In the 1950s, child malnutrition in Jamaica became defined as a medical-nutritional problem. Although local health researchers, centring around the Tropical Metabolism Research Unit (TMRU) at the University College of the West Indies, agreed that child malnutrition was largely the result of poverty, they did not assess the extent to which household income and other socio-economic factors contributed to child malnutrition (Waterlow, 1992). Instead, they measured the degree and nature of child malnutrition based on existing statistical medical data, such as infant mortality rates, and some experimental research. They were also more concerned with treatment of severe cases, especially of extreme protein deficiency, than with prevention (e.g. Waterlow and Wills, 1960). In other tropical British colonies, there was a similar focus on protein deficiency which, as Nott (2018) has argued, was a continuation of the work of the Committee on Nutrition in the Colonial Empire that had presented child malnutrition as a problem of quality not quantity. Only gradually was a more complex understanding of child malnutrition advanced, leading to the adoption of the now widely used protein-energy malnutrition (PEM) spectrum, which covers a range of conditions from a consistent lack of dietary protein and/or energy.
The GoJ and various UN agencies operating in the island in the 1950s equally medicalised child malnutrition. The GoJ adopted various schemes largely based on child feeding practices used in developed countries, such as cod liver oil distribution schemes (Cook and Yang, 1974, p. 133), while UNICEF, for instance, sponsored a free milk and school feeding programme. Jamaica was not unique in this regard. Tappan (2017), for example, has shown how through the distribution of baby formula and other schemes child malnutrition became medicalised in Uganda in the 1950s. By the late 1950s, however, nutritional researchers increasingly began to question such approaches and started to favour the vernacularisation of nutritional advice (Nott, 2016, p. 239); that is, adapting nutritional science to local contexts, paying attention not just to people’s living conditions but also their cultural beliefs and values.
The WHO, for instance, questioned the suitability of cod liver oil distribution schemes in tropical regions where sunlight exposure throughout the year allowed for optimal levels of Vitamin D, and started issuing guidelines for large-scale nutrition surveys that included attention to social and cultural factors (Jelliffe, 1955).
Informed by WHO guidelines, at least seven large-scale anthropometric surveys—measuring and weighing children—were undertaken in British Caribbean (former) colonies in the 1960s. The use of nutrition anthropometry in the colonies was not without its problems. The use of the so-called Gomez scale,Footnote 2 for instance, reinforced a racialised view of the ‘normal’ and ‘abnormal’; it divided malnutrition into mild, moderate and severe forms, but used children in Boston, measured between 1930 and 1956 and of mostly European descent, for its reference population (Scott-Smith, 2013, pp. 922–923; Gueri et al., 1980, p. 774). Nevertheless, defining child malnutrition in relation to both protein and calories, these surveys concluded that there was little severe malnutrition in the British Caribbean but that about 30 per cent of children suffered from mild to moderate malnutrition (Jelliffe, 1971a, 1971b p. 146). And to further illustrate the shift towards vernacularisation and a more multi-causal, mixed-methods approach, by the early 1960s anthropologists had joined medical scientists in researching child malnutrition, using interviews and other tools to understand the social, cultural and economic factors affecting the growth of Jamaican children.
The first survey undertaken in Jamaica after independence was carried out in 1963 by the nutrition unit of the Jamaican Scientific Research Council. It looked at the food intake of 665 pre-school children from 369 families in 59 different areas. Another survey took place in 1970, carried out with support from the Caribbean Food and Nutrition Institution (CFNI), a specialist centre of PAHO set up in 1967. And a PAHO study into nutritional problems in the Caribbean from 1963 to 1964 also included Jamaica (Aykroyd, 1965). These various studies tried to estimate the extent to which malnutrition was the major cause of death for young children in order to highlight the severity of the issue and establish the daily food intake of young children in order to recommend specific interventions (Israel, 1984). Waterlow and Ashworth (1974, p. 7, p. 12), for instance, concluded that malnutrition and gastroenteritis accounted for 40–60 per cent of deaths of Jamaican children aged 1–24 months, and that 90 per cent of children under 1 received less than the recommended daily calorie and 85 per cent less than the recommended protein intake.
