Archive for the 'Food & Nutrition' Category
September 4th, 2012 by Matthew Anderson
Sarah Weniger of LearnStuff.com passed on an info-graphic about government subsidies for corn and their negative health and environmental effects.
Created by: www.LearnStuff.com
US subsides to ethanol production ended last year and US subsidies to all agricultural products are under threat at the World Trade Organization. If you are interested in activism in this field, US PIRG (Public Interest Research Group) has a campaign to stop subsidizing obesity.
Readers with an interest in this topic may also want to look at the food and agriculture section of Corporations and Health Watch.
posted by: Matt Anderson, MD
January 11th, 2012 by Claudio Schuftan
| December blog
This month, I look forward to a world conference being held next June, in Rio de Janeiro. This is the ‘Rio+20’ Conference on Sustainable Development, whose website is at http://www.uncsd2012.org/rio20/
The overarching declared purpose of Rio+20 is once again, to raise consciousness of and arouse conscience on the environmental dimension, which until late last century was more or less forgotten. Veterans of world summits on any topic have reason for scepticism, but they are needed, and we must all do our best to see that Rio+20 really does mark a time when we all move towards living in ways that are fair and sane.
Adequate good nutrition is smack in the middle of sustainable development. Neither is possible without the other. But as I consider these issues, like you, I am also reflecting on what has been and is happening this year in the streets all over the world. This year has been and is one of direct action, and I believe that the unrest, riots and uprisings that we see and that some of us have experienced, whatever their immediate and obvious cause, all have a core mood in common. This is awareness that we are living in a world whose political and economic governance – or rather lack of governance and surrender to corporate greed – has gone wrong and has broken down.
The prevailing governance structure of the globe ignores the several crises the planet is facing, as well as the social determinants behind them. Food insecurity (1), preventable child and maternal deaths (2), price Barriers to accessing medicines (3), collapsing health systems (4) share the fact that we do have enough resources to provide for them, but these resources instead flow to over-consumption. Military expenditure and obscene wealth for a small elite (5).
Food prices including those of staple foods all over the world remained stable from 1990 to 2007; since then, prices have rocketed and fluctuated wildly. One reason, as pointed out by Olivier De Schutter, the UN special rapporteur on the right to nutrition, is the recent vast increase of speculation in food commodity futures prices. The results, early this year, were food riots in many impoverished countries, leading to uprisings in North Africa that threatened and toppled governments.
My point here is that the triggers for the unrest that escalated very rapidly in a number of grossly unjust societies, were uncontrolled and chaotic food prices, in countries whose rulers had failed to protect their people by the use of regulations and controls that could have stabilised the cost of staple foods, as wise rulers throughout history have done.
| NUTRITION AND SUSTAINABLE DEVELOPMENT
WE NEED TO HEAR WHAT THE PEOPLE ARE SAYING,
AND ‘THE PEOPLE’ SHOULD INCLUDE US.
THE CURRENT SYSTEM OF GOVERNANCE IS BROKEN.
The latest manifestation of this year’s phenomenal series of direct actions is the Occupy Movement, which includes the Occupy Wall Street movement. This began in the South in Kuala Lumpur, Malaysia on 30 July, spread to Zuccotti Park in New York on 17 September, and by early November had spread to 600 communities in the US and around 2,500 cities worldwide. Occupy is now supported or endorsed by political and other leaders even up to head of government level in many countries, including in the US and in the BRIC countries of Brazil, Russia, India and China.
The protests are against what is now often accurately termed ‘casino capitalism’. This monster has been created by what still remains the orthodox political and economic system known as ‘freeing the market’, which is technobabble for surrendering the responsibilities and duties of government, and letting transnational corporations use increasingly lenient laws they believe will increase their profits.
Until this abuse of governance is stopped and reversed, world summits on the environment, climate change, prevention of diabetes, cancer and heart disease, or the war on world poverty, are really hot air. They are also duplicitous, because the officials who organise them must surely be well aware of the big issue that is driving environmental wreckage, the melting of the Arctic and Antarctic ice-caps, and the outrageous combination of obesity, poverty and deficiency.
Eating the planet and having it
Whether we are policy-makers, professionals, citizens or consumers, or any combination of these, we won’t make progress with the idea of ‘sustainable development’ until we think through what these terms mean and imply. ‘Sustainable’ is perhaps easy to define. It means something like ‘capable of being continued indefinitely’ and in our context, taking human, living and physical resources into account. Thus, to use a well-known example, recommendations that everybody should eat more fish are not sustainable – unless few people pay attention to the recommendation.
So what about ‘development’? People like us have been brought up to believe in ‘development’. The concept of ‘underdeveloped’ and ‘developed’ countries, later tactfully changed to ‘developing’ and ‘developed’, is embedded in all discourses concerning human progress, as are allied terms like ‘emerging market economies’. What ‘development’ conventionally means is economic development. And the metric for this type of development, applied to any country, is Gross National Product. What this measures is the total amount of money turned over within a country. The more money circulates, the more economic development, which usually is simply termed ‘development’.
Human rights, justice and equity don’t enter this picture. A country whose population was mainly made up from relatively self-sufficient family farmers, with a small ruling class that was not rapacious, would by definition be ‘developing’ – or if it preferred to stay that way, ‘undeveloped’. By contrast, a country with a substantial number of vastly wealthy people and an economy based on money, whose public goods are privatised, and whose diseased population is mostly in a perpetual state of insecurity and even gross poverty if only because of the cost of health care, is ‘developed’. Another example would be a country whose national turnover of money depended on vast stocks of weapons of mass destruction, used from time to time to invade other countries. Such a country is counted as most developed. Sounds familiar?
My point here is that in its current conventional sense, ‘development’ cannot be sustainable, because it depends on increasingly rapacious and senseless exploitation of human, living and physical resources. The concept of ‘sustainable development’ in this sense is a contradiction in terms, it is in effect imagining that we can eat the planet and have it. Unless the leaders of the Rio+20 summit being held next June get their collective heads round this basic point, and insist on a new concept of ‘development’ based on rights, equity and justice, decency, happiness and freedom, we all will continue to roll on to doom.
What does this matter to us?
These seismic events are the context for the work of all professionals who, like us, are committed to doing our best to improve conditions in areas where we are competent.
So one of my first questions is: If we are trying to make nutrition interventions in impoverished countries more sustainable, why is most of what is said, written and done having so little effect? Here are some answers to this question:
- Our praxis, which is to say our application of principles and ideas, has become professionalised. In the process, we have devalued and demoted the proper role of popular knowledge in our teaching and practice.
- Our prevailing values and attitudes as researchers and practitioners are arrogant. They have impeded us from respecting and acting as equals with our national counterparts in the countries we work in.
- We still seek to control knowledge as part of an elite class. We thus fail to obtain a deeper understanding that will guide more appropriate actions which can only come from a process of genuine popular participation.
- The root of the problem is that real sustainable development involves process of popular enrichment, empowerment and participation which our technocratic project-orientated ideology by its nature fails to accommodate.
- Another reason for the irrelevance of many past and current approaches is that overall development education has continued to transmit societal values mostly as they are perceived in the North.
Those who teach or who taught us, inevitably teach us part of themselves and the frame of values that is part of their background. The context any teacher comes from has its own frame of assumptions about what is real, unshakeable and safe. These contexts can become cages.
Difficult problems tempt us to focus on their more manageable component parts. But this atomistic approach evades the more complex underlying and basic structural questions. This also prompts the ‘exclusion fallacy’, in which what we choose not to discuss is assumed to have no bearing on the issue (6). An uncritical, repetitive reliance on the same old shallow data in the interpretation of unresolved issues, which avoids seeing malnutrition as an outcome of complex social and political processes, will not and cannot do.
The predominant theories of development still see society largely as an organic whole that is normally in equilibrium. This view does not fit well with the facts. Instead, we need to view society as a complex of forces in tension and conflict, because of the divergence of interests that drive them. We should not assume that conflicts are resolvable within what is now the prevailing political, economic and social system (7).
There is now much talk about the need for ‘multidisciplinary approaches’. In principle these are needed. In practice they often assume that looking at problems from a ‘wider’ perspective will automatically lead to rational and equitable solutions. But the mere act of putting together disciplines, without taking into account where the ‘experts’ are coming from ethically, ideologically and politically, has not and will not by itself make a significant difference. This will be all the more so, if beneficiaries – who need to become de-facto claim-holders – are not fully involved in decision-making processes.
| NUTRITION AND SUSTAINABLE DEVELOPMENT
ANOTHER WORLD IS POSSIBLE, BUT ONLY IF
WE ALL ARE PREPARED TO MOVE FROM EVIDENCE
THROUGH POLICY TO DIRECT CONCERTED ACTION
The Millennium Development Goals initiative will, we now know for sure, fail to halve the 1990 global hunger rate by 2015. This is more than just a wretched item of news. For far too long now there has been a block in the way of our realising that malnutrition in all its forms is in part driven by a model of development that is inherently unsustainable, as summarised in Box 1. The people in the streets may help us to become unblocked. But this calls for us being able to understand what they (and) we are seeking so that we are more likely to get where we need to be and, once there, to know what to do.
Vocally opposing and manifesting against old ways is not enough. The current movement needs a new conceptual framework, a new system of principles and values. These need to be concrete, cogent and compelling. Debates about past historical rights and wrongs should be mainly to guide us to come up with more coherent propositions for tomorrow. We need a vision firmly embedded in a practice. We must not walk away from these debates.
In our own work, we need to open new space to discuss and agree what now must come about. We need to take full account of all causal levels of malnutrition in impoverished countries and settings, i.e., social, economic and environmental, immediate, underlying and basic causes. Vision must move to mission and to real work with tangible outcomes. A vision is not much good if it simply stays in the air as something devoutly to be desired. A vision of that sort is a mirage; it recedes as you approach it. To be of use, the vision has to point to a route, and to take into account a lot of unpleasant realities.
