The Causes and Costs of Domestic Hunger

Dr. J. Larry Brown

Ladies and Gentlemen:

It is a pleasure to participate in this important event, despite the outcome of the recent presidential election. When I was first invited, I obviously had no idea that today I would be leaving the enclave of “blue” Massachusetts for the “blue” state of Oregon -- two islands of sanity among a sea of American red. Despite it all, one does have to laugh about a president who has the audacity to claim that when 49% of the people vote against him, he somehow has a “mandate.” But life goes on, and its most important issues remain before us. Certainly, this includes domestic hunger.

When I speak about hunger, I always bring with me a young boy named Danny Holley. Danny was a twelve year-old boy in 1984, also the year of a presidential campaign. He lived on an army base in California with his mother and siblings, while his father served overseas. The Holley family often didn't have enough to eat, and the children would go to bed hungry despite the mother's job and their best efforts. Danny often collected cans and bottles to help supplement his mother's income in order to pay for food, but still it wasn't enough. One afternoon, Ms. Holley came home from work… to find that Danny had hanged himself. Beside his body was a note on the kitchen table that read: “Dear Mom, I love you, and hope that you won't be angry with me. But I figured that it would help a lot if there was just one less mouth to feed.”

  This dramatic event was covered by the news media at the time… but neither Ronald Reagan nor Walter Mondale found it worthy of any mention in their presidential race. I vowed never to let Danny's death be forgotten so I mention him whenever I speak about hunger. He is my constant companion. While an unusual event, to be certain, Danny's death and the lack of interest by political leaders somehow reflects a nation that has lost its way.

Things were not always like this in our nation. In 1966 a team of physicians commissioned by the Field Foundation researched areas of endemic poverty in America , migrant labor camps, Indian reservations, urban slums and small towns in the Mississippi Delta. In their report to Congress the following year, they underscored the desperate circumstances they had found: “If you go look, you will find America a shocking place. No other Western country permits such a large population of its people to endure the lives we press on our poor. To make four-fifths of a nation more affluent than any other people in history, we have degraded one-fifth mercilessly.”

It was common, they reported, for poor babies and young children to have no milk to drink because their parents did not have the money to purchase it. Hunger was widespread, with many households often going several days during the month with little, and sometimes nothing, to eat. Kwashiorkor, the advanced nutritional disease usually associated with Third World conditions of starvation, was not wholly uncommon. It was manifest in African-American children whose black hair had turned yellow, in Indian children with sunken eyes and rotted teeth, and in the protruding tummies and thin limbs of children in migrant camps and city slums.

These shocking findings produced public outrage sufficient to galvanize a Republican President and Democratic Congress into action. The food stamp program was expanded from a small pilot reaching only two million poor households to one of national scope covering ten times that number. 3 The federal school lunch program was augmented with a parallel school breakfast program, elderly feeding programs were begun, and the WIC program (Special Supplemental Food Program for Women, Infants and Children) was established. A decade later the team of physicians returned to the same areas of the nation to examine the situation. They reported to Congress that while poverty remained a significant problem, hunger was no longer widespread. 6 In subsequent years this conclusion was borne out by university-based scholars as well as national nutritional surveys.

The success, however, would be short-lived. The first official recognition that hunger had reappeared came in 1982, from the U.S. Conference of Mayors. Since the beginning of that decade the news media had been reporting locally and even regionally on what would become a national phenomenon, growing numbers of bread lines and soup kitchens in America . The mayors termed hunger “a most serious emergency” and some, like the mayors of Detroit and Salt Lake City , went so far as to call the situation “a national tragedy and a national disgrace.” In 1983, a report that had been commissioned by the Department of Agriculture found that hunger was growing across the nation “at a frenetic pace” but the White House ordered that the findings not be released. They became known only because lower-level civil servants, angered by the suppression of the study, gave copies to the media anyway.

The first official calculation of the extent of hunger in America was offered in the widely-covered1985 report of the Harvard-based Physician Task Force on Hunger in America . Entitled Hunger in America : The Growing Epidemic . Our group of physicians and other health experts put the number of people going hunger at 20 million. At the time this represented 9% of the U.S. population, although this figure was challenged by high-level officials in the Reagan Administration for whom this problem apparently had political if not electoral overtones that concerned them.

