See corresponding editorial on page 271. See corresponding CME exam on page 466.
Early onset of coronary artery disease after prenatal exposure to the Dutch famine13
Rebecca C Painter, Susanne R de Rooij, Patrick M Bossuyt, Timothy A Simmers, Clive Osmond, David J Barker, Otto P Bleker, and Tessa J Roseboom
ABSTRACT Background: Limited evidence suggests that maternal undernutrition at the time of conception is associated with increased cardiovascular disease risk in adult offspring. Objective: We investigated whether persons conceived during the Dutch famine of World War II had an early onset of coronary artery disease (CAD). Design: We compared the age at onset and cumulative incidence of CAD between persons born as term singletons who were exposed to the Dutch famine during late (n 160), mid- (n 138), or early (n 87) gestation and 590 unexposed subjects at age 50 or 58 y. Age at CAD onset was defined as the age at which angina pectoris was identified (according to the Rose questionnaire), Q waves were observed on an electrocardiogram (Minnesota codes 11 or 12), or coronary revascularization was performed (by angioplasty or bypass surgery). Results: Of the 83 CAD cases identified, persons conceived during the famine were 3 y younger than the unexposed persons at the time of CAD diagnosis (47 y compared with 50 y) and had a higher cumulative incidence of CAD [13%; hazard ratio (HR) adjusted for sex: 1.9; 95% CI: 1.0, 3.8] than did the unexposed persons. The HR changed little after adjustment for smoking (HR: 1.8), social class (HR: 2.0), or size at birth (HR: 2.0). Conclusions: We found an earlier onset of CAD among persons conceived during the famine, which suggests that maternal nutrition in early gestation may play a role in the onset of CAD. This finding agrees with evidence from animal experiments that identify periconceptional maternal diet as important in the offsprings adult health. Am J Clin Nutr 2006;84:3227. KEY WORDS Coronary artery disease, age at onset, maternal nutrition, maternal starvation, pregnancy, cardiovascular programming
changes in cardiovascular function can result from maternal or fetal undernutrition without affecting birth weight (3). To gain more insight into the mechanisms of disease in later life in humans after restricted prenatal nutrition, the sequelae of restricted maternal nutrition during gestation have been studied in the Leningrad Siege Study (4) and the Dutch Famine Birth Cohort Study. The Dutch famine was a 5-mo period of extreme food shortage during the winter of in World War II. The Leningrad Study reported no effect of maternal malnutrition on the adult offsprings CAD prevalence. The Dutch famine, however, was relatively short compared with the Leningrad Siege Study, which allowed the effects to be studied by trimester of prenatal famine exposure. The previous findings from the Dutch Famine Birth Cohort Study support the hypothesis that the timing of the nutritional insult is important in determining its effect in later life; exposure to the Dutch famine in late gestation was associated with decreased glucose tolerance (5), whereas more microalbuminuria (6) was present among subjects exposed during midgestation. The most marked effects were described in the group of subjects conceived during the famine and include a more atherogenic lipid profile (7), altered clotting (8), more obesity (9), and a tripling of CAD prevalence at age 50 y (10). The cluster of cardiovascular disease risk factors previously described in persons conceived in famine is in line with studies in animals, which have highlighted the importance of periconceptional maternal nutrition in programming cardiovascular disease risk (1114). The effects of maternal periconceptional diet on the course of adult disease have not been investigated. We hypothesized that CAD manifests at an earlier age in persons exposed to famine during early gestation. We reexamined the
From the Departments of Clinical Epidemiology and Biostatistics (RCP, SRdR, PMB, and TJR), Cardiology (TAS), and Obstetrics and Gynecology (OPB), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, and the MRC Epidemiology Resource Centre (CO) and the Developmental Origins of Adult Disease Centre (DJB), University of Southampton, Southampton, United Kingdom. 2 The Dutch Famine Birth Cohort Study is funded by the Diabetes Fonds (Netherlands), the Netherlands Heart Foundation (grant number 2001B087), Wellbeing (United Kingdom), the Medical Research Council (United Kingdom), and the Academic Medical Centre (Netherlands). 3 Address reprint requests to RC Painter, PO Box 22660, 1100 DD, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. E-mail: r.c.painter@amc.uva.nl. Received November 28, 2005. Accepted for publication February 24, 2006.

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INTRODUCTION

Restricted intrauterine growth has been proposed as an important contributor to later coronary artery disease (CAD) and its biological risk factors (1). Developing organ systems respond negatively to the reduced availability of nutrients, particularly during periods of rapid developmentso-called critical periods (2). Most studies in humans have access only to indirect measures of intrauterine nutrition, such as birth weight. Substantial
Am J Clin Nutr 2006;84:3227. Printed in USA. 2006 American Society for Nutrition
GLYCEMIC INDEX AND LIVER STEATOSIS
findings of a study conducted at age 50 y and included information from a subsequent study 8 y later.

SUBJECTS AND METHODS

Selection procedure The Dutch Famine Birth Cohort consists of 2414 live-born term singletons born in the Wilhelmina Gasthuis in Amsterdam, Netherlands. All infants were born between 1 November 1943 and 28 February 1947. The selection procedure for the study conducted at age 50 y was described in detail elsewhere (5), as was loss to follow-up because of mortality, emigration, and other reasons (15, 16). In short, cohort members were eligible for participation if they were living in the Netherlands at the start of the study (January 1995 and September 2002), and their address was known to the Dutch Famine Birth Cohort Study researchers. All eligible subjects were asked to participate at ages 50 and 58 y. Council registries helped trace people who had had a change of address since they were last traced at age 50 y. All participants provided written informed consent. The local Medical Ethics Committee approved the study. The study conformed to the Declaration of Helsinki. Exposure to famine We defined famine exposure according to the daily official food rations for adults. In addition to the official rations, food from other sources, such as church organizations, central kitchens, and the black market, was also available and the people may have had access to up to double the rationed amount at the peak of the famine. The rations do, however, adequately reflect the fluctuation of food availability during the famine (17). A person was considered prenatally exposed to famine if the average daily rations for adults during any 13-wk period of gestation were 1000 kcal. Therefore, persons born between 7 January 1945 and 8 December 1945 were considered exposed prenatally to famine. Cohort members born between 1 November 1943 and 6 January 1945 (born before the famine) and between 9 December 1945 and 28 February 1947 (conceived after the famine) were unexposed to famine. We defined periods of 16 wk each to differentiate between those who were exposed in late gestation (born between 7 January and 28 April 1945), midgestation (born between 29 April and 18 August 1945), and early gestation (born between 19 August and 8 December 1945), in correspondence with previous publications on this cohort (5, 10). Persons exposed in early gestation were conceived during the famine. The famine ended in May 1945, with the advance of the allied armies into Holland. Food supplies were rapidly restored, and the average caloric intake in June 1945 was 2000 kcal. Data collection Medical birth records provided information about the mother, the course of gestation, and the size of the infant and the placenta at birth (5). Socioeconomic status (SES) at birth was defined according to the occupation of the head of the family and was classified as either manual or nonmanual on the basis of the information provided by the birth records. Consenting cohort members came to the hospital. We measured height using a fixed or a portable stadiometer, weight with Seca scales (Hamburg, Germany) or Tefal portable scales (Groupe SEB Nederland BV, Veenendaal, Netherlands). Body