A vision is of no use unless it serves as a guide for effective actions. These will need to be biased towards the oppressed, because it is their rights that are being trampled. We ought to express and manifest solidarity towards the oppressed. Only then will our vision be shared with them and gain weight and credibility in its commitment to equity and justice. We can no longer abandon the have-nots to the dollar-dispensing Northern bilateral or multilateral agencies. The moment cries for us to press for more. Windows of opportunity have a way of slamming shut. (8)
It is hard for many of us to maintain political agility in a hostile environment. But the role of an avant-garde is to cause ferment. Let’s not assume that somebody else is going to take care of issues that engage and involve us. We have to get active. A strategic overhaul of our actions requires a crisis in our thinking. This I believe is why the Occupy Movement is encouraging.
The future of our work in nutrition cannot be a simple extension of the past. Business as usual is no longer an option and in the times we now live in, has little if any meaning. Tuning the engine won’t work; it needs to be taken apart and put together again, for new purposes (9).
For a start, we have to work towards checking the malign forces that propel us as professionals in the generally hopeless direction we are moving. The fundamental changes now needed, can be brought about only by organisations and people that have no vested interest in the survival of the non-sustainable development system as it operates now, and that oppresses dependent countries and their impoverished people (10, 11).
A new professionalism will emerge when we become explorers, always asking what and who will gain, or lose, from our choices and actions in our work in nutrition. New professionals ‘who put the last first’ already exist, but we remain a minority. Now we need to multiply, and interact, coalesce and organise dynamic networks among ourselves and between us and grassroots organisations.
A mere extension of what most of us have already been doing in public health and in nutrition is not strong enough to insert nutrition within sustainable development. Our big task now is not only to have conceptual breakthroughs, but also to design strategic plans that specify all necessary institutional changes.
| NUTRITION AND SUSTAINABLE DEVELOPMENT
WE NEED TO TAKE OUR LEAD FROM THE PEOPLE
WHO MOST SUFFER INEQUITY AND INJUSTICE,
AND TO BE ACTORS AND NOT MERE BYSTANDERS
What’s in store, and what’s to do?
So what should we do now? I have given this some thought. In one column here I can’t attempt much more than a wake-up call at a very significant time in history, when so many ordinary decent citizens are expressing their outrage on the streets. How can we all make progress towards genuine sustainable development, based on principles of justice and equity which is most likely to preserve Earth for our grandchildren and their grandchildren? Here are some possibilities, which I regard very much as thoughts in progress, to be improved by discussion and exchanges:
- We need to de-professionalise our work. This will mean seeking, re-valuing and incorporating popular knowledge and know-how into planned actions.
- In this process, our local counterparts, and local civil society organisations, need to take a more visible lead, even at the cost of some possible mistakes.
- All relevant knowledge needs to be shared from the very start with the beneficiaries who in the process become claim-holders.
- We need to move away from the project-oriented approach and move towards processes of popular enrichment and empowerment.
- We now need to depend less on academicians, and professional practitioners, and listen more to the everyday sufferers from the prevalent inequitable system.
- They should define the changes that are needed. Action plans are thus to be negotiated and finalised in neighbourhoods and fields, not in our offices.
- Education has to be from the claim holders’ perspective with their choice of contents and priorities. We have to be more open to their needs and values.
- Our analyses need to incorporate the structural causes of malnutrition as part of the ‘big picture’. This includes changes made by economic globalisation.
- We will thus be forced to face the complex social and political forces of oppression that prevent populations and communities from improving their own nutrition.
- We have a duty to confront head-on and to expose the malign forces that oppose greater equity so as to neutralise them, from local to global levels.
- We need to use the internet to build networks of like-minded colleagues who can consolidate a strong worldwide solidarity movement.
- We have to confront the types of bilateral and multilateral aid – often no more than tinkering – that perpetuate inequitable and disempowered societies.
- We have to play a part in forcing institutional changes in aid agencies, the UN system included, so as to make them more democratic and transparent.
- We need a whole new curriculum for public health, nutrition and development professionals, to prepare a new generation of more enlightened professionals.
The processes that can lead to real sustainability, to the fulfilment of the human right to nutrition, and to equitable societies, can and should start with small direct actions that we can help bring about more easily.
Actions at grassroots level can take many forms. These should always include examination of who is losing and who is winning, and why. At higher levels, most of us have more experience on how to start discussions leading to change. We now have to follow through! We have to commit ourselves, in a more active and even militant way, to get and to keep the process of popular empowerment moving, always confronting the status-quo that gives the impression that nobody cares.
Examples where some of these elements have worked exist. Some of these, like the Indian state of Kerala, and Sri Lanka, Cuba, and Costa Rica, are well known. Others, like the primary health care work done in Iringa in Tanzania, and the Indian Jamkhed comprehensive rural health project in the state of Maharashtra, are also sources of insight and inspiration. They all have in common bottom-centred, gender-sensitive, empowering approaches and a political choice to tackle the underlying deep roots of poverty, injustice and ignorance.
The road to real development indicated here requires that we break with the old development paradigm, as summarised in Box 1. This will mean stepping on the toes of many powerful vested interests. It has always been like this, isn’t it?
I rejoice to see the people, especially the young people, now in the streets, sometimes passionately debating with courageous establishment figures who come to reason with them and learn from and sometimes join them. The present moment is full of promise. The old ideas are broken. An era is ending. We are in for an exciting new era. We need all the courage we can muster. It’s time, I believe, that we all stopped being mere bystanders and become actors. Addressing issues like these will have to pave the way to Rio+20.
1 Holt-Gimenez E. The world food crisis: What’s behind it and what we can do about
it, Food First 2008, Institute for Food and Development Policy, Oakland, California.
2 Hogan M C. Maternal mortality for 181 countries, 1980-2008: A systematic
analysis of progress towards the Millennium Development Goals, The Lancet 2010, Early online. doi:10.1016/S0140-6736(10)60518-1
3 ‘t Hoen E F M.The global politics of pharmaceutical monopoly power, drug patents,
access, innovation anfd the application of he WT Doha Declaration on TRIPS and
public health. Dieman 2009, AMB Publishers.
4 WHO. Everybody’s business: Strengthening health systems to improve health
outcomes, WHO Framework for Action, 2007 Geneva.
5 Milanovic B. Global inequality recalculated: The effect of new 2005 PPP estimates
on global inequality, World Bank 2009 Washington DC.
6 McDermott W. The forbidden agenda, Transnational Perspectives 1989, 15:1, 6-8.
7 Langley W. Liberation theology and the politics of transformation,
Transnational Perspectives 1989, 15:1, 23-29.
8 Gitlin T. After the thaw, Tikkun 1988, 3:6, 50-53.
9 Myers N. New Economics 1987, 1, 1, 8.
10 Harman W. Redefining global development, Development Forum 1989, 17:2, 21.
11 Bracho F. The common cause for worldwide sustainable development: A Southern view, IFDA Dossier 1990, 63-67.
Please cite as: Schuftan C. Nutrition and sustainable development. [Column] Website of the World Public Health Nutrition Association, December 2011. Obtainable at www.wphna.org
August 8th, 2011 by Claudio Schuftan
| July blog Claudio Schuftan
My column this month is prepared in collaboration with my dear colleague and friend Urban Jonsson. He and I share responsibility for the critique of the Scaling Up Nutrition (SUN) initiative, which is at the end of the column. Above, we are together at the ICN in Bangkok in 2009.
It seems that the UN System Standing Committee on Nutrition (SCN) is now among the living dead. But some of its key work needs to be preserved. This column also has some necessarily hard things to say about SUN, which has now apparently taken over the SCN. It is worth remembering here that several Association members wrote to the drafters of the SUN ‘road-map’ and to the SCN, asking for the human rights-based approach to nutrition to be incorporated. We were ignored.
| THE MILLENNIUM DEVELOPMENT GOALS TO SUCCEED, INVESTMENTS MUST BE DIRECTED AT
IMMEDIATE, UNDERLYING AND BASIC CAUSES OF
PREVENTABLE DISEASE, MALNUTRITION AND DEATHS.
Investing in nutrition is as much an issue of health, of care, and of food sovereignty, as it is of human rights, of economic welfare, and of social protection. Nutrition must be central to all renewed commitments and efforts to successfully realise the Millennium Development Goals.
Acute or chronic states of undernutrition are the direct outcome of an insufficient intake of food and nutrients, of losses of nutrients due to infection or of increased nutritional requirements as it occurs during infancy, early childhood, adolescence and during pregnancy and lactation. To address all these factors, investments have to be directed to the immediate, underlying and basic causes of preventable disease, malnutrition and deaths.
The numbers of children under 5 affected by acute undernutrition, or who are dangerously too thin for their height, are appalling. As you all know, those severely undernourished are at increased risk of death. Chronic undernutrition and growth retardation of children under 5, measured as stunted growth, also impairs brain development, and undermines the health, productivity and earning potential of those children as they become adults.
Leaving these problems unaddressed during the critical periods of growth (conception to 2 years of age) perpetuates them from one generation to the next at great social and economic cost. Malnutrition is a cause and also a consequence of failed development, as well as a gross violation of human rights, particularly of the rights of women and children.
Nutrition being a condition that runs through the different Millennium Development Goals (MDGs), it is a key global public health, human rights and development priority absolutely essential to all endeavours to realise the goals. Here is the evidence:
MDG1 . Eradicate extreme poverty and hunger
The detection, treatment and prevention of undernutrition is crucial to poverty and hunger alleviation strategies. Failing to take action on all forms of undernutrition incurs annual losses to national economic development in the billions of dollars through direct losses in productivity, indirect losses from deficits in schooling, and as increased health costs (1). Poverty and hunger are also perhaps the major causes of loss of dignity.
MDG2. Achieve universal primary education
Undernutrition causes losses in primary school enrolment, attendance, performance and retention rates. Undernourished children have poorer educational outcomes and lower earnings, losing up to more than 10 per cent of earnings in their lifetime: at country level, the Gross Domestic Product lost can be as high as 2-3 per cent. This all amounts to both the right to nutrition and the right to education being violated.
