave their marital homes, thereby losing their rights to access and use the land. Research in Uganda found that HIV-affected households are more likely to lose their land than non-affected ones, with land holdings being transferred to in-laws, clan members, or creditors.212 Widows in particular disproportionately suffer the impacts of AIDS because of their disadvantaged position due to socio-cultural factors. However, the extent and outcomes of the property loss due to AIDS-related death are influenced by household and personal characteristics. The type of marriage influences loss or use of land for the bereaved household in the Ugandan study. Widows who had been in church or civil marriage were less likely than those in customary marriage or cohabitation to report such effects on family property.

The negative impact of a male household head’s death is severe in patrilineal systems as widow’s legal position, her access to resources, and the family’s ability to secure a livelihood are most at risk. As they are not in a position to inherit the husband’s land and will lose entitlements and securities that had been previously mediated by him, the husband’s death poses a serious threat to livelihood sustainability. Because these widows do not have the legal position to the land, they lack collateral needed to access rural microfinance institutions, which can be a source for financial capital to purchase inputs such as fertilizers and seed for agricultural production.213

Overall, literature has shown that the impact of death in a household due to long-term illness such as HIV varies. Actual household impacts depend on age and position of the affected household member and gender factors. The death of an adult male household head potentially has the most impact, and the death of an adult female negatively affects children’s (particularly girls’) education opportunities and participation in household labor. Death of a male household head also has severe impact on households in patrilineal systems as a widow’s access to resources are limited, thus her family’s ability to secure a livelihood are at

209 ibid. 210 Aliber and Walker (2006) 211 Forest Action Network (2002) 212 Kabumbuli et al. (2008) 213 UNAIDS (2003)

risk. Impact also depends on the financial condition of the households, with the poor being more vulnerable. Financial strain due to substantial expenses upon death of household heads has implications on the sustainability of a household’s agricultural production as assets are sold. As most households respond to these expenses by reducing household consumption, they may become more susceptible to other diseases as their nutrition is undermined.

Caregiving by family members The drain on household labor availability starts as soon as any one member falls sick and women and girls have to be taken time away from their livelihood activities to care for them. Time diverted to care giving, particularly for those with chronic or terminal illness, has implications for the viability of rural livelihoods where women are commonly the main source of labor power, particularly in Africa and especially for food production. Household tasks such as fetching water and firewood, food preparation and cooking, cleanliness, and childcare are very time-consuming and repetitive, with the burden of work traditionally falling on females. Furthermore, women do most labor-intensive farming activities, such as planting, weeding and harvesting. Mechanization (from either draught animals or tractors) can alleviate the labor burden only for the initial tilling of land and only in certain farming systems and among less poor households.214

The increased workload of women for care giving can greatly reduce their time to participate in farming activities, leading to a decline in farm production in areas where women are major farmers. In Northern Zambia, AIDS-affected households, particularly those headed by women, reduced the total area under cultivation due to labor shortages.215 In Tanzania, women spent 60 percent less time on farming activities taking care of their husbands suffering from AIDS.216 In southern Zambia, women were forced to abandon harvesting as their time became entirely taken up with the care of sick household members. In Ethiopia, women were found to spend about 100 hours a week which is equivalent to about 4 days nursing AIDS-affected household members, largely at the expense of their children and their farms.217 This care giving burden can also affect technology adoption, largely because of lack of labor for farm activities. In the Tigray region of Ethiopia, the opportunity costs of caring for sick family members significantly affect adoption of productivity-enhancing technologies.218

214 UNAIDS (2004) 215 FAO (2003) 216 Rugalema (1998) 217 ILO (2000) 218 Ersado et al (2003)

Home gardens which tend to be close to Box9: Home Gardens for Improving Household homesteads offer convenience farming Labor Productivity (Box 9). Apart from the variety of crops Home gardens and their associated crop diversity that are cultivated, women who are represent an excellent foundation to enhance providing care to sick persons can do household food security and nutrition. Improving some work in these gardens when they are home gardening requires the optimal use of local agro at home. Even people who are mildly ill biodiversity. Under home gardening, crops are grown because of their food and nutritional value rather than can do some light work in home gardens. their market value. It concentrates on smaller-sized Thus, apart from its nutritional family (or community group-run) gardens and—with contribution, home gardens provide an careful species mixes—produces year round. It avenue for recovering some lost focuses on diversity, including traditional, neglected, and under-utilized crops, and fruit trees are an household production when someone is important component. Home gardens tend to appeal sick or providing care to a sick household most strongly to women, who are often in charge of member, and therefore tends to improve selecting, cooking, and growing the family’s food household labor productivity. 219, 220,221,222, needs. 223.224,225