mass index was calculated by dividing weight in kilograms by the square of height in meters. Blood pressure was measured twice on 2 occasions (morning and afternoon) with an automated device: a Profilomat (Disentronic Medical Systems AG, Burgdorf, Switzerland) at age 50 y and an Omron 705CP/IT (Omron Healthcare United Kingdom, West Sussex, United Kingdom) at age 58 y. Mean blood pressure was calculated from both the morning and afternoon measurements. Standard 12-lead electrocardiograms (ECGs) were used for all participants. Trained technicians blinded to the clinical data scored the ECGs according to the Minnesota criteria. Nondiabetic participants underwent standard 75-g oral glucose tolerance testing. Blood was drawn for the measurement of LDL, HDL, and triacylglycerol concentrations. Total cholesterol, HDL, and triacylglycerol concentrations were measured with the use of an enzymatic colorimetric reagent (Roche Diagnostics, Switzerland) on a P-800 Modular (Roche, Switzerland). LDL was calculated by using the Friedewald formula. Participants were interviewed to obtain information about their medical history, including operations, lifestyle, and use of medication. We defined current SES according to the participants or their partners occupation, whichever was highest, using the ISEI-92 (18). The ISEI-92 scale ranges from 16 (minimum score; lowest status) to 87 (maximum score; highest status). Trained nurses carried out all measurements and interviews. The presence of CAD was defined as the presence of one or more of the following: angina pectoris according to the Rose/ World Health Organization questionnaire, Q waves on the ECG (Minnesota codes 11 or 12), or history of coronary revascularization (angioplasty or bypass surgery). Statistical methods For the investigation of age at onset of CAD, all subjects that had participated at age 50 or 58 y were included. To study associations between the progression of CAD and the timing of famine exposure during gestation and size at birth, we used the Cox regression model of the cumulative incidence and age of manifestation of CAD and calculated hazard ratios (HRs) and 95% CIs for subjects exposed in late, mid-, and early gestation and compared them with unexposed subjects. We constructed a KaplanMeier curve showing the cumulative incidence of CAD as a function of age per famine exposure group. The time of event was defined as the age at onset of angina pectoris according to the Rose/World Health Organization questionnaire. If no age at onset of angina pectoris was stated, the age at the time of the first coronary revascularization procedure was used, and, in cases where both ages were missing, the age at the time of registration of Q waves on the ECG was used. Subjects who had only participated at age 50 y were censored at the age at that visit. When adjusting for covariates in the Cox model, we used the most recently collected available measurement before the event. If the event had occurred between the time points of participation, an estimation of the covariate at the time of the event was made with the use of linear interpolation. We used logistic regression analysis to compare the characteristics of persons with and without CAD. Because of the left skewed distribution of age at first occurrence of CAD, this variable is reported in means after we applied a quadratic transformation. Body mass index, SES, the ratio of LDL to HDL, and glucose were log transformed because of their skewed distributions. These variables are reported as geometric means SDs; all

VALTUENA ET AL

TABLE 1 Maternal, birth, and coronary artery disease characteristics of men and women who participated in the Dutch Famine Birth Cohort Study at age 50 or 58 y Time of exposure to famine Born before famine General No. of subjects Men (%) Maternal characteristics Maternal age (y) Weight at the end of gestation (kg) Weight gain in the last trimester (kg) Occupation of head of family, manual (%) Primiparous (%) Birth characteristics Birth weight (g) Head circumference (cm) Ponderal index (kg/m3) Coronary artery disease No. of cases Cumulative incidence (%) Age at onset (y)5
Late gestation 0.32.43 26.8 50
Midgestation 5.32.13 25.8 50
Early gestation 5.32.8 26.134 474
Conceived after famine 4.33.2 26.8 49
All subjects 8.7 3.4 3.467 32.8 1.6 26.2 2.(4556)

Total n 975 81

3.32.8 26.8 51
Significantly different from those born before or conceived after the famine, P 0.05 (linear or logistic regression). x SD (all such values). 3,4 Significantly different from those born before or conceived after the famine after adjustment for sex: 3 P 0.05 (linear or logistic regression), 4 P 0.05 (Cox regression). 5 Mean after quadratic transformation; interquartile range in parentheses.
other variables are reported as means SDs. All statistical analyses were performed by using SPPS 12.0.2 (SPSS Inc, Chicago, IL). We considered differences to be statistically significant if P values were 0.05.

RESULTS

Study population The cohort contained 2414 members. Loss to follow-up was described previously (15, 16). At age 50 y, 1527 (63%) persons were eligible for participation. At age 58 y, 1423 (59%) persons were eligible for participation. A total of 975 subjects participated in this study. At age 50 y (range: y), 736 persons participated, of whom 491 participated again at age 58 y. At age 58 y (range: y), 732 persons participated in the study, 239 of whom had not participated at age 50 y. The participation rates among those exposed to famine (49%) and among those not exposed to famine (40%) in utero did not differ significantly (P 0.7). The birth weights of persons included in the study (3353 g) did not differ significantly from the birth weights of those not included in the study (3341 g; P 0.6). Infants born after exposure to famine in late and midgestation were lighter and smaller than the unexposed infants, and their mothers weighed less at the end of gestation (Table 1). Age at onset of coronary artery disease A total of 83 subjects had developed CAD by the end of follow-up. We found an overall cumulative incidence of CAD of 9% in men and 8% in women. Persons exposed to famine in early gestation had the highest cumulative incidence of CAD (13%; sex-adjusted HR compared with unexposed persons: 1.9; 95%

CI: 1.0, 3.8) (Table 1). The cumulative incidence of CAD in those exposed to famine in late gestation (sex-adjusted HR: 0.8; 95% CI 0.4 to 1.6) and midgestation (sex-adjusted HR: 1.1; 95% CI: 0.6, 2.1) did not differ significantly from that of those unexposed to famine (8% after exposure in mid- and late gestation compared with 8% in unexposed persons). On average, CAD manifested 3 y earlier in those exposed to famine in early gestation (mean age: 47 y; interquartile range: 4551 y) than in those unexposed to famine (mean age: 50 y; interquartile range: 4557 y) (Figure 1). Men and women with CAD were lighter (3275 compared with 3360 g) and thinner (25.9 compared with 26.3 kg/m3) at birth and had a smaller head circumference (32.5 compared with 32.8 cm) at birth, although none of these differences was significant. After size at birth was adjusted for, the association between famine exposure in early gestation and CAD was not attenuated (HR: 2.0; 95% CI: 1.0, 3.8). Coronary artery disease risk factors The distribution of cardiovascular disease risk factors according to famine exposure during various stages of gestation among subjects at age 58 y is shown in Table 2. In addition to the results shown in Table 2, famine exposure during any period of gestation was associated with elevated glucose concentrations at 120 min (P 0.04; adjusted for sex and body mass index) and an elevated ratio of LDL to HDL (P 0.03; adjusted for sex). Adjustment for the 2 social risk factors in Table 2, smoking (adjusted HR: 1.8; 95% CI: 0.9, 3.5) and low SES (adjusted HR: 2.0; 95% CI: 1.0, 3.8), had little effect on the association between famine exposure in early gestation and CAD.
FIGURE 1. Kaplan-Meier curve of the cumulative incidence of coronary artery disease (CAD) in persons born before the famine (n 24); exposed to famine in late (n 12), mid- (n 11), or early (n 11) gestation; or conceived after the famine (n 25). The cumulative incidence of CAD was significantly greater in persons exposed to famine in early gestation than in those born before or conceived after the famine, P 0.05 (Cox regression). Downloaded from www.ajcn.org by guest on June 6, 2011
Maternal constitution and fertility There were no significant differences in maternal weight, age, parity, or SES at birth between persons with or without CAD. When these variables were entered into a multivariable Cox model, the association between exposure to famine in early gestation and CAD was little changed (multivariable-adjusted HR: 1.8; 95% CI: 0.9, 3.6).