MDG3 . Promote gender equality and empower women
Undernutrition reflects gender biases in access to food, to health, to education and to other services, which are all violations of the human rights of women. Interventions to prevent and treat undernutrition can and do contribute to gender equality and empowerment by relieving women from carrying the disproportionate burden of hunger, disease, illiteracy and impoverishment. Although rural women produce more than half of the food in sub-Saharan Africa, they own less land or property than do men, as much as they have less access to credit and to other critical instruments and tools that lead to greater economic security. Undernutrition simply continues to hamper efforts to achieve gender equality.
MDG4. Reduce child mortality
Severe acute malnutrition contributes to over one million child deaths every year and thus represents a violation of the right to life. Common childhood diseases that are ordinarily treatable, often become fatal in the presence of undernutrition. About half of all deaths in children under 5 have undernutrition as a concurrent cause.
MDG5. Improve maternal health
Maternal undernutrition contributes to maternal ill-health and other complications during pregnancy, childbirth and after birth, and also to the poor health, growth and development of successive generations. Adequate nutrition and care during pregnancy and childbirth could prevent 3 of the 4 million infant deaths in the first month of life, and protect survivors from non-communicable diseases in adulthood (2).
MDG6. Combat HIV/AIDS, malaria and other diseases
Undernutrition dramatically reduces the ability to resist infection and increases the duration and severity of disease. In its presence, the progression of HIV to AIDS is accelerated, and malarial survival rates are reduced. In countries most affected by HIV, life expectancy has been reduced by more than 20 years, with a subsequent reduction of economic growth and deepening poverty levels (3) –not to mention the discrimination and denial of rights infected people are subjected to.
MDG7. Ensure environmental sustainability
Around 90 percent of all diarrhoea cases are linked to poor sanitation, unsafe water, and more globally an unsafe environment. Repeated or protracted water-related diseases episodes, easily lead to, or exacerbate under-nutrition. The newly recognised right to water is being flagrantly violated. Increasing access to safe water and sanitary services will contribute to maternal and child care practices, reduce the burden on health services, and decrease health care costs at household level and in national accounts. Environmental sustainable food production and mitigating the impact of climate change also increases food and nutrition security in the longer term.
MDG8. Develop a global partnership for development
The underlying causes of undernutrition pertain to three core areas of human survival. These are year-round sufficient food of adequate quality, access to primary health care, clean water and sanitation, and better care practices for mothers and children. In addition to these underlying causes, the whole host of basic causes have to be tackled as the core of development interventions at global and country level; this is crucial for comprehensive and effective action on undernutrition for survival and for growth and development. Donors are unlikely to fully comply with this goal, which was the only one imposed by lower-income countries during MDG negotiations. Therefore, the key to achieve this goal is the social mobilisation of claim holders.
Comprehensively and sustainably addressing the problem of undernutrition needs direct prevention and treatment interventions, and also simultaneous interventions and mobilisation that decisively address underlying and basic issues. These include claim holders demanding more equitable access to local, national and global resources, and fair access to world markets.
Governments and their partners in development can only achieve the goals as and when policies and practice assure an equitable access to resources at all levels. The effectiveness of direct nutrition interventions has been tested and proven, but remain subject to underlying and basic causes being addressed. This fact is too often dismissed or just appended as an afterthought. With this proviso, direct nutrition interventions remain crucial for optimal aid to those countries with the highest burden of undernutrition. It is an achievable means of increasing the impact on maternal and child health and other development initiatives. But what is needed for the achievement of the MDGs requires, but goes beyond, direct nutrition interventions. This point cannot be over-emphasised.
| PUBLIC HEALTH NUTRITIONISTS
IN REAFFIRMING OUR COMMITMENT TO THE MDGs WE
MUST INSIST THAT NUTRITION IS CRUCIAL TO ALL MDGs,
AS WELL AS TO A FAIR DEVELOPMENT FOR ALL.
Here is what the World Public Health Nutrition Association should now do, and what Association members and supporters should press for:
- · Prioritisation of nutrition as an indispensable cross-cutting issue requiring investments in nutrition, as well as in scaled-up programmes that address the social and economic determinants of malnutrition.
- · Nutrition interventions in support of the MDGs of a type that hold international duty bearers accountable for the implementation of direct nutrition programming, beyond the SUN initiative and its 10 billion dollars annual financial investment identified by the World Bank. No ‘packaged’ interventions are going to get us where we want to go. Packages are utterly top-down and have come about in a non-participatory way. (Isn’t the SUN initiative primarily top-down?). We have to change this.
- · Better use of available evidence on the scale, location and severity of under-nutrition in all contexts, disaggregating data by gender and by socioeconomic and ethnic groups. Claim holders and duty bearers can then, together and proactively, address non-emergency nutrition problems, rather than by reacting to them after the event.
- · Prevention and treatment of undernutrition in national health systems that foster really sustainable solutions. Such integration should include the transfer of skills, as well as the building of capacity for policy work across the health, agriculture and education sectors, and also to foster human rights learning and learning about the political economy of nutrition.
- · Integration of nutrition actions within the food security, health, water, sanitation, hygiene and education sectors and, in all of them, integration of the human rights framework. Only this will have a better and more sustainable chance to address malnutrition and poverty and their social determinants. This integration is to foster effective collaboration at local, national, regional and global level by setting up ad-hoc partnerships and initiatives that look at and address undernutrition from a more appropriate holistic and thus human rights perspective.
With only less than four years remaining to 2015, the target year to achieve the MDGs, and with the imperative for aid to be effective, it is time to tackle the problem of undernutrition decisively and definitively. Failure to do so will continue to exacerbate the plight of the most vulnerable groups in society, and will blight national development plans and global efforts to eradicate malnutrition.
In reaffirming our commitment to the MDGs, we must insist that nutrition is key to a fair development for all. Are you ready to contribute?
| THE SCALING UP NUTRITION INITIATIVE:
‘TARGETING’ THE POOR IS TO VICTIMISE THEM AS IF
THEY ARE RESPONSIBLE FOR THEIR ILL-HEALTH,
AND THEN THROWING THEM A CRUST OF BREAD.
Here we make a brief critique –and very critical it is, too– of The Road Map for Scaling Up Nutrition. This document is supposed to detail the means by which national, regional and international actors will work together to establish and pursue efforts to make nutrition interventions more impressive and effective in countries with a high burden of malnutrition ‘utilising proven interventions and through multi-sectoral and integrated nutrition-focused development policies and processes’. SUN follows the May 2010 WHO World Health Assembly resolution 63.23 on infant and young child nutrition, and is anchored in the guiding principles developed by the UN Standing Committee on Nutrition in 2009 in Brussels. These seek:
‘To ensure that nutrition policies are pro-poor, pay attention to people with specific nutritional requirements (especially children under the age of 2 years), are rights-
based, offer integrated support (food, health, care and are socially based, participatory (building on local communities, engaging their institutions and are inclusive of women’s and children’s interests), and do no harm’ (page 8).
Although this is a smorgardsbord sentence in the SUN document, it is a very good one. But unfortunately, we cannot find anything else of this in the rest of the SUN Roadmap. We also object to SUN’s proposed ‘pro-poor’ orientation; we rather favour measures that address disparity reduction and stop ‘targeting’ the poor since this is equivalent to victimising them as if they are responsible for their ill-health and then throwing them a crust of bread. This is the flaw we always saw in ‘nutrition with a human face’.
Section II of the document proposes: ‘common principles for stake-holders involved in scaling-up nutrition, for mobilising support from development partners, and for ensuring that national needs, variations in country contexts, and programme priorities are always brought to the fore. It indicates the importance of strategic leadership, synergy among institutions and coordinated mobilisation for action. It shows how the SUN effort builds on successful institutions, infrastructure and programmes, and it identifies some of the tools, processes and mechanisms for increasing impact’ (page 8).
Read the whole statement slowly and think about what it really says. It is one of the best examples of empty rhetoric, because it says everything and therefore means nothing. Moreover, it ignores the fact that there are claim holders and duty bearers involved in all of this, and that it is only their dialectical engagement that will move the ‘nutrition process’ forward. This fact was brought to the attention of the drafters of the SUN Roadmap, in writing, and the request for concrete changes in the wording received no response whatsoever.
Another typical rhetorical statement that reflects the naive political attitude of
seeking harmony and consensus among nutrition professionals, is the total absence of any reference to the processes of exploitation and power abuse/imbalances. We read the following:
‘Alignment within movements will encourage synergy and complementarities, through common goals and agreed actions, inspiring mutual respect, confidence and trust between participants, and minimising potential conflict of interest through shared common codes of conduct’ (page 10).
We ask: In which world are the authors living? …and this was written in 2010.
On some more technical issues:
- · One cannot simply take SUN’s proposed benefit/cost estimates seriously at all.. Moreover, the cost effectiveness it purports to improve is purely based on outcomes and is oblivious to processes. The World Bank is spending U$12 billion a year (page 12) with an extremely limited scientific basis.
- · SUN’s emphasis prioritises mostly technical interventions. It mixes up terms like ‘malnutrition’, ‘undernutrition’ and ‘hunger’. Also, the outdated and misleading terms ‘nutritious food, ‘food and nutrition security’, and ‘freedom from hunger’ are still used in the document. This just highlights a pervasive lack of clarity.
- · When identifying monitoring indicators, only outcome and not delivery-related and impact indicators are suggested (page10). All serious development scholars today agree that there is a need to include process indicators. This is true for all development approaches, not just human rights-based approaches. Why are, for example, none of the Paris Principles on Human Rights mentioned as a basis for monitoring indicators? This is not an oversight; this is the result of an ideological bias.
Almost throughout the whole document, one unavoidably gets the feeling that the different interventions that are being called for, are utterly ‘top-down’. The text in the ‘road map’ is not only inadequate. There is also absolutely no reference made to anything resembling an Assessment, Analysis and Action approach. Why? Again, only an ideological bias can explain this –and a clear bias there is! Another unavoidable feeling one gets is that there is hardly anything new in the document, both as far as content is concerned and in the proposed conceptualisations. Have twenty years gone by in vain?