The various Jamaican nutrition studies concluded that the high rate of infant deaths caused by malnutrition was the result of various socio-economic and cultural factors, most notably poverty, mirroring similar findings in other British (former) colonies (Nott, 2016, p. 239). Although Jamaica witnessed economic growth in the 1960s, poverty levels were high. Unemployment increased from 13.5 to 17 per cent between 1960 and 1969. And while per capita national income increased by 4.1 per cent between 1950 and 1968, income distribution was so skewed that only 30 per cent of the population enjoyed rising incomes (Jefferson, 1972, p. 52). In fact, the weekly income of the poorest 30 per cent fell by 24 per cent between 1958 and 1968 (Girvan et al., 1980, p. 115). Furthermore, the price of food increased by some 32 per cent in the 1960s, partly caused by an increase in import prices following devaluation (Jefferson, 1972, p. 72). As about 50 per cent of the income of lower-income households was spent on food, this increase in food prices significantly affected the amount and quality of food that they could give their children. That child malnutrition in the 1960s was highest in single female-headed households exemplifies the link between poverty and child malnutrition. These households were generally poorer than two-parent households as few men gave the unmarried mothers of their children financial support (Desai et al., 1969, p. 311) and most of these women undertook low-paid work. As Platt had already observed in the 1940s, these women as a result rarely breastfed for more than 3 months which further put their infants at risk of malnutrition.
Early and exclusive breastfeeding has long been seen as a means to enhance the survival chances of infants; breastmilk is easily digested and uncontaminated with infectious organisms so it protects against gastroenteritis. The various studies carried out in Jamaica in the 1960s found a rapid decline in breastfeeding: few mothers breastfed beyond 3 months and the trend was towards less breastfeeding and earlier introduction of the bottle (see Table 1). Social and economic pressures largely explain this change. Many lower-class mothers introduced the bottle to imitate those above them because the better-off tended to only bottle feed. But by the late 1960s, as in various other developing countries (see Nott, 2018, p. 779; Tappan, 2017) these women were also increasingly targeted by commercial milk companies. Newspaper adverts, billboards and other advertising hailed formula as ‘the best food for infants’. So-called ‘milk nurses’ working for commercial milk firms obtained names of women who had recently given birth in the hospital and then visited them at home and gave them samples. Some hospital staff also readily gave women who struggled to breastfeed the bottle. Under such pressure, many Jamaican women were convinced that expensive baby formula was best (Grantham-McGregor and Back, 1970; Reddy, 1971).
Like women in other tropical countries, Jamaican women found it difficult to sterilise bottles and teats (many only had one bottle and not a separate pan to sterilise it) and because formula was expensive, they also tried to stretch it so that the baby was given diluted milk. One study estimated that it would cost half a family’s weekly income to feed a child formula according to the guidelines on the tin (Jellife, 1971, p. 182). Mothers who could not afford to buy expensive formula often used condensed milk, which was cheap but high in sugar. By the late 1960s, more women started to use dried skimmed milk, which contained more protein than whole milk and was cheaper (Aykroyd, 1965, p. 146).
Jamaican mothers’ assumptions about appropriate weaning foods was also singled out in various studies as a factor accounting for high child malnutrition rates. For example, mothers rarely gave children under two fish, meat or sweet potatoes as they thought that these foods produced worms. The high status attached to commercially produced weaning foods also meant that they forewent bananas and other local foods for weaning mixtures (Aykroyd, 1965, p. 146; Ashworth and Waterlow, 1974, p. 29). A study undertaken by Arlene Fonaroff (1968), a visiting research fellow at CFNI, in the late 1960s, found that even many mothers who attended child welfare clinics held on to traditional, non-nutritious weaning practices. And Waterlow and Ashworth (1974) also singled out the gendered distribution of food in the household as a contributing factor of child malnutrition: the male head received most of the meat at mealtimes, while toddlers had to content with high-starch, semi-solid paps. Yet these studies did not dismiss this as evidence of ‘superstition’ and ‘backwardness’, like studies into child malnutrition during the colonial period had done in order to avoid addressing structural causes. Nor did they advocate instruction in ‘proper’, i.e. Western, child feeding methods. Rather, solutions were offered that actively worked with local beliefs and values and considered the context in which Jamaican mothers prepared food.