In addition to working on the farm, children may face the increased burden of helping with caregiving or household labor for which they are withdrawn from school for varying periods.226 Empirical research in Kenya found that adult morbidity negatively affects school attendance most likely because children are sharing the burden of care giving.227 Negative impacts were stronger among children in poor households. Moreover, schooling of girls was more negatively affected than that of boys. The study suggested that children, especially girls, are sharing the burden of caring for sick working-age adults. In Kenya, as in most parts of eastern and southern Africa, girls tend to assume more care giving responsibilities than boys.228 In Tanzania, a study found that care giving contributes to irregular school attendance.229 Policies to reduce the burden of taking care of the sick at home, such as improved community healthcare systems may have an added advantage of helping afflicted households keep their children in school.

Despite rapid social change, the extended family remains the most important social safety net in many African countries. In times of illness, the next of kin are responsible for the provision

219 Irwin and Parker (2004) 220 Bonnard, Patricia (2001) 221 Mohan, Soumya (2004) 222 Niñeza, Vera (1987). 223 Niñeza, Vera (1984). 224 Akhter et al. (2010), 225 Falconer and Arnold (1991) 226 Rau (2002) 227 Yamano and Jayne (2005) 228 Opiyo (2001) 229 Robson et al. (2006)

of care, and the role of people who are not relations is usually minimal. People count on support from their families. However, changes in this social fabric are appearing due to the toll brought about by HIV and AIDS due to the overwhelming burden of caring for the sick.230 The strong social ties, trust, and relationships in African society bring about a sense of collective responsibility. This has given rise to community-based care centers which relieve the burden on family members of care giving231.

Loss of farming knowledge Impact studies, particularly those on HIV,232 have indicated that farm-specific knowledge is lost due to death of agricultural producers. Agricultural knowledge is obtained from indigenous sources, experience, scientific research, and technical experts and extension workers. The knowledge is normally not written down because of oral traditions and low literacy rates in developing countries. Although extension workers can play a major role in knowledge transfer from research to farmers, a lot of information is shared within families and among farmers through social networks such as farmer or community-based organizations and solidarity groups. Adults pass on traditional knowledge to their children and grandchildren through conversations, demonstration, and working together. Therefore, when a farmer dies of disease, the knowledge may be completely lost to the detriment of succeeding generations.

A study on the likely impact of HIV/AIDS on knowledge and information flows, and on the retention of traditional knowledge around seed management in southern Mozambique found that HIV/AIDS is just one of several factors that can result in the loss of traditional crops and varieties and erosion of knowledge around seed.233 The authors noted that it was difficult to separate the effect of HIV/AIDS from other factors and safely assumed that the loss of agriculturally active adults and the increased number of orphans in the study sites will deprive children of learning opportunities from family members. Another study in Mozambique234, examined the likely impact of HIV/AIDS on farmer’s knowledge of seed using female-headed households, households caring for the sick and households caring for orphans as proxies to HIV/AIDS affected households. The level of association between HIV/AIDS and factors related to seed access and seed information flows were determined. Results revealed that HIV/AIDS affected households especially those households caring for orphans experienced constraints in access to seed and seed information. These households had smaller acreages of cultivated land under irrigation; none of them used purchased chemicals to preserve seed; and they were also less exposed to modern sources of information dissemination. The study also pointed out the methodological difficulties in isolating the

230 Munthali (2002) 231 ibid 232 See van Liere (2001), Gillespie et al. (2001), United Nations (2004) 233 Dominguez et al. (2005) 234 Waterhouse et al. (2004)

effects of HIV/AIDS on local agricultural practice and associated changes in knowledge. Methodological problems revolved around: identifying the content of local knowledge about seed and seed management, tracing changes in local knowledge and knowledge flows, and assessing the likely impact of HIV/AIDS on an already fluid situation in the study site. The study concluded that under current conditions wherein local knowledge around seed is being eroded and that various obstacles exist to learning and acquiring new information around seed, HIV/AIDS is even more likely to accelerate loss of traditional knowledge and increase the barriers to learning. It is noteworthy that due to the methodological constraints, limited studies have adequately assessed the nature and degree of loss of knowledge in smallholder agriculture. Little is actually known about the extent to which the death of one or both parents affects the transfer of agricultural knowledge to younger generations.