1 UNICEF. Progress for Children: A Report Card on Nutrition, 2006.
2 Department for International Development (DFID). Child Mortality, 2007.
3 UNAIDS. Global Report on the AIDS Epidemic, 2008.
Acknowledgement and request
Please cite as: Schuftan C. The Millennium Development Goals, and the Scaling Up Nutrition Initiative [Column]. Website of the World Public Health Nutrition Association, July 2011. Obtainable at www.wphna.org
July 12th, 2011 by Claudio Schuftan
IT IS THE GRASSROOTS ‘PULL’ THAT IS MISSING, AND WE ARE NOT PUSHING GRASSROOTS MOBILISATION STRONGLY, AS WE SHOULD.
All lower-income countries need new generations of leaders in public health and in nutrition, with a new vision and energy. What about the even younger generation, of students who are already committed, perhaps passionately, to what they believe public health nutrition stands for, and who are planning a career – maybe a lifetime – in our profession? This column is addressed to them, in the form of a letter to a student. So:
So you want to join our guild of public health nutritionists. Good! I hope you will now allow me to give you a few words of advice, some of warning, some of encouragement.
I start with an issue that has worried public health nutrition workers for many years now, namely how we have been doing professionally in the international arena. Over the years, many of us have shared this concern. Before you embark on your professional journey, you need to see this and other issues. What we have experienced can help you better to judge what you are most probably going to get involved with, in your future career. That is why I am writing you this letter.
I am one of those who do not share the feeling that international public health nutrition is much healthier today than it was ten years ago. The academic training we are giving our new graduates in public health nutrition still often is of limited relevance. This is perhaps more so for students from the South, especially when trained in universities in the North, where they have to go through core curricula that include courses of no relevance to them.
In judging the most important advances in nutrition in the last ten years, many of our colleagues think these have been greatest in preventing and treating micronutrient deficiencies. This comes as no surprise. Most nutritionists still like ‘silver bullet’ fixes. These are ‘technical’, and the technical realm is the one in which they feel more at home, and more in command.
The main issues are structural
But malnutrition is really a political problem. It is the biological manifestation of a social disease. Some other colleagues think that advances in our field in the last ten years have included greater community involvement in nutrition programmes, and increased attention to care practices addressing women and children. This is so, up to a point. But I feel most colleagues do not really have a better, action-oriented understanding of the causes of malnutrition now, than they had in the 1990s. This was the decade in which we agreed that the correct conceptual framework of the causality of malnutrition is one that considers malnutrition as an outcome of different levels of causality. These are basic and underlying as well as immediate, and social, economic and environmental as well as behavioural and biological. All these levels and dimensions need to be addressed at the same time.
For the same period, colleagues have said that we have not come up with comprehensive designs for a better management of nutrition interventions. For them, this explains why we have not been effective in addressing protein-energy malnutrition. But design and management are not the main shortcomings of the last decade, or even the last thirty years. The main problem is the top-down, often curative and palliative thrust of the interventions. Also, it still amazes me that some colleagues even think that failures can be attributed to insufficient attention having been paid to the importance of nutrition counselling. This just shows their ethnocentric bias. ‘Counselling’ does not begin to address the basic problems of impoverishment and inequity that are at the root of malnutrition the world over.
The same bias can be found when colleagues think that reduced funding for nutrition projects is the major problem or constraint to achieving better results in the battle against hunger and malnutrition. Let us face it: If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!
I further disagree with colleagues who think the issue of lack of coordination among United Nations and other aid and development agencies providing nutrition services is central to our non-success in our work. The causes of this confusion or even conflict are ultimately related to issues of control, egos, and ‘old boy networks’, although there are also a number of genuine points of contention among agencies, some clearly ideological in nature. Yes, the non-coordination exists, and it is a disappointment. But it is not the main obstacle to faster progress.
Lack of commitment by governments to meaningful nutrition interventions is another excuse that is made too often, as a blanket statement, almost as a slogan. This said, I do accept that bureaucratic obstacles are a great burden. I know this after working for six years in ministries of health in Kenya and Vietnam, the latter a country where the politics are right, but where it takes a long time to get anything done.
But taken together, I cannot agree with the reasons given above as to why public health nutrition is ineffective. The major negative factors are structural, and are to do with the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment of those whose right to nutrition is being violated, every day of their lives.
The main issues are political
One of the real issues at stake is the genuine empowerment of claim holders, the people who are suffering from malnutrition. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to reduce malnutrition on the scale that is needed. It is the grass-roots pull that is missing and, as professionals, we are not pushing grass-roots mobilisation strongly, as we should. Will this be covered in your curricula? I am a skeptic.
On UN and other aid and development agencies, the big issue is that there are just no real good role models. Interagency competition and rivalry is often disguised as technical, but is actually political and ideological. My experience is that none of these agencies is really engaged in making empowering and sustainable changes with a potential to win the battle over malnutrition. Your generation, dear candidate, will have to give these agencies new, bolder directions. They are not immune to the political discourse. Some need to be challenged, even confronted, for as long as they keep to their conservative, outdated positions.
Very few of your future professors, dear candidate, are sold on the position I present to you here. They tend to be dogmatic and conservative, sticking to outdated or obsolete concepts, and a paradigm I think is fading. This is a challenge for you as well as for them. Take your stand. We take political stands based on adopting a consistent overall philosophy, which is to say, an ideology. This puts us in opposition to those with different ideologies. It is best not to adhere to our positions as the ‘only’ ones, but as those we stand for. It is good to believe you are right, when you enter into a discussion on the deep-rooted problems of hunger and malnutrition, even when you later come to see that you need to shift your position, just as long as your revised position remains consistent. Dialectics is about change. This includes recognising and amending your own mistakes.
By now, dear candidate, I hope you can sense that politics are at the very centre of international public health nutrition. This means that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current and future education, as well as all that you will see out there in the job market that is waiting for you shortly. What this points to dramatically is the almost taboo question, so rarely addressed, asked or answered: ‘How would you classify yourself politically?’ Why is this not asked in the first place?
It is said that, on micronutrients and breastfeeding, more concrete achievements are possible. This is precisely the silver-bullet type option many of our colleagues choose. Why should addressing tougher underlying and basic intersectoral issues be seen as impossibly difficult? These are what will ultimately lead to sustained improvements in public health –if we all put our hearts and minds to the task. Nutritionists in your generation need to face the more difficult choices and challenges in the battle against malnutrition and its real causes.
Properly understood, public health nutrition is part of the larger development perspective. I see it as being our point of entry to the big picture where it rightfully belongs, according to the integrated conceptual framework of the causes of malnutrition. Nutrition will keep its rightful identity in such an approach. To be taken seriously, our discipline has to be engaged with all aspects of development; if it stays territorial, it will remain only marginally relevant.
Are the impediments to public health nutrition too great?
Dear candidate, the current condition of international public health nutrition will continue to pose increasing frustrations and challenges for you. My acute concern is seeing how politically uninterested so many of your generation, particularly in North America and Western Europe, have become.
Those who say that international public health nutrition was just one fashion that now has had its day might be right, after all. If so, this is because our vocation may have turned out to be irreversibly irrelevant in global terms in addressing malnutrition, the rates of which are now rising again. It is just tough trying to beat the gigantic odds of inhumane and often outrageous economic globalisation, structural adjustment, and expanding ‘market economies’, that have no room for the problems of impoverished people.
But international public health nutrition must not and cannot be a passing fashion! We invite you to join in. If leaders and citizens turn their back on problems like these, they are part of a movement towards an inhumane, unjust and unsustainable world that will have gone wrong, for ever.
Yes, you can make a difference
In closing, dear candidate, I convey to you my confidence and optimism that our work has the ability to make a difference. The question is, what difference, and what for. Routine, pat solutions will not do. It is not a matter of an increasing number of activities in international public health nutrition starting to take place again in low-income countries. It is a matter of what kind or type of activities. Issues of inequality and of the right to nutrition are at the base of the problems at hand. And if nutrition is used as a way to revert such inequalities, I will be an optimist. But we need your upcoming generation, dear candidate, to get the job done. Perhaps you can start by questioning the curriculum you will be exposed to.
I have worked in many places on most continents, and this, in my experience, is what awaits you if you decide to join us. I see your role as a potential agent of change. I hope that, by now, you have a sense of what motivates us, the older workers who keep going as best we can, and of what we stand for. Principles include those that are ethical and social. Motivation can include romantic approaches such as those of charity and the desire to help the needy, but what’s most needed are political approaches that attempt to fight inequalities and injustice by empowering people to fight for their own rights.
Unfortunaytely, many of our commitments and energies wane as we get older, dear candidate. Do what is bold, now that you are young. Reach for the stars.
Ho Chi Minh City
June 7th, 2011 by Claudio Schuftan
| May blog
I share a concern with many so I have made it the topic of this column. (1) But in this day and age of information overload these things get forgotten, they get conveniently swept under the carpet.
I am intrigued to know whether you have come to a similar conclusion as that of this column, as regards the state of international nutrition and specifically the relative balance of attention given to solving the problems of micronutrient deficiencies and those of protein-energy malnutrition. I invite you to read on.
|ARE WE KEEPING THE UNACCEPTABLE CAUSES OF BOTH MICRO- AND MACRONUTRIENT DEFICIENCIES IN THE PROPER PERSPECTIVE?
In my early days of work in nutrition, during the late 1970s and early 80s, most attention in impoverished countries focused on protein-energy malnutrition. Its culmination was the era of multisectoral nutrition planning in the 1970s, when we took this form of malnutrition seriously, and understood the importance of working with a range of development sectors. Those of us who pursued multisectoral planning met with disappointment, partly because of the mainly ‘nutricentric’ lens through which development was viewed, and partly because at least some of us failed to pay adequate attention to the underlying social, economic and political determinants of malnutrition.