DISCUSSION

We found that the risk of CAD before the age of 61 y in persons conceived during the Dutch famine was double that of unexposed persons. This association was independent of size at birth and of smoking and low SES. Of the 83 persons with CAD, those who were conceived during the famine were 3 y younger at diagnosis. Ours was the first study to describe the course of CAD in the offspring of mothers nutritionally deprived during early gestation. Women were less fertile during the famine (19). Those who did conceive may have been of a different constitution. However, the correction for markers of maternal constitution or fertility,
including maternal weight, age, parity, and SES, did not change the association of prenatal famine exposure with CAD. Selective participation of persons who were fit enough to attend the clinic and prior excess mortality among the most seriously affected persons may have led to an underestimation of the effect of prenatal famine on subsequent CAD progression. However, we believe that the estimate reported in this article is relatively accurate, because analyses of the prevalence of angina pectoris and history of coronary revascularization surgery among persons who were not able to visit the clinic, but who agreed to a home or telephone interview, yielded results in the same direction (RC Painter, SR de Rooij, and TJ Roseboom, unpublished observations, 2005). Moreover, there was no excess all cause or CAD mortality among people conceived in the famine (16). Although not statistically significant, persons with CAD were also lighter at birth than were persons without CAD. This finding agreed with results from other studies (1, 20). Suboptimal intrauterine growth has been described to have programming effects on many cardiovascular disease risk factors, including hypertension (21), impaired glucose tolerance
TABLE 2 Characteristics of men and women who participated in the Dutch Famine Birth Cohort Study at age 58 y1 Time of exposure to famine Born before famine Glucose at 120 min (mmol/L) Insulin at 120 min (pmol/L) Triacylglycerol (g/L) LDL:HDL BMI (kg/m2) Ever smoked (%) SES3
Late gestation 6.1.3 2.52 28.502
Midgestation 6.1.3 2.3 27.49
Early gestation 6.1.3 2.62 28.45
Conceived after famine 5.1.3 2.4 28.48
All subjects 5.9 2.294 1.3 1.0 2.4 1.0 28.3 4.48 14

Total n 721

5.1.2 2.3 28.46
All values, except for ever smoking, are geometric x or geometric x SD. Significantly different from those born before or conceived after the famine after adjustment for sex, P 0.05 (linear or logistic regression). 3 Socioeconomic status, determined by using the ISEI-92 (18).
in adults after prenatal exposure to the Dutch famine. J Am Soc Nephrol 2005;16:189 94. Roseboom TJ, van der Meulen JHP, Osmond C, Barker DJP, Ravelli ACJ, Bleker OP. Plasma lipid profiles in adults after prenatal exposure to the Dutch famine. Am J Clin Nutr 2000;72:1101 6. Roseboom TJ, van der Meulen JHP, Ravelli ACJ, Osmond C, Barker DJP, Bleker OP. Plasma fibrinogen and factor VII concentrations in adults after prenatal exposure to famine. Br J Haematol 2000;111:1127. Ravelli ACJ, van der Meulen JHP, Osmond C, Barker DJP, Bleker OP. Obesity at the age of 50 y in men and women exposed to famine prenatally. Am J Clin Nutr 1999;70:811 6. Roseboom TJ, van der Meulen JHP, Osmond C, et al. Coronary heart disease after prenatal exposure to the Dutch famine, 1944 45. Heart 2000;84:595 8. Gardner DS, Pearce S, Dandrea J, et al. Peri-implantation undernutrition programs blunted angiotensin II evoked baroreflex responses in young adult sheep. Hypertension 2004;43:1290 6. Gopalakrishnan GS, Gardner DS, Rhind SM et al. Programming of adult cardiovascular function after early maternal undernutrition in sheep. Am J Physiol Regul Integr Comp Physiol 2004;287:R1220. Fleming TP, Kwong WY, Porter R, et al. The embryo and its future. Biol Reprod 2004;71:1046 54. Edwards LJ, McMillen IC. Periconceptional nutrition programs development of the cardiovascular system in the fetal sheep. Am J Physiol Regul Integr Comp Physiol 2002;283:R669 79. Roseboom TJ, van der Meulen JHP, Osmond C, Barker DJP, Ravelli ACJ, Bleker OP. Adult survival after prenatal exposure to the Dutch famine 1944 45. Paediatr Perinat Epidemiol 2001;15:220 5. Painter RC, Roseboom TJ, Bossuyt PM, Osmond C, Barker DJ, Bleker OP. Adult mortality at age 57 after prenatal exposure to the Dutch famine. Eur J Epidemiol 2005;20:673 6. Trienekens G. Tussen ons volk en de honger. (Between our people and the famine.) Utrecht, Netherlands: Matrijs, 1985(in Dutch). Bakker B, Sieben I. Maten voor prestige, sociaal-economische status en sociale klasse voor de standaard beroepenclassificatie 1992. (Measures of prestige, socio-economic status and social class for the standard classification of occupations. ) Sociale Wetenschappen 1997;40:122(in Dutch). Stein Z, Susser M, Saenger G, Morolla F. Famine and human development. The Dutch Hunger Winter of 1944-45. New York, NY: Oxford University Press, 1975. Barker DJP, Osmond C, Forsen TJ, Kajantie E, Eriksson JG. Trajectories of growth among children who have coronary events as adults. N Engl J Med 2005;353:18029. Law C, Shiell A, Newsome C, et al. Fetal, infant, and childhood growth and adult blood pressure: a longitudinal study from birth to 22 years of age. Circulation 2002;105:1088 92. Lithell HO, McKeigue PM, Berglund L, Mohsen R, Lithell UB, Leon DA. Relation of size at birth to non-insulin dependent diabetes and insulin concentrations in men aged years. BMJ 1996;312:406 10. Curhan GC, Willett WC, Rimm EB, Spiegelman D, Ascherio AL, Stampfer MJ. Birth weight and adult hypertension, diabetes mellitus and obesity in US men. Circulation 1996;94:3246 50. Barker DJP, Martyn CN, Osmond C, Hales CN, Fall CHD. Growth in utero and serum cholesterol concentrations in adult life. BMJ 1993;307: 1524 7. Bloomfield FH, Oliver MH, Giannoulias CD, Gluckman PD, Harding JE, Challis JRG. Brief undernutrition in late-gestation sheep programs the hypothalamic-pituitary-adrenal axis in adult offspring. Endocrinology 2003;144:2933 40. Phillips D, Walker B, Reynolds R, et al. Low birth weight predicts elevated plasma cortisol concentrations in adults from 3 populations. Hypertension 2000;35:1301 6. Ward AM, Moore VM, Steptoe A, Cockington RA, Robinson JS, Phillips DI. Size at birth and cardiovascular responses to psychological stressors: evidence for prenatal programming in women. J Hypertens 2004;22:2295301. Vonnahme KA, Hess BW, Hansen TR, et al. Maternal undernutrition from early- to mid-gestation leads to growth retardation, cardiac ventricular hypertrophy, and increased liver weight in the fetal sheep. Biol Reprod 2003;69:133 40. Goodfellow J, Bellamy MF, Gorman ST, et al. Endothelial function is