It was strongly recommended that infant feeding was taught through practical demonstrations, using foods, cooking equipment and methods that were feasible in local homes (Ashworth and Waterlow, 1974). Such teaching had to discourage the use of non-nutritious food stuffs, such as white potato (possessing a high water content), and to persuade mothers to abandon harmful practices, including withholding food from children when ill. Yet mothers were not to be dissuaded from traditional practices that were neither harmful nor beneficial, such as giving children non-toxic ‘bush teas’. In fact, medical staff were encouraged to actively work with traditional beliefs. For example, they were told that they should work with the belief in duppies—ghosts or spirits—telling mothers that their children would be less susceptible to duppies if fed an adequate diet (Fonaroff, 1968; Aykroyd, 1965).
Gradually, the teaching of infant feeding did become more ‘realistic’, ‘affordable’ and ‘local’ as it did in many other developing countries, such as Uganda (Tappan, 2017). PAHO (1970), for instance, drew up feeding guidelines for the Caribbean but left out ‘those specific details that require modification to suit local circumstances’. And slowly attempts were also made to implement various proposals to prevent a further shift towards bottle feeding (De Morales and Larkin, 1972; Ashworth and Waterlow, 1974). For instance, in 1974 milk nurses were banned from the Victoria (maternity) Jubilee hospital and the hospital of the University of the West Indies (Gleaner, 7 April 1974).
Recognising that poverty was a main cause of child malnutrition, it was also recommended that more and better day-care facilities be set up for children of working mothers (Ashworth and Waterlow, 1974, p. 79). And even more commonly recommended was an increase in maternal and child welfare clinics. By the late 1960s, there was a shortage of district midwives and public health nurses so that these clinics were often held only every other month and they only reached about one-third of all infants born (Ashworth and Waterlow, 1974, p. 75). From the late 1960s onwards, the number of clinics rapidly increased, providing easy access to clinics that monitored the weight of children and offered supplementary foods to pregnant and nursing women and at-risk children, where needed.
State interventions in this period were also stimulated by international agencies and encompassed a mix of technical and structural solutions. For instance, PAHO (1970) and other aid agencies active in the region placed significant responsibility on Caribbean governments, asking them for instance to fortify all imported dried skimmed milk with vitamin A; distribute low-cost iron and folic acid supplements for children under 2 years through health clinics; and subsidise foods for children, such as multi-mix weaning foods made from locally available ingredients. In line with this advice, in 1967 the GoJ assumed responsibility for the USAID-sponsored Food-for-Peace programme, which included a school feeding programme and the distribution of dried skimmed milk and CSM (a mixture of cornmeal, soya and powdered milk) to nursing and pregnant women and children up to the age of 2 years. The inclusion of CSM limited somewhat the drive towards localisation as it built on both the colonial interest in protein deficiency and the high modernist mentality to replace tradition with scientific and technological interventions (Scott-Smith, 2015).
However, by the late 1960s, the Food-for-Peace programme only reached a small proportion of at-risk children because their mothers tended to be poorer and less educated and therefore less likely to attend the child welfare clinics that distributed the milk and CSM (Ashworth and Waterlow, 1974, p. 31).Footnote 3 Expanding its efforts, the GoJ began to control the price of some 15 food items to protect low-income groups, pursued a policy of import controls to encourage the use and production of local foods stuffs, ordered research into ‘indigenous agricultural produce’ that could be marketed locally, and used radio to convey messages about healthy child nutrition (Ashworth and Waterlow, 1974, p. 24, p. 39; Ministry of Trade and Industry, 1970).Footnote 4 It was not unique in doing so. For example, Ghana, which had gained independence 5 years earlier, equally adopted policies to reduce imports and lower food prices (Robins, 2018).
The various measures adopted by the GoJ in the late 1960s and early 1970s, then, illustrate as Mozaffarian et al. (2018, p. 3) have argued, the extent to which public health nutritionists in developing countries in the 1960s embraced a policy that focussed on increasing calories and selected micronutrients through producing low cost, energy dense staples accompanied by the fortification of staple foods and food assistance programmes for vulnerable populations. Although during this period, the focus shifted from treatment to prevention and more attention was paid to local context and culture, measures adopted did little to address one of the main causes of child malnutrition: household poverty. The following section will demonstrate that it took a new government to offer a more holistic approach to the problem of child malnutrition, which combined a reliance on global agencies for food and loans with the use of novel health coalitions.