A large portion of the nutrition community reacted by pulling in the opposite direction, labelled ‘nutrition isolationism’. This is, in effect: ‘If we will not be taken seriously by other development sectors, we will ignore them, and pursue nutrition interventions we can carry out and control largely on our own’. And indeed there were attractive candidates, such as new understandings of the consequences of micronutrient deficiencies, particularly iron, vitamin A, iodine, and now zinc. Improved technologies and logistics for delivering micronutrients in the form of massive dose supplements and fortification, made possible significant and attractive achievements within relatively short periods of time.
Hence, many in our profession have pursued such micronutrient interventions –in some cases with evident remarkable success– and can take some pride in their accomplishments. Nothing in this column should suggest a reduction in efforts directed toward micronutrient malnutrition. But, at the same time, it is clear that we have neglected the overriding problems of inadequate caloric intake, inadequate care and inadequate health care and its determinants, which are continuing to take such an enormous toll on vulnerable populations.
Today, we know considerably more about addressing protein-energy malnutrition through the combined efforts of improving food sovereignty, food security, the nutritional care of women and children, and other public health interventions, than we did years ago. But the attention of the nutrition community and the resources of donors nowadays are still often more attracted by the glamour of micronutrients, a largely technical and often top-down solution (as close to a ‘quick fix’ magic bullet as we are likely to get in our field). Most of us, and donors, prefer this to the messier and often politically sensitive business of poverty alleviation, people’s empowerment, and equity, and the need to be sure that mothers and children have access to care and needed services, and to sufficient and adequate food to eat year round.
Follow the grants
If one asks nutrition experts to list nutrition research priorities, even those coming from countries with disturbingly high rates of moderate and severe malnutrition, a majority will list micronutrient-related problems. This is not surprising, given the orientation of donor assistance and the appeal of journal articles. But the list hardly reflects the most urgent nutrition needs of, for sure, African and South Asian countries.
Governments and donors have all too often concluded that they can ‘check off’ their concern and attention to nutrition by launching a micronutrient project, or a pitifully isolated breastfeeding project, and ignore entirely the challenges of protein-energy malnutrition that so seriously affect the ultimate welfare of women and children between birth and 2 years, as well as the longer term development prospects of impoverished countries.
|Here then is the challenge we face: We need not only to maintain our momentum in pursuing micronutrient interventions, which reduce suffering and save lives, but also to redress the imbalance, and the relative neglect of the problems of protein-energy malnutrition and household food insecurity, that often require a very different set of interventions.
Our hope in the years to come is that the technical skills and partnerships which have driven salt iodisation and vitamin A, iron and zinc supplementation programmes, can be coupled with the political acumen that has sparked successful social mobilisation movements to bring about the significant structural changes capable of the sustainable reduction in global undernutrition we all desire.
|THE GAP BETWEEN ENGINEERS AND ACTIVISTS
DIFFERENT CHALLENGES IN COMBATING
DEFICIENCIES AND PROTEIN-ENERGY MALNUTRITION
The time has come for the nutrition community to see that micronutrient interventions and protein-energy malnutrition interventions have progressively drifted apart (2). These have become different tracks, responding to what seem different challenges. More, they have grown into two, by now, well differentiated separate domains.
Recognising this fact is important, because it links this discussion to the future of international nutrition and to the evolving debate on public health nutrition and its future role central to our own Association. I invite you to respond to this column in the space provided at the bottom with a consenting or dissenting view on whether this imbalance is not as relevant today as it was in the final years of the last century.
More than before, in the last twenty or more years, and following sources of funding, a significant number of nutrition workers have chosen to focus their efforts on the alleviation of micronutrient deficiencies. Does this represent an attempt to avoid the more difficult choices and challenges in the battle against malnutrition? And further – in the name of nutrition – focusing on its more achievable areas of impact, thus choosing the relatively easier path to staying involved in nutrition work and in our profession?
Often, this greater micronutrient focus represents swings from earlier work in protein-energy malnutrition. Examples are manifold, for instance in the work of the US Agency for International Development (USAID), some of that of UNICEF and WHO, as well as that of bilateral donors, and certainly of the Micronutrient Initiative.
Technical and political issues
The difference between these two areas of concentration is between one that is primarily technical with only few political overtones, and one that is the opposite: primarily political with some added important technical challenges. The micronutrients endeavour does have a potential for silver bullet solutions to work, while working to alleviate protein-energy malnutrition does not. Professionals who seek tangible results to report in the literature, like to have silver bullets in their armamentarium.
Myself, I made my choice over 30 years ago. Having lost faith in silver bullets, I have steered my professional life in the direction of a primarily political focus with technical overtones. I have no regrets. Silver bullets have not worked beyond pilot stages, and are not replicable even close to the scale needed. Protein-energy malnutrition has always claimed my attention. It is a sore reminder of the social injustices that underlie it. If anything, my conviction has been strengthened since I adopted the human rights-based framework as my paradigm of action.
This is not an academic nuance. As you my readers will know, I am clear that solutions to protein-energy malnutrition are largely outside the field of nutrition itself, and solutions for micronutrient deficiencies are importantly, though not altogether, inside the realm of what we can do technically. It follows that these two components of nutrition work have to adopt different strategies and require different skills, approaches and tactics.
Colleagues who get involved in micronutrients work get absorbed in resolving mostly immediate causes, and only some of the underlying causes, of malnutrition. They rarely touch its basic causes. They also address more top-down programmatic challenges, such as management, distribution logistics, and food technology issues. Not all this type of work is strictly nutrition engineering though. Work on food fortification, in Brazil for example, tries to push the issues into the socioeconomic and cultural arena and tries to involve consumers and to promote community participation.
People involved in micronutrients work typically lobby for policy changes that are relatively uncontroversial and apolitical, and tend to get support more readily from national decision-makers. Examples of such policies are starting nutrient fortification schemes, or getting salt iodisation legislation and regulations passed.
When applying information, education and communication techniques in micronutrient work, such as seeking to change the dietary habits of a population, or changing the behaviour of pregnant and lactating mothers, colleagues face many more problems. Then, socioeconomic and irresponsible, aggressive marketing issues come to the fore. They feel they are less well equipped, or less in control, or less inclined, to handle those issues. Too often, nutritionists end up teaching mothers to feed themselves and their families foods that they cannot afford, or, when using social marketing techniques, seek to impose changes in behaviour without seeking people’s understanding of why these changes are needed and beneficial. Social marketing fails to put people more in control of their own lives (3).
|COMBATING PROTEIN-ENERGY MALNUTRITION
THIS IS ALL ABOUT POVERTY ALLEVIATION AND
DISPARITY REDUCTION, NOT ECONOMIC GROWTH
To combat protein-energy malnutrition means dealing with issues of equity, popular participation, wealth redistribution, physical and economic access to health, and to education. It is about the appropriate care for women and children. All these have been adversely affected by the many structural adjustment programmes imposed on impoverished countries worldwide, as a condition of receiving foreign loans. (3) Protein-energy malnutrition does not respond unless its immediate, and also its underlying and basic causes are tackled simultaneously and all together. Interventions at each causal level are necessary, but not sufficient.
Because micronutrient strategies so heavily depend on government-based and donor-based service delivery and logistic interventions, as well as on ongoing capacity building at lower levels, they very often create dependency on a given technology and on the continuation of centrally funded and controlled services. For these and other reasons, sustainability remains elusive.
In contrast, resolving protein-energy malnutrition requires empowering people and communities to get involved in actions that they themselves select and demand as legitimate claim holders. Although often not yet achieved, this has the potential of creating less dependence and more self-reliance and sustainability (4).
Micronutrient interventions can reach coverages in the 90 per cent range almost universally – where there is massive funding and support by the donor community. Then what? Will we see a switch back to protein-energy malnutrition work, which by then may well have become worse? Protein-energy malnutrition will not go away in the next generation. The donor community pays mostly only lip-service to needed structural changes. Governments are not tackling these basic problems on their own either. Moreover, macroeconomic policies imposed by the World Bank and other Bretton Woods institutions more often than not have the effect of making protein-energy malnutrition worse(3).
Nutritionists tend to choose tracks in their careers according to their preference, plus the level of tolerance of frustration they can stand. Do political ideology and ethical commitments also shape their choices, especially when faced with only snail pace progress? Are ultimate goals of social transformation part of the equation in their choice? If the answer to this question is ‘no’, I see a bleak future for the role we can play in the battle against malnutrition in the world. Changes will come about without and despite us, and history will bypass us.
Engineering and activism
Challenges like these are not being clearly spelled out to young and aspiring professionals during their undergraduate and graduate training. Some say we are trained less than engineers (5). I would say we need more than engineers: we need nutrition activist engineers.
Any work in nutrition is not only engineering or activism. It involves both. But if we are to overcome the great challenges facing us, the balance must shift towards activism. We need more commitment to face the basic determinants of malnutrition and ill-health. We need to train young nutritionists accordingly, preparing them better for their role as activists, clearly understanding and capable of intervening in the political dimensions and determinants of malnutrition. Dr Rama would agree. So will Jim Levinson. They both are examples of people who live(d) their beliefs.
1 Schuftan. C. Ramalingaswami. V, Levinson. J. Micronutrient deficiencies
and protein-energy malnutrition. Letter to the Ediror, The Lancet 351,
p. 1812, June 13 1998.
2 Schuftan. C. Point counterpoint: The gap between nutrition engineers and
nutrition activists. Ecology of Food and Nutrition 38, 6, 1999.
3 Schuftan. C. Questioning the Solution: The Politics of Primary Health Care
and Child Survival. [Book review] Health Policy and Planning 13,1, March 1998.
4 Schuftan. C.: The community development dilemma: When are service delivery, capacity building, advocacy and social mobilization really empowering? Community Development Journal 3, 3, pp. 260-264, July 1996.
5 Berg. A. Sliding Toward Nutrition Malpractice – Time to Reconsider and
Redeploy. Martin Forman Memorial Lecture, 24 June 1991.
You are invited please to respond, comment, disagree, as you wish. You are free to make use of the material in this column.