(22, 23), and lipid metabolism (24). Consistent with our previous study of the Dutch Famine Birth Cohort, persons conceived during the famine had higher plasma glucose concentration at 120 min and higher ratios of LDL to HDL cholesterol than did persons who had not been exposed to famine in utero. It is possible that the effects of famine on CAD are mediated through these 2 biological risk factors. It was not possible for us to explore the effect of these risk factors on CAD incidence because, for many subjects, we did not have measurements from before the onset of disease. Moreover, many of the subjects were being treated for type 2 diabetes or hypercholesterolemia. There are many possible processes by which persons conceived in famine could have increased rates of CAD. Slow intrauterine growth has been shown to be associated with hormonal axis programming (25, 26), alterations in cardiovascular control mechanisms (11, 12, 27), altered myocardial structure (28), endothelial dysfunction (29), and accelerated atherogenesis (30). In future studies we hope to elucidate the role of these factors in the pathophysiology of coronary artery disease after prenatal famine exposure. Persons conceived in famine not only had a higher cumulative incidence of CAD, but the disease occurred at an earlier age. Models in which animals were prenatally nutrient restricted had premature aging (31) and more rapid age-related progression of the biological risk factors of CAD (32, 33). There is some evidence of an association between low birth weight and increased aging rates in human studies too (34, 35). Although little research has been carried out elucidating the underlying mechanisms, Jennings et al (36) suggest that telomere shortening induced by prenatal undernutrition may be responsible for the premature senescence of tissues such as the liver and kidney. These studies also pointed out that catch-up growth, such as that which may have occurred in fetuses conceived during famine but exposed to adequate nutrition during the remainder of gestation, could result in further telomere shortening. In summary, our findings suggest that maternal nutrition in early gestation may play an important role in the course of CAD. This suggestion is in line with evidence from animal experiments that identified preconceptional and preimplantation maternal diet as important for the offsprings adult health (1114).
We are grateful for the willing cooperation of all participants. OPB, TJR, PMB, DJB, and CO conceived of and planned the study. RCP, TJR, SRdR, and TAS carried out the study. RCP, CO, and DJB performed the statistical analyses. All authors critically discussed the results. None of the authors had a conflict of interest.

13. 14.

17. 18.

REFERENCES

1. Barker DJP. Fetal origins of coronary heart disease. BMJ 1995;311: 171 4. 2. Hoet JJ, Hanson MA. Intrauterine nutrition: its importance during critical periods for cardiovascular and endocrine development. J Physiol 1999;514:61727. 3. Harding J. The nutritional basis of the fetal origins of adult disease. Int J Epidemiol 2001;30:1523. 4. Stanner SA, Bulmer K, Andres C, et al. Does malnutrition in utero determine diabetes and coronary heart disease in adulthood? Results from the Leningrad siege study, a cross sectional study. BMJ 1997;315: 13429. 5. Ravelli ACJ, van der Meulen JHP, Michels RPJ, et al. Glucose tolerance in adults after in utero exposure to the Dutch Famine. Lancet 1998;351: 1737. 6. Painter RC, Roseboom TJ, van Montfrans GA, et al. Microalbuminuria
impaired in fit young adults of low birth weight. Cardiovasc Res 1998; 40:600 6. Martyn CN, Gale CR, Jespersen S, Sherrif SB. Impaired fetal growth and atherosclerosis of carotid and peripheral arteries. Lancet 1998;352:173 8. Ozanne SE, Hales CN. Lifespan: catch-up growth and obesity in male mice. Nature 2004;427:4112. Petry CJ, Dorling MW, Pawlak DB, Ozanne SE, Hales CN. Diabetes in old male offspring of rat dams fed a reduced protein diet. Int J Exp Diabetes Res 2001;2:139 43. Nwagwu MO, Cook A, Langley-Evans SC. Evidence of progressive

30. 31. 32. 33.

deterioration of renal function in rats exposed to a maternal low-protein diet in utero. Br J Nutr 2000;83:79 85. 34. Law CM, Swiet de M, Osmond C, et al. Initiation of hypertension in utero and its amplification throughout life. Br J Obstet Gynaecol 1993;306: 24 7. 35. Aihie Sayer A, Cooper C, Evans J, et al. Are rates of ageing determined in utero? Age Ageing 1998;27:579 83. 36. Jennings BJ, Ozanne SE, Dorling MW, Hales CN. Early growth determines longevity in male rats and may be related to telomere shortening in the kidney. FEBS Lett 1999;448:4 8.