Loss of savings and of household and farm assets Investments in agriculture are paid for with savings (which tend to be limited for poor households) and remittances from family members in urban areas or abroad. Although rural savings may be low, farmers who get paid seasonally and in bulk like cocoa farmers in West Africa may be able to put some money aside for farm investments and health care. When there is illness in the household, savings and remittances are diverted from intended use in agriculture to pay for healthcare. Kimuyu reported that the participation of rural dwellers in East Africa in rotating saving and credit associations (ROSCAs) was partly driven by the need to raise money for school fees, meet medical expenses and buy food.235 Amuedo- Dorantes and Pozo observed that international remittances raise health care expenditures.236 Using Mexico’s 2002 wave of the Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH), they found that approximately 6 pesos of every 100 pesos increment in remittance income are spent on health. Healthcare costs are high for poor households (see Box 10) and so when monies they can easily lay hands on are not enough to cover the costs, household and farm assets are sold to generate supplementary income (Figure 3). Such adjustments are also made to cover funeral expenses when a household member dies. The implication of these expenditures is that affected farm households reduce agricultural investment. It becomes difficult for them to adopt new technologies or buy inputs for their farm activities. Those who sell farm assets lose their production base and may take a long time to recover. For instance, a farmer who sells his/her cow to pay for healthcare loses another generation of cattle.

235 Kimuyu (1999) 236 Amuedo-Dorantes and Susan Pozo (2009)

Box 10. Economic Burden of Illness to Households

While illness does not automatically mean significant reductions in agricultural output (and thereby farm income), the direct costs people incur due to illness may impose a great financial burden on resource-poor farmers, thereby affecting sustainability of their farm. A multi-country study of onchocercal skin disease in Ethiopia, Sudan, and Nigeria found that people with this disease spent 15 percent of their annual income on health-related expenditures. A review of studies on the economic burden of illness for households in developing countries focusing on malaria, TB, and HIV found that in resource-poor settings, illness imposed regressive cost burdens on patients and their families, particularly for TB, HIV, and AIDS which were more than 10 percent of income. HIV-afflicted households tend to incur high healthcare expenditures as found in Tanzania, South Africa, Thailand, and Côte d’Ivoire. In Côte d’Ivoire, health-care costs specific to the person with AIDS accounted for almost 80 percent of the household health-care budget. In the Rungwe district of Tanzania, rising medical expenses significantly increased the probability of a household’s falling below the poverty line. High medical expenses further undermine the household ability to purchase, maintain, and replace essential farm inputs as well as to adopt technologies requiring such. A study in Uganda found that it was difficult for HIV-affected households to adopt recommended agronomic practices that boost the production and quality of produce because they had limited funds to invest in farm inputs and implements.

Sources: WHO (1997), Russell (2004), Tibaijuka (1997), Booysen and Bachmann (2002), Pitayanon et al. (1997), Bechu (1998), Mwakalobo (2003), NAADS (2003)

Studies of TB in Asia show that TB-afflicted households tried to obtain transfer payments from relatives, used savings, took out loans, and sold assets, either livestock or land, to pay for TB treatment.237,238,239 Evidence of coping mechanisms such as using cash reserves and savings, borrowing, selling livestock, or receiving gifts from other households in response to malaria episodes has been observed both within and outside Africa. 240,241,242,243 In Thailand, HIV-affected households used household savings, borrowed money, and sold assets, most often land.244 Several studies in Africa also found that some HIV-affected households sold their land to cope with the impact of the condition.245,246,247,248 In Kenya, cattle and productive farm equipment are sold in response to severe cash requirements after incurring a male AIDS-related death in the family.249 In Mozambique, cash, livestock, household assets, and total and per adult equivalent income were found to be lower for households experiencing

237 Karnolratanakul et al. (1999) 238 Pryer (1989) 239 Croft and Croft (1998) 240 Nur (1993) 241 Jayawardene (1993) 242 Conly (1975) 243 Bonilla and Rodriguez (1993) 244 Pitayanon (1997) 245 Drimie (2003) 246 Mbaya (2002) 247 Rehmtulla (1999) 248 Rugalema et al. (1999) 249 Yamano and Jayne (2004)

death.250 There were some cases in Kenya that due to financial stress after the death of the household head, older daughters were married off for bride dowries to accumulate needed assets.251