While there was no single universal definition of hunger, our Harvard-based group defined hunger as “chronically inadequate nutritional intake due to low income status.” Whether chronic or episodic in nature, hunger was the lack of sufficient calories and nutrients for physical growth or the maintenance of good health. Frequently extending over longer period of time, it could lead to serious chronic health conditions both in children and adults.

Since 1995, the federal government has used its own measure of nutritional deprivation based on an annual survey conducted by the Census Bureau as part of the Current Population Survey. Known as the “Federal Hunger and Food Security Module,” annual data released through the Department of Agriculture consistently have placed the number of Americans living in households with serious food problems at more than 30 million, with the latest report for 2002 putting the number above 35 million. Representing more than 12% of the population, this proportion is significantly higher than the somewhat more conservative Harvard estimate. But the federal figures also reflect a somewhat different definition.

It is with this history, a nation carrying the burden of 30-plus million people consistently without adequate nutrition, that we can now examine what hunger does to its victims and why it occurs amidst extravagant wealth.

  The adverse consequences of chronic under-nutrition, as well as the social sequelae of those consequences, make hunger a critical problem for the nation. Moreover, a small but growing body of knowledge also points to the problem of obesity as a health consequence frequently associated with inadequate income and even hunger.

  In the American context, hunger presents quite differently than it does in developing nations. Hunger in this nation typically takes the form of what the World Health Organization calls “silent undernutrition”. It is reflected in the young child who is several pounds beneath the low end of the pediatric growth chart. She may present simply as a thin child, but a trained professional will recognize that she is experiencing growth failure. Her symptoms are different from the starker Third World context, but from a health perspective the child is in difficulty.

  Because children are growing organisms, and because their height and weight gain is plotted on internationally-standardized pediatric growth charts, they perhaps are the easiest population group in which to detect the consequences of inadequate nutrition. Typically, youngsters who fall below the fifth percentile in weight or height for age on growth charts are candidates for further investigation. This indicates that what is being observed is not normal genetic variation, but a “man-made” outcome produced by the variables associated with social injustice. Moreover, this analysis is confirmed in the work of child development clinics now dotting the landscape of urban teaching hospitals across the nation where children experiencing growth failure due to poverty are nursed back to health with appropriate nutrition.

  While the link between inadequate nutritional intake and health status reflected in the height and weight of children is well-established, significant new scientific research in recent years has broadened our understanding significantly about other insidious effects. Direct, demonstrative and deleterious links exist between inadequate food intake and a variety of poor developmental outcomes in children. The health status of youngsters from impoverished homes experiencing hunger and food insecurity is much worse than for non-deprived children. They get sick more often, have much higher rates of both iron deficiency anemia and serious ear infections, and are hospitalized more frequently. In short, not getting enough to eat makes kids sick.

  As a result, low-income children miss more days of school and are less prepared to learn when they do attend, making the relationship between food intake, health status and learning far more poignant than previously understood. Further exacerbating this interactive impairment of young bodies and minds are behavioral and emotional outcomes that accompany food deprivation. At-risk children have significantly higher rates of emotional problems, mental disorders and withdrawn or disruptive behavior. A brief review of known outcomes underscores the insidious intrusion of under-nutrition within the young body.

  In the arena of general health status , household food insufficiency is associated with overall poorer health outcomes. In one national sample, food insufficient pre-school and school-aged children had elevated rates of stomach aches, head aches, and colds. Other studies have corroborated these results while some have established additional consequences. There also exist higher rates of emergency room visits as well as physician visits among hungry children.
  Other research indicates that food deprivation is associated with considerable psychological and emotional distress on the part of children. In studies in Philadelphia , Baltimore and Pittsburgh , for example, low-income children from households with inadequate food were more likely to exhibit impaired psychosocial functioning, including higher levels of anxiety, irritability, hyperactivity and aggression. In a national sample children from food-deprived households manifest significantly higher levels of aggressive and destructive behavior as well, conversely, as withdrawn behavior. Related outcomes apparently extend into the teenage years as well. Two studies show that food-insufficient teens are more likely to have no friends, and to exhibit both depressive disorders and suicidal behaviors. These outcomes, not surprisingly, seem to impact the educational environment as well. A team of Harvard-based medical researchers recently found that hungry children are much more likely to have a history of mental health counseling, and are more likely to require special education services.