Findings). All aspects of the study with the exception of the preparation of the Final Report were completed between April and December 2002.
The Definition of Poverty and its Measurement
Definitions of Poverty Literature on the nature and definition of poverty abounds to the extent that it is not possible for this or any other CPA to review this work in any detail. A realistic starting point can be provided by citing some of the definitions used: The condition of being without adequate food, money, etc. The Collins English Dictionary (Having) an income which, even if adequate for survival, falls radically behind that of the community as a whole J.K. Galbraith, 1962 (The) inability to attain a minimum standard of living World Bank, 1990 (The) pronounced deprivation of wellbeing World Bank, 2000 (The) deprivation of essential assets and opportunities to which every human being is entitled Asian Development Bank, 1998. At some risk of over-simplification, recent definitions of poverty are more allembracing in nature, incorporating concepts such as voicelessness, powerlessness, vulnerability, lack of self esteem and lack of opportunity, rather than being confined simply to the inability to satisfy basic consumption requirements. For the purposes of this study, the concept of wellbeing is considered to be a useful general term to bracket non-income aspects of poverty such as those described above.
Income and Non-Income Poverty In general, there will be a high correlation between lack of income and lack of wellbeing people and households with inadequate income are likely to be suffer from an increased vulnerability to changing economic and social circumstances, reduced income-earning potential, inadequate housing, lack of basic infrastructure (safe water, electricity, reasonable road access), susceptibility to household
disruption due to domestic violence, teenage pregnancy, drug use, HIV/AIDS. The converse will also be true more often than not not poor households are far less likely to be affected by loss of wellbeing. However this correlation is far from total. On the one hand, low income communities or cultures (urban and rural) may not consider themselves to be poor (We are poor but we are not in poverty) if they consider that their basic needs (food, utilities, employment, etc.) are being met and if they see their local community as supportive and non-threatening. On the other hand, higher income households may experience a serious lack of wellbeing if they are affected by social problems of a general (e.g. endemic crime/ violence or racial discrimination) or intra-household (e.g. drug use, domestic violence and abuse as in suburban America or Europe) nature. Another way of looking at this group is that they are sources of potential future poverty if current problems are not attended to, i.e. these problems could result in loss of income thereby causing the household to slip into income poverty. Either way, any poverty assessment should not confine itself to an assessment based on income criteria alone but should address issues related to loss of wellbeing which are not always directly associated with income poverty. In very poor countries where income poverty is high and a high proportion of basic needs are unmet, a poverty assessment needs to be slanted towards this aspect. On the other hand, in more affluent countries, such as Anguilla, there should be greater emphasis on the non-income aspects. 1.4.3 Absolute and Relative Poverty The Galbraith definition cited above is notable in that it introduces the notion of relative as opposed to absolute poverty. Absolute poverty implies a standard below which the household could not survive in a healthy or satisfying way. In contrast relative poverty is concerned with the inequality in incomes (or consumption) between different groups with no reference to the level of actual income. There are advantages and disadvantages of both approaches. Approaches to poverty based on absolute poverty are generally easier to conceptualise all that is

Source: Princess Alexandria Hospital (the only hospital in Anguilla) and Statistics Department
Between 1995 to 2001, the leading cause of death was disease of the circulatory system (such as hypertensive disease, ischemic heart disease and cerebrovascular
disease) varying between 40 to 60% of all deaths followed by neoplasms. Death due to infectious and parasitic disease is very low - between 0 to 10% of all deaths between 1995 and 2001. This was corroborated in interviews with health officials who considered that the major health problems facing Anguilla were hypertension (18% of the population), diabetes (14% of the population) and obesity. Obesity and to some extent diabetes are related to the lack of physical activity and overconsumption of processed or refined foods - most of the food eaten in Anguilla is imported. Although mortality trends are hard to ascertain due to the small number of occurrences, there is no evidence of a poor or deteriorating health situation. Table 2.4 provides a summary of other key health data for Anguilla. A comparison with other countries is provided. This table indicates that Anguilla has a high life expectancy and provision of health facilities (physicians, hospital beds) comparable to other countries in the region. Table 2.4 Health Statistics Selected Countries
Health Statistic Life Expectancy Rural pop w/access to safe water % Rural pop w/access to excreta dis. % National Health Expend* p.c. $US NHE as % of GNP Physicians per 10,000 pop. Hospital beds per 10,000 pop. Anguilla 74.3 c. 97 c. 4.2 17.5 30.6 BVI 72.8 97.n.a 3.9 11.5 n.a Dominica 77.6.6 4.93 35.9 Barbados 76.6.6 12.8 74.1 Jamaica 74.5.4 13.USA 76.8 n.a 99 3,858 13.1 26.5 5.2
Source: Pan American Whole Health Alliance, Pan American Health Organisation, World Health Organisation, 1996 1998.
For the first time the 2001 Census contained questions on disabilities, illnesses, medical services and insurance coverage. No comparative data therefore exists. A review the information from the 2001 Census reveals the following: 5.3% of the population responded that they have a disability or a long-term illness. Nearly a quarter of those with disabilities are 65 or over. With regard to assistance for their disability, 77% of those who responded received no assistance;
13% of respondents who used a medical facility during the past year used a hospital overseas and 4% used the hospital or clinic in St Martin. Most people used a private doctor in Anguilla (29%) or either the hospital or Public Health Centre (25% each). [This implies that health statistics compiled in Anguilla may not give a complete picture of health conditions in the country]; and with regard to life and health insurance coverage, 57% of respondents indicated that they had either one or the other or both with coverage higher for the working age population. 90% of Government employees indicated they had insurance coverage but it was much lower among the self employed (between 40 and 60%).

Q3 17,3.5 48,200 14,000 23% 17.7% 36.6%
Q4 33,2.7 64,500 23,900 20% 23.7% 60.3%
Q5 Over 33,1.9 108,900 58,500 12% 39.7% 100.0%
ALL 587 3.1 54,700 47,000* 17,600 13,900 * 19% 100.0%

12.4% 18.9%

Source: SLC, July 2002.
Consumption = household expenditure + gifts in kind + consumption of home produced goods. In practice, in Anguilla, there is
next to no home production. Consumption is conventionally used as the primary indicator of poverty in preference to income which is harder to assess, subject to greater fluctuations and cannot be disaggregated into food and non-food components. In this report, the terms expenditure, consumption and spending are treated synonymously.
Quintiles are obtained by first sorting the households by per capita income and then dividing them into 5 equal groups derived
by dividing the households into 5 equal groups. The first quintile (Q1) represents the 20% of households with the lowest per capita expenditures through to Q5 which represents the 20% with the highest spending.
Estimation of Poverty Lines
The Minimum Cost Food Basket The basis of poverty line estimation is the specification of a Minimum Cost Daily Food Basket (MFB) for an adult to achieve a diet of 2,400 calories per day taking into account local dietary preferences and the need for a balanced diet. The MFB used in this study4 has been prepared by the government nutritionist based on food baskets used for previous CPAs and knowledge of local dietary characteristics. Prices were derived using the current Consumer Price Index and visits to local supermarkets, where the great majority of food on the island is purchased. The computations were made using proprietary Caribbean Food and Nutritional Institute (CFNI) software. The total cost of this basket is EC$8.40 per day or $3,066 per annum for an adult.
The Indigence Line The indigence line is defined as the cost of the MFB. Adults with total expenditure below this amount, i.e. EC$3,066 per annum, are classified as indigent, or extremely poor. Essentially they are unable to satisfy their basic food needs. In determining whether or not a household is indigent, account is taken of the number and age of children5 in the household as well as the number of adults (18 years and over). Using this data, a household indigence line (HIL) is established for each household. Households with total expenditures below the HIL are categorised as indigent. The HIL for a model family of 2 adults and 2 children under 13 years would be around $7,700 which is almost 40% lower than if no adjustment for household composition was made. The concept of a model household is however problematic as only 1 in 6 households have 4 persons, only some of which will have 2 adults with 2 small children. As noted in the previous paragraph, the HIL for each

Table 3.4 Comparative Poverty Indicators
Headcount Poverty Gap Poverty Gap Squared
Country Anguilla Dominica BVI Turks and Caicos St Kitts Nevis Grenada St Vincent St. Lucia
Survey Year Households 1999/2000 1999/1995 1995