As a consequence of particularly high medical costs (Box 10) such as for HIV and TB, some households withdraw children from school. In Uganda, households afflicted with TB withdrew children from school as families could not afford school fees.252 In India, as children were withdrawn from school, some took up employment to help support their families.253,254 In South Africa, HIV-affected households withdrew children from schools to cope with rising costs.255

Generally, households seem to adopt a similar range of coping strategies to deal with costs related to illness and deaths. However, the specific coping strategies that households use and their impact on the sustainability of the household economy (that is, household’s access to strategies and the affordability and sustainability of these strategies) are influenced by two factors: household’s vulnerability or ability to cope with a shock, and type of illness. 256 The household’s vulnerability or ability to cope with a shock is based on its asset portfolio which includes human, physical and financial assets, and intangible social resources. The social resources include kin and friendship networks, links to influential contacts, and membership in organizations such as savings groups, credit associations, or funeral societies which household members can turn to for information, support and financial help at times of illness. As a substitute to the disintegration of the extended family system, religion has become an important tool that brings people together (both relations and non-relations). In both Christian and Islamic traditions, the church/mosque has been referred to as social parents bringing spiritual as well as moral support to its members and communities where women’s, men’s, and youth guilds play an important supportive role in times of illness and death. During funerals and illness, religious groups support members by offering prayers of hope and giving financial, moral, and material assistance.257 In developing countries, social networks are one of the most important assets that households use to obtain funds for medical treatment. However, some studies suggest that the poorest have the weakest social assets and are more likely to be excluded from inter-household community support mechanisms.258 If these social assets are made more accessible, households are less likely to resort to sale of physical assets, making them less vulnerable to future shocks.

250 Mather et al. (2004) 251 Yamano and Jayne ( 2004) 252 Saunderson (1995) 253 Ramachandran et al. (1997) 254 Rajeswari et al. (1999) 255 Oni, et al (2002) 256 Russell (2004) 257 Munthali (2002) 258 Russell (2004)

Different diseases impose different cost burdens. As such, the type, severity, and duration of illness will determine the coping strategies that households adopt and their risk to livelihood sustainability.259 Russell (2004) conducted a brief review of coping strategies and their economic success or impact based on four illness categories (see Box 11). Based on his review of TB and HIV and AIDS studies, which he used for the categories of chronic/long- term illness and terminal or steadily deteriorating health, respectively, the coping strategies (particularly the sale of major assets such as land and livestock) that households use were

Box 11: Coping Strategies for Four States of Health

Acute mild or moderate illness. Households affected with common illness, particularly those with young children, frequently use savings, pawn jewelry, borrow, and temporarily cut other spending to finance medical costs. While it is easy to assume that minor illnesses have the least threat to the household economy, studies in Sri Lanka, Vietnam, and Bangladesh found that minor illnesses are a significant shock to poor and vulnerable households, specifically those with few assets, forcing them into debt or to deplete their few remaining assets to meet minor healthcare expenses.

Recurring illness. Use of cash reserves and savings, borrowing, selling assets and labor, and reliance on social networks are coping strategies used to mitigate or manage the costs of recurring illness such as malaria. Although the disease burden of recurring illness is larger than common illness, few studies have looked at its link to impoverishment at the household level.

Chronic and long-term illness. In developing countries where social safety nets are limited or non- existent, chronic conditions such as diabetes, hypertension, and tuberculosis eventually impose high costs over time if regular treatment is required and if the sick are recurrently incapacitated. Research in Thailand found that the financial impact of TB for poor households was devastating, with 15 percent of poor households selling property and 10 percent taking out loans to finance treatment costs. Studies conducted in South Asia also found that a large percentage of TB-affected households become indebted due to medical expenses. Overall, the cost burden is high, forcing potentially unsustainable strategies that reduce assets, increase debt, and cause vulnerability to future shocks.