Please cite as: Schuftan C. Micronutrient deficiencies and protein-energy malnutrition [Column] Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org
May 27th, 2011 by Claudio Schuftan
| April blog
One of my heros is Rudolf Virchow. He was a social visionary who in the late 1840s, articulated the social – and the economic and political – determinants of ill-health, malnutrition and misery. He did this with, I dare say, even more bite and relevance than has the WHO’s Commission on the Social Determinants of Health, over a century and a half later.
Rudolf Virchow was a clinician founder of epidemiology in the service of public health. Aged 27 and living in Breslau, in Germany, he was asked by the rulers of Prussia to identify the reasons for an outbreak of typhus in Upper Silesia. His report stated that the cause was poverty and in particular the outrageous living conditions of impoverished communities. He said: ‘The proletariat is the result, principally, of the introduction and improvement of machinery…shall the triumph of human genius lead to nothing more than to make the human race miserable?’ In the same year, 1848, the first proletarian uprisings shook many European governments, and Virchow helped to build barricades in Berlin.
|FUNDAMENTAL PUBLIC HEALTH NUTRITION
NUTRITION IS A SOCIAL SCIENCE, AND
NUTRITION IS NOTHING MORE THAN
POLITICS ON A GRAND SCALE.
The spirit of Rudolf Virchow permeates this column. Many of us older professionals recall that what we were saying and writing in the 1970s and early 80s was considered radical and extreme. Well, a good bit of it is now mainstream – even if more in lip service than in action. The mood I want to set here is captured in the heading above, which paraphrases Rudolf Virchow’s most celebrated quote, substituting ‘public health nutrition’ for ‘medicine’.
What I am getting at here, in reminding us of Virchow and the many other trenchant observers and activists that came after him, including in our lifetimes, is that we seem to keep on and on diagnosing the obvious. Thus, why do we go on emphasising sectoral solutions that address what we think are ‘new breakthroughs’ in nutrition, without addressing what is fundamental? So much is important. But what is fundamental? Don’t you feel we are sucked into fashions in nutrition work? Yes, important is the help given to some needy groups. But yes, fundamental, is the promotion of permanent structural changes.
We keep projecting trends and tendencies of the bad stuff we want to be stopped. But tendency is not destiny. The destiny is in our hands. When dealing with food and nutrition problems, it is important to act on the ultimate causes, as well as on their effects. It is little use to take care of the malnourished while the basic causes of hunger and malnutrition remain. We can propose steps to block such causes, or we can help solve their consequences. The greatest waste in the latter task is time, wasted on diagnoses for checking easily verifiable tendencies, wasted on excessive methodology. Decisions are thus delayed by a system without any synchrony with the velocity of what is happening. We simply often fail to strike the right balance between theory and practice, between academicism and activism.
Politicians and policy-makers often base their opinions on what they hear from those who do not know anything about the subject, and are viewing it from the outside. Or else, they make policy on the basis of what they hear from those who do know a great deal about the subject, and are viewing it from the inside, but from a biased point of view – which is to say, more often than what we’d like one of us.
All the elements needed to study malnutrition in its wider economic and political context are there. These include inequity between the various sectors of society, and the role of state and private interests and the conflicts between them. But in spite of this, our colleagues often continue to discuss matters within a narrow and constricting frame of habits, behaviours and knowledge – or ignorance. Our colleagues implicit social model, part of which for them often is an unacknowledged ideology, somehow does not allow them to appropriately react to the complexity of the social and economic phenomena they witness. An approach that assumes classlessness focuses its analysis on those who are seen as ‘just happening to be poor’, and not on the economic system that produces and reproduces poverty. As a result, most strategies to eradicate poverty have been directed at poor people themselves. Problems are thus ‘solved’ in an isolated and technical way, because there is still a lack of understanding of what determinants are really important and how they need to be addressed and resolved. In our system, colleagues who point out valid discrepancies between ideology and reality are marginalised or punished, rather than being respected and rewarded.
Projects dreamed up in a social vacuum must play themselves out in the real world of injustice and conflict. Projects we get involved-in often turn out differently from what we expect or intend them to. Am I not right? We need nutrition experts who are strong and flexible enough to ask the right questions rather than sell the wrong answers. Intervention strategies need to call for radical changes in the environment and the social system. It is only such strategies that have long-term potential.
IT’S THE RICH THAT GET THE GRAVY,
IT’S THE POOR THAT GET THE BLAME.
AIN’T IT ALL A BLEEDING SHAME.
The rhyme above appeared in my column some month ago. It does not give me peace. Reading it again, I feel something is missing. What are we supposed to do differently or better? What is the overall problem in our work in nutrition? Is it that too often we are trying to find reducible solutions to irreducible problems? Is it that the wrong technologies have for too long been destroying genuine community life and have thus led to maldevelopment that has perpetuated malnutrition? Does technology ‘dilute and dissolve’ ideology? I think yes. I agree with those who say that a technocratic utopia is the most banal of all utopias.
What, then, is the appropriate role of the science of nutrition in people’s development in situations where exploitation and oppression are ongoing, but room still exists for technological initiatives to marginally ‘improve’ the material wellbeing and nutrition of poor people –at least up to a certain point? Conversely, can affected communities be easily mobilised for political action, for structural changes, if the current system still so allows? Should progressive forces stand aloof from such space? Should they be part of the effort to distract mass attention from the need for fundamental social change? Or should a combination of economic and political mobilisation also be pursued? These questions are not easy. Public indignation is difficult to sustain; it can be dissipated by token, merely symbolic patch solutions.
Ideological or technical ‘fixes’
We need to confront the fact that there are two kinds of problems: reducible and irreducible. The difference between them is simple. Reducible problems have clearly definable solutions, while irreducible ones do not. You know when you have got the answer to a reducible problem –it fits like the right piece in a puzzle. But, beware! Problems such as inequity and injustice appear irreducible, because their solutions are deemed ‘not fixable’. But do not worry, we are told. Technological advances are the answer to reducible problems, so it is imagined that they can and will solve the irreducible problems as well. This is, of course, an illusion.
When the world is messy, the tendency is to fall back either on ideology or on technology. Good young people respond to the seduction of technology. ‘It’s more independent of experience and you don’t have to know much’. But technology is not the origin of change; it merely is the means whereby society changes itself.
Technology has flattened differences around the world. Cultures that took centuries to build and sustain have been transformed by ‘development’ in a few decades. Political action is almost always successful in response to strongly felt needs –more liberty, a different racial division, or simply more bread. Technology invents needs and exports problems. (By the way, are you by any chance fixed up with an Ipad? Or perhaps an Iphone?).
Political action always has motives –a why– such as grievances, and the need for redress; it follows a long period of abuses and usurpations. Great technological changes, on the other hand, do not have a why. Technology, unlike politics, is irreversible. We may be able to develop a new strain of wheat and so contribute to stave-off starvation somewhere. But it may not be in our power to cure injustice anywhere, even in our own country, much less in distant places.
We need to change our system of thinking rather than trying to conquer hunger and malnutrition by the use of technology. Technology is basically improvisational. It treats the symptoms; it provides no lasting cures. Moreover, technology is part of the problem. New policies will thus require a patient and possibly painful re-education of us all.
Technical pragmatism, even by women and men of good will, comes up with strategies with no political sensitivity, that are ‘implementable’, or ‘do-able’, and are appealing to all ‘reasonable’ people. Technocrats paste together fragments of several alternatives, often resulting in a pastiche and not a real synthesis.
If this is the best that the best applied thinkers of the international nutrition establishment can produce, then indeed our thinking is no more than aimless wandering in a desert
|HAPPINESS AND SUFFERING
HUMAN HAPPINESS IS INDEFINABLE.
HUMAN SUFFERING IS CONCRETE.
IT MANIFESTS AS HUNGER, UNEMPLOYMENT,
POVERTY, ILLITERACY, IGNORANCE…
The real challenge in our present world is not to maximise happiness (which in practice is interpreted by neo-liberalism as maximising economic growth, higher gross national product, consumerism, or acquisition of quantity of goods). The challenge is to organise our society to minimise suffering.
Ultimately, our civilisation will not be judged so much on its vast accumulation of scientific knowledge, as on its trusteeship of that knowledge and its efficient application to the betterment of living and the minimisation of suffering. We – you – cannot continue increasing our – your – affluence, while most have not even got their essentials. Will acting on this truism lead to conflict? Probably. Conflict is not necessarily violence. Conflict is common where there are competing interests. Conflict is a necessary means to attain true dialogue with people in authority. Therefore, avoiding it –as we often do– is no solution. So where does this put us?
Raising our own consciousness
Our nutrition community needs a programme of consciousness-raising, so that empowered in this way, we ourselves can raise the consciousness of others and empower them. We need to generate an attitude of inquiry and of demand among the beneficiaries of our programmes, so that they can move from fatalism and apathy, to the realisation of their own power and rights to change reality in their favour.
Nutritionists should bring to their beneficiaries systematic knowledge of the wider social structure and its workings along the lines of their inalienable human rights –a knowledge that is critical in the choice of strategies for social change. Nutritionists should also bring knowledge of initiatives to change society that have been applied elsewhere, so that lessons can be learned from those experiences. The power of new ideas needs to be mobilised through the communications revolution we now live within. New forms of learning, education, awareness creation and ‘conscientisation’ need to be proactively pursued in this endeavour.
As nutrition professionals, we have a responsibility to be leaders in the abolition of absolute poverty wherever it exists. Relative poverty, which can be seen as dissatisfaction with one’s relative position in the income pyramid, is important, but it is not morally important as a priority. A new ethos is required, involving discouragement of consumerism. This cannot be done without a substantial change in power relations.
People-who-happen-to-be-poor are not capable of engaging in conflict until they de-facto show that they are no longer servile and afraid. They need to move from a culture of silence to a position of dignity – and the adoption of the human rights-based framework is the better way forward. Where do you and I stand, when it comes to promoting this transition, and to provide rallying points for mobilisation in this direction?
Work in nutrition can lead to liberation. Any action that gives the people more control over their own affairs is an action for real development. This is true even if it does not offer them better health or more bread in the short run. But for this to happen, our work needs to be built from the bottom up. Otherwise we are part of the culture of Social Darwinism, in which the ones who make it are the richest, the most powerful, the ‘whitest’ and the ‘malest’.