Population

20% 29% 16% 18% 16% 16% 29% Na Na
23% 39% 22% 26% 31% 32% 32% 38% 25%
6.9 10.2 4.1 5.7 2.5 2.8 15.3 12.6 8.6
3.2 4.8 1.7 2.6 8.9 10.0 9.9 6.9 4.4
.31.35.23.37.40.37.45.56.5
Source: As for Table 3.2.
In terms of population, the incidence of poverty in Anguilla is the lowest of all the above countries apart from BVI (see Figure 3.1). The incidence of household poverty, the more relevant concept, is however higher than in BVI, Turks and Caicos, St Kitts and Nevis. The difference in ranking represents the variation in household size between poor and not poor households (it is extremely high in St Kitts and Nevis). It should also be mentioned that the non-food component of the poverty line is much higher in Anguilla than in St Kitts and Nevis; in consequence, poor households in Anguilla are likely to have a higher standard of living than poor households in St Kitts and Nevis. In terms of the other indicators, Anguilla fares well both the poverty gap measures and the Gini coefficient are lower than those in most of the other countries in the table implying both that the severity of poverty is lower in Anguilla and that the distribution of expenditure is more even.
Figure 3.1 Comparative Poverty
38% 35% 31% 32% 32% 29% 26% 25%

% of Total

22% 18% 16% 16% 16% 19%

20% 20%

ANGUILLA

Dominica

Turks & Caicos

St Kitts

Grenada

St Vincent

St. Lucia

Poor Households

Poor Population
Characteristics of Poverty in Anguilla
In this sub-section, we examine the characteristics of the poor population in Anguilla as a whole. The majority of tabulations presented below are for the poor and the not poor populations. Tabulations by expenditure quintile are contained in Volume 2.
Demographic Characteristics (a) Age and Sex Table 3.5 summarises how the age and sex of the population varies between poor and not poor households.

Case Study 2 Teenage Mother living with her family K is a 15 year old mother with a one year old daughter. They live with her mother and younger brother in a two-bedroom house that her mother has recently built. The discovery of Ks pregnancy was traumatic. She was enjoying secondary school, doing well academically and had many friends. When she was 14 years old she found that she was 5 months pregnant. She reports that her friends suspected the pregnancy, teased her about it and informed the teacher who took her to the clinic. After the confirmation of pregnancy she was taken to the police station and her mother was called. K reports she felt worried and that her mothers reaction was initially very negative she cursed me as was that of her father and grandmother. They have subsequently become very supportive, however. During her 6
month of pregnancy, K left school because she felt bad about being there. Her friends
stopped speaking to her when they learnt about the pregnancy and this made things very difficult for her. However, she returned to school after childbirth, repeated third form and intends to continue with her education. K feels ambiguous about her status as a mother. She states that she feels a little bit good, but remarked that motherhood helps a lot. When not at school, she no longer socialises with her friends and spends her time cleaning, doing housework and playing with her daughter. She feels badly about this and reports being lonely at times, although she spends time with her brother and a younger sister who lives elsewhere. K has no contact with the father of her child, though he is legally mandated to pay child support through the Department of Social Development. Her mother provides the major source of support, providing for most material needs. Previously, her grandmother took care of the baby during the day, but since K moved to live with her mother, she has found another woman whom her mother pays for child care. K feels that her pregnancy while at school was not good, I had to come out of school, but that she is getting through life OK. She has a positive and very supportive relationship with her mother, but would like to look for a job with her mother after graduating from school and provide for her daughter with her own money. She thinks about being married in the future and wants her daughter to have a good life - when she go big she go look for a job.
Case Study 3 Middle-aged single mother with large family
F is a 44 year old single mother of ten children (7 boys and 3 girls) ranging in age from 9 to 23 years. She lives with 8 of her children and a male partner who has recently moved in. Her four room house is built on land given to her by her father. There is no running water, no bathroom and no cistern. To alleviate overcrowding, F subdivided one bedroom with a wooden partition. One of her sons sleeps on a couch in the living area. F married when she was 18 years old, having already given birth to one child which was being raised by her mother. After 12 years of marriage her husband suddenly went abroad, leaving her with eight children to raise. There has been no further contact and no economic support. She subsequently became involved with another man with whom she had two more children. He was abusive and, after an incident during which he stabbed and beat her with a broken bottle, he was deported. After that F struggled hard to raise her children alone. She never had what to give them and had to look for bread for them to eat. Her work in a restaurant kitchen enabled her to take home food, but this was deducted from her pay at the end of the week, so that no money was left. When her son became sick, she was forced to leave the job and depended on doing favours or chores for friends in exchange for which she would get food, or a piece of clothes or a twenty dollars. What I went through I wouldnt wish on a dog. I didnt have current (electricity), didnt have nothing. We would be in darkness. When I got a little money I would buy some kerosene oil. At present, she also receives EC$600.00 from Public Assistance most of which is spent on food, though she also manages to pay her phone and electricity bill. Other than this F receives little help and depends on charity. Her relationship with her mother, who took care of the children while she worked, has deteriorated badly. There is little contact between them. Her present partner is chronically ill and unable to work, though he helps with chores. Her two eldest boys have left school early, are unemployed and can neither read nor write. She worries about their future but feels helpless to intervene claiming she grew tired of struggling to pay for books, uniforms and lunches and that if they want to come out and fight for themselves, I cant stop them. Her two eldest daughters are also unemployed. One has four children, the other three. Fs health is poor. She has arthritis, high blood pressure and has been experiencing back pains. The doctor attributes this to kidney problems, but she has not followed through on tests because she cannot afford these and does not want to know. The knowledge would make me sicker and probably kill me. She already has an outstanding bill of EC $400.00 for her sons medical treatment and hospitalisation. F is depressed and often feels suicidal - I dont have a drop of water, nothing. I does cry a lot. Asked about the future, she replied I want to go home and rest my tired body. I want to dead. I dont want to be here.

The Working Poor Statistically speaking, the working poor constitute the largest sub-group of the poor in Anguilla around 70% of poor households in Anguilla have at least one person working and 30% have 2 or more workers. (a) Employment Characteristics Employment characteristics of the working poor were presented in Tables 3.10 and 3.11. These showed greater concentrations of the working poor in the tourism sectors and in manual and service occupations. These jobs tend to be amongst the lowest paid (Table 3.17): in the hotel and restaurant sector, wages are 70% of the overall median; for domestic workers, the wages are lower still, at 55% of the median level. Table 3.17. Additional Characteristics of the Working Poor
Employment Income Hotel and restaurant workers Domestic worlers Other indicators % workers working less than 30 hours per week % workers less than 8 months per year % HHs with all workers in tourism sector

from SLC.