Terminal and steadily deteriorating health. HIV infection, a condition which causes a steadily deteriorating health status, imposes an enormous cost burden on many households in developing countries. Research in Zimbabwe reports that more than 60 percent of households have borrowed money to cover the direct costs of the disease; about one-third have reduced expenditure on basic needs; and between 20−30 percent have sold assets. Studies from various parts of Sub-Saharan Africa indicate that HIV and AIDS, through loss of income and loss of productive asset sales, causes a process of household impoverishment. A study by the Southern Africa Partnership Program provided the example of livestock sales: “Sales of chickens, goats, or cattle are classic coping strategies that households all over Sub-Saharan Africa employ. Some level of livestock sales is normal and does not result in increased poverty. At a certain point, however, household livestock holdings reduce to the level where they are no longer sustainable. At this point, livestock sales as a coping strategy become erosive.” Moreover, sale of livestock does not only affect the livestock subsector but also has implications for the crop production subsector due to reduced availability of draught power and manure, which has implications for a household’s future production. Source: Russell (2004); Southern Africa Partnership Programme. 2005

259 ibid.

unsustainable, leading to greater impoverishment.

8. Infectious and Parasitic Disease Projections It is predicted that in 2030, the four leading infectious and parasitic causes of mortality worldwide among people aged 15 years and over will be HIV, TB, diarrheal diseases, and meningitis (Table 2). These four diseases have been the top communicable diseases that caused deaths in poor countries. Notably, malaria, which was ranked seventh in 2004, is projected to rise to sixth place in 2030. On the other hand, Hepatitis B is expected to be the seventh leading infectious cause of death for the working age population in 2030, falling from its sixth rank in 2004. Overall, the number of deaths caused by infectious and parasitic diseases for people aged 15 years and over is projected to decrease from 2004 to 2030. According to the WHO,260 the projected reduction in deaths worldwide due to communicable diseases between 2004 and 2030 will be mostly due to epidemiological change, offset to some extent by population growth, and improved healthcare. It should be noted though that worldwide death from AIDS (people of all ages) is expected to increase from 2.2 million in 2008 to 2.4 million in 2012 before declining in 2030. Widespread availability of antiretroviral (ARV) drugs is expected to slow the pace of the AIDS epidemic. Deaths due to other communicable diseases such as TB and diarrheal diseases are projected to decline faster than deaths caused by AIDS.

Table 2. Leading infectious and parasitic disease causes of mortality (000s) for people aged 15 years and older in low-income countries, 2004 and 2030

2004 Deaths 2030 Deaths Rank Cause (000) Rank Cause (000)

1 HIV 1,259 1 HIV 704 2 TB 846 2 TB 499 3 Diarrheal diseases 271 3 Diarrheal diseases 189 4 Meningitis 87 4 Meningitis 50 5 STDs excluding HIV 52 5 STDs excluding HIV 35 6 Hepatitis B 47 6 Malaria 34 7 Malaria 40 7 Hepatitis B 26 8 Schistosomiasis 34 8 Schistosomiasis 23 9 Trypanosomiasis 29 9 Trypanosomiasis 18 10 Leishmaniasis 25 10 Leishmaniasis 11 All infectious and parasitic All infectious and parasitic diseases 3, 340 diseases 1, 981 Source of basic data: WHO (2008b)

260 WHO (2008a)

The 10 leading infectious and parasitic causes of disease burden among people aged 15 years and over are shown in Table 3. Disease burden was measured through disability-adjusted life years (DALYs), which are the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability. One DALY can be thought of as one lost year of “healthy” life. The measured disease burden is the gap between a population’s health status and that of a normative global reference population with high life expectancy lived in full health. For the working age population in low-income countries, the five most important contributors to the burden of disease among communicable and infectious diseases in 2004 and 2030 are HIV, TB, sexually transmitted diseases (excluding HIV), diarrheal diseases, and lymphatic filariasis. HIV has the greatest impact based on the projected DALYS, which is measured in terms of mortality and morbidity.

Table 3. Leading infectious and parasitic causes of disease burden (DALYs) for people aged 15 years and older in low income countries, 2004 and 2030

2004 DALYs 2030 DALYs Rank Cause (000) Rank Cause (000) 1 HIV/AIDS 34,172 1 HIV/AIDS 19,875 2 TB 19,820 2 TB 11,784 3 STDs excluding HIV 4,891 3 STDs excluding HIV 3,539 4 Diarrheal diseases 4,562 4 Diarrheal diseases 2,804 5 Lymphatic filariasis 3,665 5 Lymphatic filariasis 1,819 6 Meningitis 1,921 6 Malaria 1,015 7 Malaria 1,369 7 Meningitis 900 8 Leishmaniasis 935 8 Trachoma 554 9 Hepatitis B 928 9 Trypanosomiasis 475 10 Trachoma 891 10 Schistosomiasis 472 All infectious and parasitic All infectious and parasitic diseases 86,715 diseases 49,840 Source of basic data: WHO (2008b)