Pioneering new methods
The 1972 general election led to a People’s National Party (PNP) government led by Michael Manley, which adopted a democratic socialist programme that included policies to reduce poverty and social inequalities. As suggested by various UN agencies, a year after it took office, it adopted a nutrition programme that addressed nutrition from different angles—health, agriculture, and education—and focussed on food supply, food demand, and the ‘biological use of food’ (e.g. mother and child health programmes) (WHO, 2008, p. 147; Cook and Yang, 1974, pp. 134–136). The Manley government also devised a national food and nutrition policy that aimed to achieve by 1980 adequate nutrition and dietary well-being for all; more locally produced foods; and the elimination of malnutrition in vulnerable groups, including young children (Gleaner, 5 August 1976).
The import-substitution scheme Growing and Reaping our Wealth (GROW), which was launched in 1973, was mostly a response to a rising bill of imported food stuffs, caused largely by devaluation. The food bill increased from Jamaican dollars (J$) 43.3 million in 1968 to J$60.2 million in 1971 and rose even further after the oil crisis (Ministry of Agriculture, 1973). In fact, between mid-1973 and mid-1975, the food price index increased by 90 per cent: in the space of 20 months food prices had nearly doubled so that half the population spent at least 60 per cent of their income on food. The rise in wages until 1975 counteracted this price rise to some extent but unemployment levels also soared from 22.9 per cent in 1972 to 26.8 per cent in 1980. Furthermore, the flow of food aid supplied by USAID, including food supplements for pregnant and nursing mothers and infants dropped sharply, as the US turned against Jamaica because of the PNP government’s attitude to ‘foreign investors, to trade policy, foreign loans, aid alliances with other Third World countries, and matters of formal diplomacy’ (Kaufman, 1985, p. 87). As a result, in the mid-1970s, Jamaica experienced a nutrition crisis. This along with financial and other constraints limited the GoJ’s ability to meet the aims of its national food and nutrition policy (Marchione, 1977, pp. 62–64).
Considering the economic decline, which was unprecedented in post-war Jamaica, it is remarkable that child malnutrition did not increase during the 1970s (see Table 2). Headline figures, however, mask pockets of high child malnutrition, which became particularly pronounced in certain rural areas as the decade progressed. Several factors explain why there was an overall improvement in the nutritional status of young children during the 1970s. First, a rapid increase in the informal sector—jobs not recognised as normal income and on which no taxes are paid, including illegal activities—provided unemployed or underemployed communities with some income. Second, policies adopted by the PNP government led to better income and employment, especially for rural households. Particularly important here was Project Land Lease under which privately held lands were leased by the government, and then (for period of 5 years) to small farmers in the area to allow them to supplement their own holdings. By 1980, almost 38,000 farmers had been placed on 75,000 acres of land (Stephens and Stephens, 1986, p. 74).
Third, the PNP government expanded existing food subsidies and school feeding programmes (Riley, 2005, p. 177). In December 1971, the Jamaica Labour Party (JLP) government had signed a Food-for-Peace agreement with USAID for a new school feeding programme. A government-owned company Nutrition Production Limited (NPL) was set up, which supplied children in the parish of Kingston and St. Andrew with a bun (and initially also a patty—a pastry with various fillings, such as beef or chicken, inside a flaked shell) and a half pint of milk. This protein-enriched meal, for which children only paid a few J$ cents as the scheme was heavily subsidised, provided one-third of the required daily calorie and protein intake. The milk, for instance, was a re-combined milk consisting of skimmed milk powder fortified with butter, oil or soya and flavoured with vanilla. It was largely because most schools in the parish did not have kitchens that the programme opted for conveniently packed buns or patties (Gleaner, 17 December 1971, 6 October 1975, 17 March 1978). Outside Kingston and St. Andrew, schools under the Food-for-Peace programme were given oil and other supplies and funds to buy meat and vegetables to provide children with a cooked lunch. But when NPL facilities were increased, gradually schools in other parts of the island could also opt for what became known as the ‘nutribun scheme’.