Median income EC$1,402 EC$1086 Poor HHs 19% 26% 26%
% of overall median (EC$2010) 70% 55% Not Poor HHs 11% 13% 15% ALL 12% 21% 17%
Source: Income data from 2001 Census (Report on Economic Activity, Tables 16/17); other data
Table 3.17 also indicates that poor households are more likely to be wholly dependent on the tourism sector, and have workers who either work part-time during the week and/or are not employed continuously throughout the year16. Low and inadequate income from a primary job results in the survival strategy of multiple occupations17 as the poor seek to identify several simultaneous sources of income. Men, for example, may supplement income from construction with fishing or gardening. Poor women18 who bear the triple burden of child care, housework and income generation, will earn small sums by engaging in menial work, for example, preparing or growing and selling food on the road-side, braiding hair, baby sitting or breaking stones for house construction. Mention was made of the negative effect that the absence from home of parents who are working double shifts has on family life. (b) The High Cost of Living The situation of the low paid is exacerbated by the high cost of living. All food is imported and subject to import duties; as a proportion of income, this type of taxation falls heaviest on the poor. The quality of the land and the high cost of water make it virtually impossible to supplement diets with home-grown produce, as occurs in many other countries. Part-time fishing does provide an important source of additional protein (or income if marketed) but it is also seasonal. Utility costs (water and electricity) are high and recent increases in water rates will have a greater negative impact on the poor, while the cost of electricity prevents the poorest families from accessing this basic necessity of modern life. Housing costs are significant for those renting the median monthly rent for a 2-bedroom house is EC$536 although several dilapidated houses rent for less.

Non-Anguillian Households (a) General As a result of its rapid economic growth, Anguilla has attracted migrants from neighbouring Caribbean countries and especially those facing economic problems, such as the Dominican Republic, Jamaica and Guyana. A special group of immigrants also arrived from Montserrat, displaced by the volcanic eruptions, though many of them have since returned. There is also a small minority of Americans and Europeans, most of whom are affluent and many of whom are retirees. In local parlance, migrants are referred to as non-belongers, a term which has acquired pejorative connotations. Non-Anguillian households now comprise around a fifth of all households. However the incidence of poverty, at 10 %, is much lower than amongst Anguillian households (23%); there are also no indigent non-Anguillian households. This is not surprising as migrants require work permits to remain in Anguilla and these are conditional upon a job offer. Migrant households are also less likely to have young or elderly dependents and are thus smaller 2.5 persons as opposed to 3.3 persons in Anguillian households. There are however specific circumstances that affect migrants sense of wellbeing and make them vulnerable to poverty. (b) Employment The great majority of the adult migrants are employed. Many have found jobs in the tourist industry or are self-employed as semi-skilled artisans whilst others are involved in teaching and other professional/ managerial occupations (see Table 2.11). Most do not cite lack of income per se as a major issue. Instead their major concerns are with what they perceive as wage discrimination against them and with their exclusion from public sector employment, which they feel is reserved for Anguillians. This, they argue, excludes some of them from jobs, which provide higher and more regular (weekly or monthly) remuneration. They also feel that they have no redress against sharp practices by employers19.
It should be noted that similar complaints were voiced by Anguillian informants
The Spanish-speaking Dominicans also correlate the inaccessibility of employment with language difficulties. Those who have not mastered English at school do poorly in terms of academic qualifications and subsequently in the job market. (c) Housing and Transportation Over 80% of non-belongers rent accommodation and they occupy over 56% of all rented properties. Renting can put a strain on scarce financial resources. High rental costs20 and pressure on available housing also mean that lower paid migrant households end up in housing which is over-crowded -almost a quarter of immigrant households are overcrowded which is almost double the proportion of overcrowded (over 2 persons per room) Anguillian households. Migrants from the DR appear to be the worst affected by residential overcrowding and they also mentioned the poor quality of available residences, referring specifically to the lack of running water, the absence of bathing facilities, pit latrines and occasions when they had to use the bush. While vehicle ownership among immigrants is similar to that among Anguillians, the absence of public transportation makes life difficult for those not owning vehicles. This is not however a problem specific to immigrants. (d) Health and Education In terms of health services, migrants from the DR expressed concern at discrimination in fees, arguing that they pay higher rates than Anguillians, with the result that they often felt the need live with it (the health problem) or to return to the DR for medical treatment. There are no formal restrictions to access to education for migrants. Although the Spanish-speaking children of migrants from the DR start at a disadvantage, remedial English classes are provided although not always by people trained in teaching English as a second language. However, younger migrants also voiced the

On average rent constitutes around 20% of total household expenditure for migrants from the Caribbean. In 17% of cases
however, rents exceed 30% of their spending. The proportions for Anguillian renters are slightly lower.
opinion that there was no point in attending and doing well at school since jobs were not available to them. (e) Immigrant status, social exclusion and community Immigration problems and uncertain residential status were cited as major causes for concern. Several migrants spoke of what they perceived to be the tightening of restrictions, the shortened time given for their stay in Anguilla and the cost of work permits. Their own lack of knowledge of immigration policy combined with what they perceived to be changes in the regulations exacerbates confusion and uncertainty. Migrants from the DR, in particular, claimed entitlement to Anguillian status through family members, including grandparents, who had originally migrated from Anguilla to the DR. They were acutely resentful of their non-belonger status and consequent stigmatisation and social exclusion. Informants report that they are resented by locals who ask the rhetorical question Spanish, what you doing here? In response, members of the DR focus group claimed: We are not here to take over the island and we should have equal rights as any citizen living in Anguilla. This is linked to the problems mentioned above relating to language, employment and housing. Migrants from Montserrat also felt isolated, claiming that they did not choose to come to Anguilla, and that, as forced migrants from volcanic disaster, they should be made to feel more welcome (see Case Study 6). On the other hand, non-belonger groups tend to be close knit and mutually supportive. This is particular apparent among those from the DR who generally live in the same geographical areas and provide accommodation, information and other supports for each other, new comers in particularly, either informally or through the Dominican association. In this context, it should also be noted that the Social Development Department receives few requests for assistance from non-Anguillian households.
Case Study 6 A Poor Non-Anguillian Household Ms. L is a 72 year old Montserratian. She migrated to Anguilla in 1995 after the volcano erupted and she lost all her property. She is a widow and lives with her son. They rent a two room house in which she feels she lacks sufficient privacy as a woman. She indicates, however, that she can afford no better and is making do. The rental is EC $300.00 per month. The house has a bath, but no running water. There is a cistern in the yard which is refilled with water every two months at a cost of EC$ 80.00. Electricity which is fed into the house with a drop cord costs EC$ 80.00 per month. The relocation grant that she received from the British Government of EC $250.00 a month came to an end in March 2002. Without this sum, she finds her basic living costs very difficult to manage and reports that she is enduring much hard times in Anguilla. Making matters worse, her son is out of work due to a down turn in the construction industry. There is also the need to go to the shop for everything and the high cost of food and other essentials. She finds that no matter how hard I try the minimum I spend each week is 200 dollars. In Montserrat, by contrast, she was able to grow much of her own food and keep livestock and poultry in her back yard. In addition, old age, declining health and her difficulty walking any distance, along with the absence of public transportation, require her to hire taxis, a costly undertaking. Health care constitutes another source of high expenditure. She suffers with diabetes and hypertension and has to visit the clinic weekly for tests. As a non-Anguillian, the cost of medical attention and hospitalisation is considerably higher than she previously paid in Montserrat. She complains bitterly that, as a national of an Overseas Territory, she should not be discriminated against in terms of medical fees. While Ms. Ls troubles are mainly financial, she is also troubled by the loss of family and friends since her migration from home. She, however, indicates that some persons in her neighbourhood do try to make her feel at home and she has no plans to return to Montserrat.