Attempts have been made to estimate the extent of rural labor loss due to AIDS mortality. The U.S. Department of Agriculture has estimated that the reduction in numbers of agricultural laborers in Southern Africa will reduce agricultural labor productivity by 12 percent per year, which will result in a 3.3 percent loss in grain output.261 Moreover, FAO,262 using epidemiological data, projected that by 2020 the nine most severely hit Sub-Saharan African countries would lose from 13 to 26 percent of their agricultural labor force to HIV and AIDS (Figure 4). Botswana, Mozambique, Namibia, South Africa, and Zimbabwe are expected to lose between a fifth and a quarter of their agricultural labor in less than a

261 As cited by ILO (2004) 262 FAO (2004)

generation. A study by de Waal and Whiteside263 poses that the FAO labor loss scenario would open the region to a “new variant famine” in which the loss of young and middle-aged people would leave households more vulnerable to food shortages caused by drought, policy change, or conflict. However, in light of stabilization and decline of the epidemic and the increasing availability of antiretroviral agents (ARVs) in these countries, these arguments are open to qualification and revision,264 which will require scenario analysis at a lower prevalence of HIV infection and lower rate of conversion of HIV into full blown AIDS.

Figure 4. Projected agricultural labor force loss due to HIV and AIDS in the most affected countries of Africa, 2000 and 2020

0 Projectedagricultural forcelabor (%) loss 2000 2020 Country

Source: FAO (2004) Note: Figures must be interpreted with caution as projections were estimated prior to the stabilization and decline of HIV epidemic and the increasing availability of ARVs in these countries.

Improved health care is helping to slow down the relentless pace of the AIDS epidemic, particularly with the advent of ARVs. “HIV was a death sentence and is now a manageable chronic disease like diabetes or high blood pressure”, says Dr. Templeman of AgriAids.265

“There is light at the end of the tunnel, if there is continued investment of resources in disease control,” said Gabriel Rugalema, senior officer for HIV/AIDS at FAO. “Levels of HIV infections have stabilized and are actually falling in many countries. Incidences of malaria are falling worldwide, even in countries where it is endemic such as The Gambia.” A 2009 report from WHO says that the percentage of the global population falling ill to TB is dropping

263 de Waal and Whiteside (2003) 264 Rau et al. (2008) 265 AgriAids (www.agriaids.org.za)

annually, though growth in drug-resistant from the parasite presents a major challenge.266 Reports from the International Scientific Council for Trypanosomiasis Research and Control (ISCTRC)267 indicate that Africa is winning its battle against sleeping sickness. Aerial spraying and localized use of insecticide has eradicated the tsetse fly that carries the Trypanosome brucei gambiense and Trypanosome brucei rhodiense from 36,000 square kilometers of land across Angola, Botswana, Namibia, and Zambia.268

In an effort to increase access to malaria services and attain the Millennium Development Goal of combating malaria and other diseases by 2015, Africa is making dramatic progress in tackling malaria from different angles. For instance, infection rates in Zambia, more than halved from 2001 to 2008 due to widespread distribution of mosquito nets, targeted spraying of insecticides and better and cheaper diagnosis and treatment, said Rob Newman, director of the WHO Global Malaria Program.269 According to Newman, eight African countries have halved their infection rates in the last decade: Eritrea, Rwanda, Botswana, Namibia, South Africa, Swaziland, Cape Verde, and Sao Tome. There are programs in their infancy in much bigger countries like Democratic Republic of Congo and Nigeria. About 74 percent of African nations have waived taxes on anti-malaria drugs, 64 percent have removed taxes on insecticide-treated mosquito nets, while about half have waived taxes and tariffs on nets, netting materials and insecticide.270 The African Leaders Malaria Alliance (Alma) views malaria as a ferocious public enemy that must be fought until it is eliminated. They have resolved to do that through universal average coverage with indoor residual spraying, long- lasting insecticide-treated nets, rapid diagnostic tests, and artemisinin combination therapy (ACT).271 All these initiatives pinpoint to a reduction in malaria prevalence in Africa.