Nutribuns were developed by USAID with a recipe designed around a ‘base’ product that could be modified using any number of locally available substances and were first used in the Philippines in 1970 following a series of typhoons (USAID, 1972). This flexibility was central to what Scott-Smith (2015, p. 245) has called ‘ready-made solutions in humanitarian action’, and by 1978, some 120,000 school children in Kingston and St. Andrew—and 100,000 in rural areas—were supplied with nutribuns or a cooked lunch (Gleaner, 10 September 1978).Footnote 5 Initially this school feeding programme had a positive impact on the nutritional status of schoolchildren. However, effects diminished over time, largely because children were not obliged to eat the food, and once the novelty had worn off they opted for cheap but less nutritious snacks sold at the school gates (Edwards, 1984, p. 79).
And a fourth factor why overall child malnutrition levels did not increase in the 1970s is the PNP government’s emphasis on primary healthcare, the first line in the prevention and treatment of child malnutrition. From the mid-1970s till the early 1980s, Jamaica had a thriving system of primary healthcare. In the early 1960s, there were only 73 health centres but by 1977 there were already 382. In 1978, the Ministry of Health decided to build 430 new health centres with loans from international donors. About 365 of these were eventually built so that most people were able to access a clinic within 10 miles of their home (Riley, 2005, pp. 179–180).
Many rural clinics employed officers called Community Health Aides (CHAs). This use of lay health workers first began in 1969 when the GoJ, the University of the West Indies and Cornell University Medical College set up a rural health project in Elderslie, in the parish of St. Elisabeth, which had a high rate of infant mortality caused by malnutrition (Alderman et al., 1973, p. 1168). The Manley government made CHAs an integral part of its expanded primary care system, largely driven by a shortage of trained medical staff.Footnote 6 By the end of the 1970s, some 1300 CHAs were employed, each serving about 600 people. CHAs did a lot of routine clinic health work but focussed mainly on maternal and child welfare. They had to encourage exclusive breast feeding; improve weaning practices; encourage a more balanced and affordable family diet by reducing the reliance on imported foods and increase the use of home-grown alternatives; and increase regular attendance at clinics so that children’s weight could be monitored and at-risk cases be given supplements (Riley, 2005, p. 180; Marchione, 1984). This model has since been copied by many other countries.Footnote 7
The impact of the increased use of CHAs on malnutrition varied from parish to parish. In Elderslie, for instance, it did not reduce overall levels of malnutrition but succeeded in lowering high mortality associated with nutritional deficiency because children that were mildly or moderately malnourished were sought out and then treated in their homes. Yet in Hanover parish, malnutrition levels of children under 2 fell by about 40 per cent after the introduction of CHAs. This was largely because the parish employed nearly twice as many CHAs as other parishes and also had a relatively continuous supply of food aid from the US (Marchione, 1984, pp. 229–234).
From the mid-1970s onwards, the GoJ had to scale back various policies that benefited the nutritional standard of the poor. For example, under agreements with agencies like the IMF, the price controls on certain food items were repealed and CHAs were no longer able to hand out supplementary food. The first IMF agreement was signed in 1977 and more followed, each with their own set of conditions that aimed largely to reduce government expenditure including spending on healthcare. The second half of the 1970s also witnessed more unemployment, a further hike in food prices, and food shortages. The latter two impacted the school feeding programme, reducing the nutritional value of the nutribun (Gleaner, 22 August 1980). Nevertheless, the government continued to implement its national food and nutrition policy. In 1978, for instance, it embarked on a nutrition education programme, which began with a mass media campaign that aimed to convey five basic messages, including that babies should be exclusively breastfed for the first few weeks and then weaned onto nutritious food (Gleaner, 14 February 1978). Furthermore, the Jamaican Scientific Research Council expanded its import-substitution programme, focussing on such things as using indigenous roots and tubers for composite flour formulations (Gleaner, 30 March 1978). This along with an increase in self-sufficiency amidst high food prices led to a 10–20 per cent increase in domestic food production between 1977 and 1979, which further explains why the overall nutritional status of children did not decline in the second half of the 1970s (Weiss, 2004, p. 465).
In the 1970s, then, local and external factors combined to produce a nutrition crisis. The GoJ adopted an innovative scheme to monitor children at risk of malnourishment and also various policies to ensure the food security of low-income households. But the decline in child malnutrition during this decade also owed much to overseas food aid and loans. The loans, however, came with conditions that also posed a threat to the nutritional status of children as the following section will show.