  The link between hunger and educational outcomes is itself nested within a particularly robust field of inquiry that strongly links nutritional status with cognitive function in children. Children from food-insufficient households do not perform as well on academic achievement tests as do food-sufficient children, and in some comparisons hungry children not only have higher rates of tardiness and absences, but also are more likely to have to repeat a grade in school. In two national studies, for example, household food hardships were negatively correlated to both school test results and achievement test results in elementary school children. In a review of the literature for Scientific American , Professor Ernesto Pollitt and I explained a key mechanism by which food deprivation seems to impair cognitive function. In a nutrient-deprived state, the body allocates energy in a triage manner, with the first priority being critical organ function. If there remains dietary energy thereafter, it is devoted to height and weight gain, hence the development of growth clinics mentioned earlier to aid hungry babies and toddlers. The final priority for limited dietary energy is for interaction with the environment, listening to parents, interacting with peers, and engaging in the learning process. It is this latter avenue, a child's inability to engage in these activities, that produces cognitive dysfunction. Rather than causing structural changes in the brain, under-nutrition impairs cognitive function through this more “benign” and insidious method.

The toll that food deprivation takes on the capacity of the mind to learn also is associated with other factors that impair the learning process. Children from hungry and food insecure homes are more likely to repeat grades , be absent or tardy, and be suspended from school. In short, otherwise normal and capable children are sent through the schoolhouse door with at least one arm tied behind their backs because they do not have the nutritional basis for learning. Hunger impairs them in terms of their health status, psychosocial and emotional well-being, and cognitive function. The public health and economic implications of this evidence are significant.

That an inadequate food supply actually impairs the lives and well-being of significant numbers of Americans is well-established. But what are the factors that produce this condition in the wealthiest nation the world has ever seen? Several factors often are raised, each of which we shall address before turning to the primary cause. Some people labor under the belief that there is not enough food to go around, that even with our abundance the United States somehow either does not produce enough food or, if it does, there is such regional variation that food does not get to those who need it. In fact, not only does the U.S. produce enough food for all its people, but some experts estimate that it has the capacity to feed most of the world's hungry as well.

Another idea often advanced is that the poor experience hunger because they make bad purchasing choices. One former President suggested that the poor simply are “too ignorant”. Here too, the scholarly evidence is enlightening. All population groups could learn more about getting more nutritional value for their food dollar. Too many non-nutritious purchases are made, and too few healthy diets are the norm. But no evidence suggests that low-income households make poorer purchasing choices than do the rest of the population. Indeed, the Continuing Survey of Food Consumption suggests that poor households do as well as non-poor in terms of knowing what they should purchase. They simply do not have the money to do it. Moreover, we might come at this notion of ignorance from a somewhat different standpoint, that of common sense. It is well-established that hunger in this nation was reduced, then returned, and that the rate now goes up and down from year to year. If we were seeing an outcome resulting from ignorance, it is not likely that the impact would vary like it has over time. In other words, when the prevalence of hunger suddenly spikes, it makes little if any sense to suspect that it reflects a sudden upturn in ignorance. Conversely, when the rate of hunger goes down, little would lead us to attribute it to a sudden increase in knowledge.

So how then are we to understand the existence of 35 million people without enough to eat? For this, we must evaluate the factors that comprise the concept of social injustice: the economy, wages, poverty and public policy. Virtually all hunger, all food deprivation, and all adverse health consequences associated with not having enough to eat, are the direct result of policy decisions and other forms of governmental action.

To see the impact of human hands in creating food deprivation in our nation, let us return to the era already discussed when hunger returned to America. Throughout much of the 1970s domestic hunger seemed under control but, as we have seen, it returned with a vengeance in the early 1980s. Within but a few years bread lines and soup kitchens in major cities went from but a handful in each place to 300, 400, even 500 in number. Clearly something quite abrupt had happened to cause this situation. Indeed it had. Toward the end of the 1970s and into the early 1980s, a national recession led to high unemployment and unusually high interest rates. Millions of people lost their jobs, thousands and thousands of farmers lost their livelihood, and many people once secure in their middle class existence went through unemployment due to down-sizing, only to re-enter the labor market with a much lower income. But while the recession was significant, it was not unprecedented; the nation had experienced some tough economic circumstances not too many years before, but these times had not lead to the proliferation of bread lines and soup kitchens. The bread line phenomenon in the 1980s had not been seen since the Great Depression years of the 1930s. Something else was at work.