You are free to make use of the material in this column, provided you acknowledge the Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org
Please cite as: Schuftan C. Fundamental public health nutrition: Nutrition is a social science and nutrition is nothing but politics on a grand scale, Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org
November 30th, 2010 by Matthew Anderson
| December blog
Ouadougou. I began this month’s column in Ouagadougou, Burkina Faso. How come I am here? Well, the government here is in the process of finalising guidelines for ministries to prepare their next mid-term plans. Demonstrating real vision, the government wants to make sure that the cross-cutting issues of gender, the environment, and human rights, are incorporated in these plans. In the area of human rights, they requested the help of an external consultant. The local UNICEF office was approached to find a francophone consultant. And this is how I became involved. I cannot yet tell how much the issues of macro- and micro-causes and of political, economic, and social determinants of ill-health and malnutrition will be taken up in the work I am doing right now here. But I am sure working hard on it… So see what follows.
IN SEARCH OF THE BIG PICTURE IN OUR WORK IN DEVELOPMENT
Africa is a good continent to be in. I have done much work here; always going after what the real causes of malnutrition are (here meaning undernutrition and nutrition insecurity, or to speak plain, hunger).
Macro- and micro-causes
For many of us, undernutrition and hunger are nothing but the biological translation of a social disease with particular historical roots in each case. Their basic causes will here be called macro-causes. The more immediate and underlying causes will here be called micro-causes.
Macro-causes are conditioned by the overall policies that govern economies, both within any country and in foreign relations and trade. With many others, I contend that macro-causes explain most undernutrition and hunger in societies with capitalist modes of production. Nutritional vulnerability is a manifestation of a society’s inability to enable its poor populations to earn their livelihoods adequately and not an issue of overpopulation or of insufficient agricultural production. In short, impoverished societies struggle for their own livelihood while actually contributing to the livelihood of other societies (1).
Political and technical approaches
Macro-causes are not removed or even touched by the vast majority of conventional nutrition intervention programmes. The fight against undernutrition and hunger thus has to change, to become much more of a political struggle. Technical approaches simply cannot achieve the fundamental structural changes needed to end hunger.
Removal of a few (or even one) of the main macro-causes is more likely to alleviate undernutrition and hunger than acting on many micro-causes simultaneously. Macro-causes are now frequently mentioned and identified by planners analysing specific country situations, but the plans they devise seldom address these causes frontally.
Micro-causes impinge on the physiological condition of malnutrition. These include health, environmental, and biologicalvfactors. These are those most frequently identified and selected for direct intervention by Northern planners. They largely emphasise technical approaches, and justify Northern-trained experts who often come with ready-made off-the-shelf analyses…and ‘packages’. To many of us, The Lancet Series on Nutrition suffered, to a great extent, from such an outlook.
All experts bring their own view of development. Nothing new here. Their proposals for nutrition programmes will reflect their ideology, of which they may be unaware. Over the years, a focus on micro-causes has led to myriad packages of solutions or interventions that pretend to be apolitical and free of ideological connotations or influence. But ultimately one either bows to the system or objects to it, totally or partially. Is not this a political stance?
As nutritionists, we keep inventing new ‘more comprehensive’ or ‘multi-sectoral’ or ‘evidence-based’ approaches to old problems, as if these would change major contradictions and maldistribution of power in the system that is causing the problems of malnutrition to begin with.
How to get to the point
I contend we basically cannot agree on the content of needed nutrition interventions if we do not share the same understanding of why people are poor, undernourished and hungry to begin with. Different socioeconomic contexts call for different nutrition plans. This does not imply that only macro-causes should be identified and acted upon. An appropriate understanding of hunger and malnutrition will include consideration of and acting upon a mix of macro- and micro-causes.
The challenge here is to determine, in each national (or regional) context, how much and what kind of macro-changes are needed for micro-changes to have some chance of success. The connections between macro- and micro-causes must be made explicit so as to justify the needed macro-changes. Any plan or programme geared to ameliorating malnutrition as a public health and social problem will have to include a mix of interventions designed to affect change in both macro- and micro-causes. Technical measures in themselves are not tools for income redistribution; at most, they may have a partial redistribution impact as a side-effect – assuming that they reach the lowest income and marginalised groups.
In this context, our role is indeed delicate. Sensitisation and advocacy skills are perhaps more important than technical know-how. The strategy that is to follow a comprehensive diagnosis of the problem(s) at hand can either a) first, define a set of specific activities directed to address and remove or minimise the effect of micro determinants (the classical approach) followed by an estimate of the potential of such a package of interventions to solve or address the major problems of hunger and malnutrition, or, b) alternatively, invert this sequence).
So that anybody can understand these links, a list of the key macro-causes should be identified with beneficiaries (claim holders), and a summary made of why and how each one of them contributes to the persistence of undernutrition and hunger; a list of possible interventions should then be prepared also with beneficiaries’ participation. Through a process of ensuing social mobilisation, the list will become the basis for demanding the removal of some of the structural constraints that are ultimately determining the state of chronic hunger in identified sectors of the population.
Why populations are impoverished
Countries that are poor, and poor regions and communities within any country, are impoverished through similar pathways. Consider the following 20 macro-causes of undernutrition and hunger:
- Low percentage of national income going to the lowest 20 percent of the population (income maldistribution);
- Land maldistribution;
- High percentage of landless agricultural labourers;
- Rural unemployment;
- Urban migration;
- Urban unemployment;
- Low minimum wage policies not in tune with the cost of a minimum food basket and not following food price inflation;
- Low farm-gate prices for food crops as opposed to their urban retail prices;
- Marketing boards’ of agricultural commodities exploitative practices towards small farmers;
- Low percentage of foreign export earnings reinvested in agriculture;
- Food import policies (or food aid) in contradiction with national efforts to increase local food production;
- The share of agriculture in the national GDP slipping in favour of other sectors of the economy;
- Credit bias towards the modern agricultural sector as opposed to the traditional agricultural sector;
- Lack of agricultural input subsidisation for small farmers, especially for food crops;
- Foreign aid not reaching the neediest;
- Women left outside development programmes with little incentives to incorporate them in the money economy;
- Little emphasis and scanty budgets for genuine community development and rural cooperatives;
- Low primary school enrolment rates especially for girls;
- Feeble efforts to increase adult literacy, especially for women; and
- Scanty budgets for preventive health services.
Undernutrition and hunger is indeed a social disease! It cannot be eradicated by medical interventions, not even if these are comprehensive. Nor can it be eradicated by a combination of medical and agricultural interventions.
Redistribution of resources and wealth, and the consequent increase in purchasing power of the needy majority, are necessary to reduce undernutrition and hunger. But not even these are sufficient. Poverty has many masks, such as cultural and educational deprivation, poor health, and inadequate sanitation and housing, each with its own features. We should not think that improvement of the features of such masks will have any lasting effect. The real face of poverty is socioeconomic deprivation and gross power imbalances in society.
How far can we go?
Many among us have divided the remedial actions finally proposed into two groups: ‘recommendations’ and ‘interventions’. Recommendations often concern macro-causes and the need to change or remove them; they are usually worded in very vague, general terms and have no specific implementation budgets or deadlines set aside. Interventions often concern micro-causes, are prepared in more detail, have a fixed implementation deadline, and usually have budgets.
How outspoken are we prepared to be in proposing corrective measures directed to the macro-causes? This will depend on the political environment in which each of us works. Political and professional risks are usually high (2). Many colleagues feel that their positions in academe, government, or international or private organisations might be jeopardised if they demand radical solutions. They take a ‘survivor’s’ attitude. This is disturbing.
We need to stop thinking that we cannot contribute much to the selection and implementation of non-nutritional interventions that are outside our immediate field of expertise.
Macro-causes can be exposed in a number of ways. Not all of these need to be dramatic or sensationalistic. For example, the possible interventions that flow from the analysis of macro-causes could be listed under a soft yet realistic title, such as: ‘Conditions under which interventions addressing the more immediate determinants of malnutrition will have a better chance of having an impact’ (3).
This should be followed by an estimate of the realistic potential of each macro- intervention to ameliorate undernutrition and hunger. This should include, and be based on, the demands that mobilised groups of claim holders will place in front of authorities. This kind of presentation is meant to show that, if macro-causes are removed or minimised, interventions that follow, geared towards removing micro-causes, are more likely to have a real and lasting impact.
Political and ideological constraints, as well as the attitude and commitment of decision-makers towards eradicating hunger, will determine how far any planning team can go. Beware though that such constraints can be overcome; social mobilization is the key that unlocks the Gordian knot.
The main problem with taking a ‘macro’ approach, is that it will look ‘too politically radical’ to the governments addressed. If so, they are probably not genuinely interested in solving the problems at hand. We often underestimate this. Sometimes it is hard to tell, given the lip service governments pay to their commitments.
Analyses of the type summarised here hopefully have an educational value, especially if they are documented with some hard evidence about issues that politicians and decision makers already know well, but choose to ignore.
We tend to assume that decision makers are rational and righteous, and will accept hard scientific evidence and react to outrageous injustice. Such assumptions are usually mistaken.
Colleagues who participate in the planning process may gain a new consciousness as a consequence of using this approach. This alone makes the effort worthwhile.
1 Makhoul N. Agricultural Research and Human Nutrition: A Comparative Analysis of Brazil. Cuba, Israel and the US. International Journal of Health Services 1983, 13, 1:15-24
2 Chossudowsky W. The Neoliberal model and the mechanisms of economic repression. Coexistence 1975, 12, 1
3 Schuftan C et al. Recommended national food and nutrition plan for Liberia. Mimeo. Interministerial technical committee on food and nutrition planning. Monrovia, 1982).