9. Conclusions and Recommendations This paper has reviewed the various ways in which health affects farm labor productivity, and how agriculture affects the health of people. In discussing health and productivity, nutritional status, which affects health and has direct linkage with farm labor productivity, has been discussed. The paper used a conceptual framework to discuss the impact of health on agricultural productivity, and then looked at the effects and outcomes of illnesses and how households adjust to them. This review has shown that the household’s vulnerability or ability to cope with a shock is based on its asset portfolio, which includes human, physical, and financial assets, and intangible social resources. Health is treated as both an investment and consumption asset, as is agriculture. When both health and agriculture thrive, a

266 Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA) (2009) 267 www.au-ibar.org/isctrc.html 268 CTA (2009) 269 The Daily Monitor (2010) 270 The Daily Monitor (2010) 271 The Daily Monitor (2010)

reinforcing cycle of health can result, but when either suffers, the cycle becomes one of lowered agricultural productivity and lowered health.

By investing in health through good lifestyles, (avoiding exposure and taking preventive measures) adequate food and good nutrition, and appropriate healthcare, a person’s health can be improved or the rate of depreciation of the stock of health can be reduced. Taking appropriate steps, then, will improve households’ resilience and enhance their ability to cope with emergencies such as ill health. Good health is an asset for agriculture, as healthy people can produce more. Conversely, agriculture is an asset which contributes to good health and resilience. Farmers with access to appropriate inputs (including knowledge, land, tools, fertilizer and seeds) and remunerative markets will increase their productivity and earn good incomes with which they can thrive nutritionally, acquire more assets (including health), and become more resilient.

The following research and policy-related recommendations are based on the issues raised in this review.

Research-related recommendations:

Empirical studies on disease-specific impacts on labor productivity are limited. Few studies have examined the health-labor nexus for the lesser known agriculture-related diseases. Impact of these diseases on household labor and dynamics has not been fully analyzed.

Recommendation 1: Studies should be commissioned to understand disease-specific impacts on farm labor productivity to provide justification and guidance for disease control programs.

Recommendation 2: Research should look at devising methodology that can correctly capture farm labor productivity at the household level given the burden of disease.

Recommendation 3: Research should focus on the impacts of lesser known agriculture- related diseases such as food-borne diseases, pesticide poisoning, and zoonotic diseases.

It has been observed under the so-called “paddies paradox” that rice irrigation schemes in West and East Africa increase the number of mosquitoes but malaria disease may increase, decrease, or remain substantially unchanged. It is speculated but not proven that unchanged or decreased malaria incidence can be attributed to higher income and improved livelihoods in irrigated areas, which tend to improve access to malaria treatment and may support an increased use of malaria preventive devices.

Recommendation 4: Research on the “paddies paradox” and implications for the agricultural as well as the health sector should be commissioned. Climate change is affecting, or likely to affect, infectious disease occurrence. Surface water patterns influence breeding of disease vectors. Appraisal of the present and future impact of climate change and variability on the transmission of infectious diseases is a complex and pressing issue.

Recommendation 5: Research is needed to learn about the effects of climate change on human infectious diseases and the mitigation and adaptation policies and programs required.

Micronutrient malnutrition, or hidden hunger, affects millions of people worldwide every year. Biofortification is a cost-effective means of adding essential micronutrients to staple foods through breeding to achieve proven benefits for health and nutrition. It has been found to be highly effective in averting DALYs due to micronutrient deficiencies, especially in Asia and Africa. A biofortified crop can generate new biofortified varieties for farmers to grow for years to come in many different countries after a one-time investment. The orange flesh sweet potato (rich in vitamin A) is a success story of agriculture and health partnership in biofortification. Cassava and beans, commonly found in the diets of low-income people, are being fortified with additional nutrients.

Recommendation 6: Research and development on the availability of and access to nutritious (micronutrient-rich) staple foods through biofortification should be expanded.

Recommendation 7: A study for a broader and more systematic approach to understanding the interaction between health and nutrition, on the one hand, and agricultural labor productivity, on the other, should be conducted, and the knowledge used or adopted for the formulation and design of health and nutrition, and agricultural labor and sector policies and programs.

Policy-related recommendations:

Although a large number of rural women are involved in agriculture, especially food production, they encounter difficulties in getting access to land, production inputs, credit, and extension services.

Recommendation 8: Programs to assist rural people should pay particular attention to women, who tend to be disadvantaged in many developing countries.