The return of hunger to the nation was ushered in not by the economy alone, but by new public policy that was adopted as more households were becoming economically vulnerable. Starting in 1982, the Reagan Administration submitted its first four-year budget for the period 1982-1985, the Omnibus Budget and Reconciliation Act. It was passed largely as submitted, by a Democratic Congress. This budget cut more than $12 billion from the federal food program safety net that had been created during the late sixties and early seventies. Nearly $8 billion was cut from the food stamp program, largely through reducing the allotment or value of the stamps to an average of .72 cents per person per meal. Another $4 billion was cut from child nutrition program like the school breakfast program.

So now we have an equation: more people jobless during a recession + the intentional weakening of federal programs to feed people during tough times = more bread lines and soup kitchens. And this is precisely what happened at the time. It is now well-established by a plethora of research over subsequent years. In short, human vulnerability is a fact of life because we cannot predict or control economies let alone the well-being of individual households. But what we can control is whether families are protected from the occasional vicissitudes of economic lurches. But when households are more vulnerable, and policymakers remove the supports that help them get by during those times, something will happen. It is, as we have seen, an equation. Hunger was the inevitable product of political choices made at the time.

But this can hardly be the end of the story. Why, we must ask, did food deprivation in the U.S. remain relatively stable at 30-plus million each year, even during the exceptional booming economy from 1992-1999? To answer this question we must peer into the face of social inequality. The tremendous boom years of the 1990s, and the explosive growth of the stock market, produced a national economy and personal wealth of a nature unrivaled in modern times. Whether measured in household income, per capita income, wealth accumulation or net worth, the numbers reflected a highly prosperous nation. Everyone, it seemed, was doing better. But “seemed” is the key word, for in truth something else was going on. The tremendous accumulation of income and wealth by segments of the population masked two other factors. One was the dramatic shift of resources up the income scale and away from working and low-income households. The other was the shift to a job market increasingly based on lower and lower wages.

At the end of 1999, the average hourly wage was $11.87. This was at the peak of the boom era. Yet this amount actually was lower than it had been in 1979 (adjusted for inflation) when it was $12.05. For salaried workers, the median weekly income was $567 in 1999, about the same as it was in the 1970s ($558). While by these measures income was stagnating, there was a flood of both income and wealth being thrown off by the sizzling economy. But it went mostly up the economic ladder, not down. In 1979, the poorest quintile of the labor market received $13,504 a year, in contrast to $13,320 in 1999, again adjusted or in constant dollars. The next quintile, including many blue collar households, saw their income go up only $100 annually over this twenty year period. The middle quintile saw a growth of $300 annually. The richest quintile saw a pay-off of $45,000. The top 5% of households saw their income increase by more than $100,000, and by 1999 it averaged $254,000 annually.

Another way to examine this era is to look at the proportion of aggregate income received by different quintiles. By 1999, the poorest 20% of the population got 4.3% of all income, a drop from 1979. The next quintile also went down from 11.6% in 1979, to 9/9% in 1999. By this latter year, the aggregate income of the wealthiest 20% was 42.2 percent of all income. And the wealthiest 5% of the population in 1999 got 20.3% of all the income in the United States.

The increase in income and wealth for the very richest were so great that, when averaged among the population, it made it look like everyone was doing much better. But like with any average, we need to look at the ends of the distribution (Bell curve). The tyranny of the mean is a well-accepted cliché among economists who have a favorite quip: “A man standing with one leg in ice and the other in scalding water on average feels just fine.”

Hunger and food deprivation exists in the United States because we are tolerating such great inequality. It is impossible to press the burdens we press upon so many millions of households without deprivation being felt among families and children. And it is impossible to tolerate such economic disparities and then anticipate that they will have no impact when our nation's safety net is so threadbare.