(c) Assessment SDD is concerned with the long term effectiveness of its poverty reduction programmes. Firstly, SDD struggles with under-resourcing. There are 6 fieldworkers, 4 of whom have some social work training. Resourcing issues are exacerbated by having to deal with increasing numbers of cases which are not considered to have a strong social welfare basis, e.g. requests for overseas medical treatment and overseeing child maintenance and support. The lack of field staff has also meant that there is no adequate means to collect statistical data. SDD officers therefore do not have a clear understanding of the effectiveness of the assistance programmes and whether these activities are actually reducing poverty. Concern was also raised that poverty reduction was mostly being dealt with in the form of immediate tangible aid. The short-term sticking plaster approach was not considered to have an impact on reducing poverty on a long term basis primarily due to its failure to address the root cause of the situation of the poor and vulnerable. This approach did not facilitate a proper assessment of a persons needs. Once the immediate problem had been dealt with no monitoring of the outcomes occurred. The third concern was the politicisation of the provision of public assistance that has generated high expectations by some sections of the general public of having their requests met. Others have become accustomed to seeking personal political intervention to facilitate requests. This makes it difficult for SDD to identify and then target longer-term poverty needs. SDD indicated that few if any immigrant/ non-belonger families use their programmes because of the lack of dependents in non- belonger families, high rates
of employment and the social/ community support systems which operate within these groups. In discussions with representatives of immigrant groups, different reasons were given which primarily related to an understanding that they were not entitled to SDD programmes. Further, cases were cited where immigrants and those with non-belonger status were turned away from seeking help or were treated diffidently or brashly by government officials. Although SDD has indicated that programmes are available to those with belonger and non-belonger status there is a strong perception within immigrant groups that this is not the case. Information dissemination or round table discussions between government officials and immigrant representatives could assist in overcoming current perceptions. Some activities suggested by SDD which could to redress the above concerns include: provision of programmes geared to money management, debt management, household budgeting and living on limited incomes that could offer self help and assistance for people to control their own finances and manage on low incomes and equip people with a life tool to help them help themselves; a means to identify the most needy and vulnerable households so that actions and programmes could be better targeted to those households and the programmes could be better designed to meet their needs; and those who receive Public Assistance and other financial assistance should have a designated worker to assess overall needs health, housing, childcare etc and make appropriate referrals to the other agencies where necessary.

The immigrant support group representatives highlighted the social welfare implications of non-belongers, perceived discrimination in being unequally entitled to government welfare, health and education services, the lack of clarity with tenure rights including rental arrangements, and general problems with conditions of employment abuse and not having recourse to the legal system to redress the situation. Again the perception was a lack of access to government services. It was considered that this lack of clarity had added to the financial burden of some immigrant families making them vulnerable to financial hardship. 4.5.4 Inter-Agency Co-ordination In general there is good co-ordination between SDD, the PHCD and the Education Department. NGOs also indicated that their relationship among themselves and with government departments was generally acceptable. In discussions with officers from all three government departments and NGO representatives it was considered that social problems in Anguilla are generally comparable to those which would be found in any developed country declining family support for the elderly, drugs, domestic violence and one parent households. No particular problems were seen as particularly Anguillian and no problems were overwhelmingly more pronounced. Two problems which were highlighted were firstly, boredom amongst the youth they need something to do, and secondly, lack of family support for the elderly. All indicated that poverty was thought to reduce expectations and self esteem rather than produce deviant behaviour.
Implications for Future Poverty Reduction Programmes
With the exception of the work of the Social Development Department, the NGOs and the activities related to Special Educational Needs, programmes of the institutions reviewed in this Chapter do not explicitly target the poor. The great majority of the programmes described in this Chapter are geared to the Anguillian population as a whole. As a result of these programmes, access to primary and secondary education and to most health services is available to all. Furthermore, several of the achievements of these programmes have occurred in the last 10 or so years both the SDD and the PHCD have been in existence for less than 10 years.
The primary reason for this situation is that poverty as such has not been perceived as serious enough to merit more pro-active interventions. This is largely borne out by the conclusions of the analysis of the current level and characteristics of poverty on the island: the incidence of severe income poverty is very low, and the incidence of social problems revealed by the PPAs only very rarely affect more than one household in 10; the majority of poor families have at least one person working; the poor do not suffer from significantly worse access to health and education services; their housing and utility provision is almost always of a reasonable standard; and many possess durable goods typical of a modern society.

Action IV3: Undertake Needs Assessment Studies The needs of the indigent and the vulnerable vary considerably: the elderly have completely different requirements to single parent households; and, for example, some elderly households will have very different needs from others. In many cases, non-financial assistance will be just as important as direct income support. The objective of these studies would be to assess the needs of the indigent and other client families of SDD in terms of housing, utilities, water, assistance with transportation, child care and support, employment. Results would then be discussed at case conferences with other relevant agencies in order to identify the potential for assistance, to develop small scale assistance programmes (e.g. meals on wheels, home visits, child care, transport) and to better target existing programmes and NGO activities. Action IV4: Increase the involvement of NGOs in identifying poor and vulnerable households The NGOs already provide a valuable service in this respect. This role should be formalised so as to ensure that all indigent and vulnerable households are known to the authorities who can then take remedial measures. Action IV5: Develop links between SDD and employers The needs assessments (IV3) will identify the working potential within indigent and vulnerable households. The objective of this proposal is to provide a direct link between this information and potential employers who might have vacancies. The small size of the island and the limited number of potential beneficiaries is considered to make this a feasible approach.
Action IV6: Strengthen procedures for Child Support This action is considered a priority given that inadequate and irregular child support payments are a major cause of poverty and vulnerability to single parents. 6.3.3 The Unemployed and the Underemployed Unemployment in Anguilla is currently low although it appears to have increased slightly since September 11. Employment on the island is highly dependent on the tourism industry and unemployment will thus increase if this sector does not recover quickly. The following Actions will contribute to alleviating any increase (see also IV5). Action U1: Promote Small Scale Job Creation Develop programmes for apprenticeships, household (gardening, handy-man jobs), and personal (baby sitting for working mothers, shopping/ transport assistance to the elderly). Action U2: Develop Micro-credit Investigate with the commercial banks and the ADB the feasibility of small loans to buy equipment to support Action U1 (e.g. credit for purchasing lawn mowers). Action U3: Promote Small-Scale Cultivation and Hydroponics Such schemes are currently being investigated by the Ministry of Agriculture (with UNDP support) for the hydroponics. They would provide a valuable supplement to incomes and/or reduce food costs, especially for low income families. 6.3.4 The Working Poor A significant number of the working poor are likely to be covered by some of the Actions proposed for the vulnerable and the indigent. The following priority Actions will however benefit this group as a whole.

World Bank, World Development Report1990 Poverty, 1990 World Bank, World Development Report 2000/2001 Attacking Poverty, 2001