Forests play an important role in contributing to the productivity of agriculture and food security and provide herbs for healthcare. In addition to providing food, medicine, firewood, and fodder, forests ward off disease-carrying vectors like mosquitoes. Communities should take up afforestation and agro-forestry (economic trees) programs to restore the ecology.

Recommendation 9: Policies and programs to support collective action and knowledge-

sharing for ecological restoration and maintenance should be enhanced.

School feeding, food for schooling, food for work and cash transfer programs (conditional and unconditional) have been found to be effective in protecting low-income families from complete devastation and total exclusion from the development process. In conditional cash transfer programs, beneficiaries are granted money transfers in exchange for sending their children to school, for regular medical check-ups, for vaccinating children, for participating in a nutrition program, for participating in an ante-natal program, etc. Unconditional cash transfers are given to poor and vulnerable people with no restrictions on how the cash is spent, and no requirements beyond meeting the eligibility criteria. Targeting is important to ensure that only those who are entitled benefit from these programs. School feeding programs (children are fed at school) and food for school programs (households receive food when their children attend school) promote school enrollment and attendance. However, it is important that nutrition programs begin from conception to age two to promote physical and cognitive development of children and ensure their high productivity and earnings as adults. Programs that educate households about the importance of nutrition or provide nutrition for children from conception to age 24 months (-9 to 24 months) should be promoted.

Recommendation 10: Social protection and provision of social safety net interventions should be made part of rural development policy. Rural people facing insecurities in food, nutrition, health, shelter, and education, among others, should be assisted through public- supported programs, with an exit strategy based on time or specific objectives and/or results.

With increasing demand for agricultural products, the use of pesticides has increased, along with pesticide poisoning of members of farm households. Safety should be promoted in the use of chemicals for combating weeds, insects, and fungus. Capacity has to be developed for safe administration of pesticides, especially in developing countries with no or very little regulation to protect people who deal with pesticides.

Recommendation 11: Policies that encourage education on the use of protective clothes against harmful effects of pesticides should be supported and where necessary legislation to enforce safe use of pesticides should be enacted. Additionally, regulation over the testing, production, formulation, transportation, marketing, disposal, and use of pesticides in conformity with international standards should be encouraged.

Mycotoxins like aflatoxin infect many staple foods in developing countries, which in turn affect the health of people who consume these foods. There is potential benefit to public health of reducing aflatoxin exposure in developing countries. One way of solving the aflatoxin problem is for consumers to recognize the foods with aflatoxin and for producers to be careful with post-harvest processes (especially drying). Grains with low moisture content keep longer, and they are safe from insects and molds. However, most African farmers sun- dry food, increasing the risk of aflatoxin infection.

Recommendation 12: Education targeting rural people on sources and negative impacts of aflatoxins, and optimal ways of drying food commodities, should be promoted.

Agricultural development programs should be mindful of their health effects. For instance, before the construction of irrigation dams and water harvesting projects like wells and dugouts, and land improvement and restoration projects like bunding and terracing, the possible attraction of disease-causing vectors by the projects should be born in mind. The health externalities of these projects should be discussed fully by health and agriculture professionals and policymakers during project planning and implementation so that any negative effects can be minimized. To guide these discussions, an environmental impact assessment should be done during the planning stage of the project.

Recommendation 13: Inter-sectoral partnerships between agriculture and health should be promoted for synergistic rural development. This will require regular monitoring of the situation and occasional impact assessments to assess the effectiveness of these partnerships.

Movement of animals from one country to another occurs frequently, especially for grazing and for the market and so diseases easily spread in countries that share the same border. Virus-based animal diseases also spread through the wind from one country to another. Effective disease surveillance, diagnosis and treatment is expensive and it is more cost- effective if countries in a region pull resources together to undertake the activities as the diagnostic center set up in Ethiopia for animal disease diagnosis for countries in East Africa. This will improve productivity of livestock farming and reduce the incidence of zoonoses.

Recommendation 14: Regional cooperation on animal disease surveillance, diagnosis, and treatment should be promoted.

Recommendation 15: To tackle zoonoses, “The One Health” concept, based on the understanding that human health and animal health are inextricably linked and that a holistic approach is needed to understand, to protect, and to promote the health of all species, should be adopted by all countries and development organizations. For instance, recent global development initiatives such as joint veterinary and human health surveillance, and control of zoonotic and pandemic diseases such as SARS and avian influenza should be expanded in the context of the One Health principle.

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