  What needs to be done? When people think about hunger, they typically think about charity – collect wasted food and give it to the poor to eat. In the short-term, there is nothing bad about it. People are hunger, government is not doing its job, so these programs and the well-meaning people behind them simply must feed people. People don't eat in the long-run, they need to eat now, so thank goodness these programs are there! But when it comes to actually ending hunger, it is a different thing. Charitable hand-outs, by definition, do not end hunger. They only feed a hungry family for the moment, and poor people have the peculiar habit of getting hungry again the next day.

  There are two reasons that no modern, wealthy democracy should protect the nutritional status of its people by relying on charitable hand-outs over the long-term. The first has to do with capacity, and the other with appropriateness. In terms of capacity, the only vehicle we have that is large enough to end and prevent hunger is the federal government. Two decades of charitable efforts don't even begin to come close to the reach of the food stamp program, even in its weakened state, in terms of delivering nutrient content to the plates of parents and children. When the food stamp program was cut most recently, during the so-called welfare reform legislation of 1996, so much purchasing power was removed from poor households that if you loaded the lost food on trucks in army-convoy style (eight trucks to a mile with 5,000 pounds of food on each truck) the line would stretch to the moon and back. Even if the private sector could have doubled its food collection efforts overnight, it wouldn't even begin to make up for the cutback in this one federal program alone. In short, private charity isn't capable of doing what government can do to address hunger. It isn't even close. To paraphrase William H. Woodside, former chairman of Primerica, it is government's job to address hunger; it cannot be done by the private sector and it should not be done by the private sector.

  Woodside's comment raises the next issue, that of appropriateness. Even if we could feed the hungry through soup kitchens and food pantries, it would be wrong. People need justice, not charity. They need dignity, not hand-outs. Our vision and our goal should not be a nation where more and more people eat the soup and sandwiches that charities pass out, but one whose people do not need charity. Even when given with sensitivity, there is something about receiving charity that is demeaning. None of us would want to take our family to eat in a soup kitchen; parents do not want to take their children out of the home to have others feed them. While they may be happy for the food at the moment, the very process is belittling.

No matter how well meant the effort, no matter how cozy the environment, no matter what's in the bag of food, it is an indignity for an adult to be reduced to relying on others to feed her children. It is the essence of adulthood, of dignity and self-respect, that we feed our families. Anything else is an indignity.

  So charity is not the answer. The incredible efforts of the charitable sector are not a sign of collective success, but a symbol of public failure. And the very existence of the charitable enterprise has corrupted politics. It has turned public officials from justice fighters into timid pacifists. Political leaders have become the cheerleaders for charity, and charity has become the public pablum that excuses their inaction. The ultimate recipients of this “sweet charity” are not the hungry themselves, so much as the political leaders whose lack of leadership it masks. Private charities to feed the hungry reflect the failure of American policymakers to do their jobs. Charity represents their failure to bring us into the sisterhood of modern industrial nations that long ago adopted policies to protect their people from the man-made scourge of hunger.

Aside from charity, there exist two other avenues by which we might remedy hunger and other forms of nutritional deprivation in the nation. One would be to treat the symptom, an approach seemingly antithetical to good public health practice. The other would be to address the root cause of the problem, which is growing income and wealth inequality and lack of opportunity for more and more people.

  It is possible to end hunger without addressing poverty and inequality, and this is the quicker, easier, and least costly approach for now. Could we wave a magic wand, clearly ending structural inequalities would be preferable, but in the political and policy climate in which we live, it's more reasonable to think of ending hunger than poverty. Leaving structural inequalities as they are, hunger could be ended by the President and Congress in a matter of six month simply by using the programs already at our disposal. We do not need new bureaucracies and new programs; we simply need to aggressively use those that exist and are known to work well, when fully funded and extended to people in need. For an estimated $8-9 billion a year we could better fund the food stamp program and extend it to the 45% of eligibles that it now fails to each; mandate all schools to offer the federal school breakfast program, and all communities with low-income children to participate in the federally-funded summer food program; expand after-school snacks and increase the coverage of elderly feeding programs. These steps, and small fine-tuning with a handful of other programs like WIC and Head Start, would mean that no one in the United States has to go hungry, or demean themselves by taking their children from the home to eat in a soup kitchen.

  But we also can be working on a parallel track to address the structural injustices that cause hunger. This will require a change in the social contract, the nature of the relationship between government and households. To be precise, it will require the reconstruction of a social contract, for the one that has been the hallmark of social policy since the New Deal hardly exists any longer. It has eroded dramatically over the past quarter century through regressive social policies that remove any semblance of protection for those most vulnerable, as well as tax policies that have produced the largest income and wealth disparities since the era of the Robber Barons.

  Your grandparents' generation knew what a Social Contract meant. People carried their own weight and government guaranteed them a modicum of security. You worked, and unemployment insurance was there if you became too ill. Today, UI fails to protect millions, and benefits have dropped to half their original level. If you became ill, health insurance covered your care. Today, 44 million people don't even have such protection, and many who do can hardly pay their monthly premiums. Your grandparents put in their work years and Social Security made sure they could live in old age. Today, government leaders are trying to privatize this program, thereby removing its social protections for millions. All this has been eroding for at least two decades, and a new Social Contract will have to built in the next five to ten years.

  The most likely policy construct through which a new social contract might be built is referred to as asset policy. To reach comfortable middle class living standards, households need more than income. They need other assets as well: one form is financial wealth in the form of a home, a savings account, investments and a retirement plan. Households also need what is called human capital assets, a good education, as well as skill-based training. This three-legged stool, income, wealth, and human capital, comprise assets. While this current asset policy construct is new, its manifestation is actually built on long-standing governmental policies. The Homestead Act of another era or, more recently, the GI Bill were federal policies that invested in asset-building through the promotion of property ownership, home ownership and higher education. Millions of GIs, for example, entered the middle class through this form of governmental largesse. Currently many people benefit through other governmental investments such as pre-tax retirement accounts and home mortgage deductions, as well as college loan funds and other mechanisms that help households accrue the assets they need for economic security and well-being.

But what has been good governmental policy for the many has not been extended to the downtrodden. Social policy has seen most of us as targets of governmental investments, but has seen the working poor as a drain on the economy. But the new vision of asset-based social policy is to treat all households the same, as targets of governmental investment so that low-income households also can acquire the assets they need for greater independence and security.

This can be done in numerous ways,as the following examples illustrate. By indexing the minimum wage to inflation, and restoring it to at least its purchasing power of, say, the 1970s, we can insure that no working households brings home a paycheck insufficient to feed the family. Similarly, the earned income tax credit can be expanded, along with its state tax corollary, to insure household incomes. In the area of wealth-building or financial assets, IDAs or individual development savings accounts are a small representation of how low-income households can accrue wealth. Similar ideas, with significantly more potential impact, include the expansion of home ownership through set-aside savings plans whereby a partial amount of the rents paid by public housing tenants are put into a dedicated account so they can save for a down payment on a home. Another potential vehicle to promote wealth-building would be the creation of Children's Savings Accounts (CSAs), whereby, for example, each child born in the U.S. would receive a $1,000 investment in a dedicated account. The investment could be matched in subsequent years by other federal investments and/or be augmented by family contributions. Under various options and scenarios, the original investment could grow to $50,000 or more by the time youth reach college age, and $500,000 if left to accrue until retirement. Moreover, CSAs could be earmarked for specific purposes such as a college education, a first home, starting a business, or retirement income.

The beauty of asset development policy is that it is universal in nature, treating rich and poor, alike, as players. Moreover, the concept is built on widely-shared values: work and responsibility, on the one hand, and meaningful opportunity and reward on the other. If we are to move as a nation to address the growing disparities that are at the heart of the social injustice that cripples us, asset policy is probably the only viable avenue by which to do so.

  Social injustice in our nation has many children, but perhaps few are as troubling as hunger. Seven thousand years after the first cities were formed to protect the food security of existing populations, the wealthiest civilization in the history of the world somehow finds itself incapable of doing the same. But hunger, as we have seen, stems not from a shortage in the food supply, or from lack of capacity and know-how, but from structural inequalities built into our economy and social system. While it is possible to end hunger in America within a year by better utilizing the federal programs designed to feed those at risk, it also is possible to address the root cause of food insecurity by re-framing the nation's social contract.