SO MANY WORDS AND WHERE IS THE ACTION…
Ho Chi Minh City. I am back home now in Vietnam. After reading an exceptionally long list of emails I have just received, I fell into a pessimistic mood. I was thinking of roads paved with good intentions. This is what came out:
1 So we organise, expose, rationalise, denounce, analyse, network, liberalise, accuse, mobilise, study, decentralise, communicate, prioritise, implement, point a finger at, develop, monitor, evaluate, (reanalyse), measure, research, publish, present, advocate, persuade, correspond, orient, contribute to a list server, meet, declare, assess, legislate, decree, (reorganise), define, negotiate, devolve, fund, train, invest, capacitate, (reorient), build, seek answers in the internet, strengthen, deliver services, educate, give credit to, (redefine), provide literacy, procrastinate, lose our temper, despair, dismiss, reform, impose conditionalities, …or throw money at…
2 And then do all the above some more…
3 But what does this really do to stop the relentless march towards pauperisation, polarisation, violations, globalisation, desperation, exploitation, conglomerisation, monopolisation, transnationalisation, ‘IMFisation’, depreciation, masculinisation, centralisation, global speculation, devaluation, degradation, privatisation, depletion, erosion, deforestation, malnutrition, corruption, unfair competition, pollution, domination, oppression, repression, growing gaps, fundamentalism, authoritarian regimes, mergers, ill-health, disempowerment, growing inequities, free market excesses and abuses, maldevelopment, social unrest, trade imbalances, displacements, refugees, tribalism, and nepotism ?
4 So what? Who are we really failing, serving, fooling, satisfying, helping, cheating, speaking for, representing, defending, misleading, pleasing, empowering, condoning, letting get away with, supporting (by design and by default)?
Does anybody out there care to add to this list… or make it rhyme… or help me out of this terrible mood? Where has the big picture gone? And what are we doing about it?
September 11th, 2010 by Matthew Anderson
I would like to think that you often ask yourself – as I do – what all of us could all do better to achieve greater justice, given that most of us work in or with countries with appalling social inequities. Allow me to share with you some of my thoughts on this.
I see our role as helping put in place social processes and mechanisms that will drive sustainable human rights-based policies and practices in health and nutrition. These need to be part of how we help to instill a new will and commitment in decision-makers to change underlying preventable structural inequities in society.
We can come to this from an ethical motivation, or else from a political motivation. Both stances can drive us to become more involved in lessening inequities. They should both propose, not packages of universal solutions, but paths to follow to get things that need to be done, specifying by whom, with whom, and against whom.
Living as we do in a mean, unfair and selfish world, I believe we need to graduate from the ‘universal package’ approach to the ‘paths to follow’ approach. Let me explain why.
|The human right to adequate nutrition
Rights are different from needs. Aid and development policies and programmes based on the concept of need, as they almost invariably are, see the malnourished child as an object. Needs do not necessarily imply duties or obligations, but may invoke no more than promises. In the rights-based approach, the malnourished child is seen as a subject with legitimate entitlements and claims. Rights always imply, and carry with them, duties and obligations.
Human rights concepts applied to nutrition have evolved since the 1980s. Early thinkers began by claiming an inalienable ‘right to food’ of all human beings. But after the worldwide adoption of the UNICEF-proposed conceptual framework of the underlying and basic, as well as the immediate. causes of malnutrition, it became clear that food security was only one element of nutritional well-being. This led to the coining of the concept of the ‘right to nutrition’ (meaning adequate nutrition), addressing all types of causes of malnutrition. This in turn led others to pursue a yet more ambitious aspiration for the ‘right to development’.
The concept of ‘the right to nutrition’ has been opposed by the governments and other policy-making bodies in high-income countries, particularly the US. Also, the US concept of human rights differs substantially from much of the rest of the world. In the US, civil and political rights carry more weight than economic, social and cultural rights. The US government also objects to the idea that rich countries have obligations towards impoverished countries, despite the rich continuing to be responsible for their impoverishment and for infringing their economic, social and other rights.
How inequity is perpetuated
||AS WITH SLAVERY, THERE ARE ETHICAL LIMITS
TO THE TOLERATION OF EXTREME POVERTY
Those responsible for the current process of globalisation, with its progressive accumulation and concentration of economic and political capital, see human rights as a threat, because the human rights-based approach is an alternative to neo-liberalism: It has divergent and rival imperatives and justifications.
Conversely, the human rights based-approach sees neo-liberalism as a political and economic system out of control, which creates uncertainty and dependency, brings about fear, aggression, and fundamentalism, and makes ever-expanding spaces for private interests. Neo-liberal politicians and economists push for the rights of individuals (for example, property), limited state activity, and for a free-wheeling market, and say that the poor are responsible for their own poverty. Hidden in the unacceptable current social differences and social injustices is the neo-liberal ideology, with much money, much poverty, much silence, much omission, much disdain, much disillusion.
Often, policy-makers in rich donor countries accuse human rights activists of not being preoccupied with issues of bad governance in poor countries. We counter-argue that political outcomes are not only determined by the interaction between content matters (policy) and institutional structures (polity), but by raw political interests (often post-colonial interests in the case of donors).
In policy circles, concepts tend to be discussed over and over again, but they are only rarely implemented in reality. Those that have the power to define what poverty is, also have the power to define its causes, and thus to decide to act on what they see as solutions. Those in charge in rich countries think and act as if only their small cut-out of reality is the real valid one. They deny other dimensions of perceived reality – and these are those that need to be addressed.
In opposing this latest manifestation of globalisation – which is capitalism gone to extremes – what is missing is an integration of the multiple international human rights obligations, in the process of negotiating, among other issues, debt relief and free trade agreements. Existing arrangements are the result of poorly negotiated multilateral or bilateral compromises. There is an asymmetry in the bargaining power that rich and poor countries bring to these negotiations. It is thus urgent to carry out human rights impact assessments in the contexts of debt and trade, especially their effects on women and on other vulnerable groups. Additionally, we must confront the unequal distribution of power structure within governments.
In other words, globalisation, unequal representation, free-wheeling markets, dependency, the neo-liberal political and economic ideology, the debt crisis, and international ‘free trade’ agreements, all limit national human rights policy space, as well as policy space for nutrition. They also amount to an outrage. As with slavery, there are ethical limits to the toleration of extreme poverty.
The myth of the market
||THE STRUCTURAL CAUSES OF POVERTY DETERMINE PREVENTABLE ILL-HEALTH AND PREMATURE DEATH
|Why then are nutritionists in their profession still not committed to a human rights philosophy? Such a commitment does give us the best chance to counter the increasingly negative impacts of globalisation in its current form, which is creating and accelerating poverty – most often with malnutrition as an outcome. At the same time, globalisation is creating growing disparities, exclusion, unemployment, marginalisation, alienation, environmental degradation, exploitation, corruption, violence and conflict, all of which in one way or another impinge on nutrition.
People who are being marginalised by globalisation today are being pushed to and past the limit, and they need to channel their frustrations into positive action. But people who happen to be poor are still being offered top-down social services, and are thus not really active claimants of their rights
Are we part of the problem?
The human rights approach introduces or reinforces a crucial missing element in development work: people forcefully demanding their inalienable rights. This is its added value in all work being done in the area of nutrition. So why has it not generated more enthusiasm?
The rights-based approach takes the entitlements of those being marginalised as its starting point. Human rights and equity go hand in hand. The rights-based approach thus focuses on the basic and structural causes of poverty, which are the main determinants of ill-health and malnutrition.
There is still a segment of the human rights community that thinks that world order issues can be settled without confronting the power issues that are still slanted against the welfare of the majority of the marginalised. But is this a contradiction?
The Millennium Development Goal of halving worldwide malnutrition rates by 2015 will not be achieved through the piling up of yet more ‘benevolent’ free market policies. We are being sold a mythical utopia in the absurd belief that ultimately a global ‘free market’ will cater to everybody’s needs and make everybody happy. I ask: how much are nutrition professionals influenced by this myth?
How we can be part of the solution
Because of the gross flaws of globalisation, a more humane global governance is now needed – more than ever.
There is no need to argue about whether globalisation or bad governance is the most important cause of human rights violations. The human rights approach shows us what states should do or should not do. When they fail the test, many governments complain of being victims of a global process as an excuse for not implementing their obligations.
How much of their general budgets governments devote to nutrition, to health, to food security, to education and to poverty alleviation, is of substantive human rights concern. So is how such expenditures are distributed among the various socio-economic population groups. Governments violate human rights when they fail to offer adequate and participatory health and nutrition services to the poor.
To take a very real current issue as an example, if the provision of such services are privately organised, governments still remain responsible for the egalitarian and quality provision of the same. But do they accept this responsibility? Mostly they do not. Short of opposing it, civil society watchdog groups should be monitoring the privatisation of public goods and denouncing its shortcomings more forcefully.
A human rights-focused analysis of statistical data should examine to what extent various expenditures on nutrition and other social services are equitably distributed among the diverse socio-economic groups. The same watchdog groups have a role in scrutinising the actions funded to make sure they ‘respect, protect and fulfil’ the human rights of the poorest.
Are governments the sole holders of human rights duties? Legally, the answer is yes – governments are the actual signatories of the respective covenants. But, in reality, there are indeed other duty bearers.
Take the example of children as rights holders. The duty bearers of children’s rights are, first and foremost, the immediate care-giver (the mother or other), followed by the family or household members, the community and neighbours, and then local, sub-national, national and international institutions. These all amount to a web of complementary duty-bearers.
This points to nutrition, and the responsibility of its professionals. Together with empowered community leaders, and working with civil society organisations, we need to ensure duty bearers’ responses at all these levels.
What then is to be done?
This is the theory. The challenge right now is to convert these concepts into working programmes, where people’s claims are forcefully exerted as their inalienable right.
The recognition of the fundamental right to adequate nutrition of all humanity is the ethical and political basis of the overall approach nutrition professionals should embrace. But proper understanding of this right has largely so far been confined to international institutions specifically engaged with human rights issues, especially United Nations agencies. How much can these agencies shift current and upcoming nutrition programmes to a human rights focus? Perhaps quite a bit. But all actors, including health professionals, need to see the picture.
One first challenge will be to create a common language to be used by UN and other international agencies, governments and their agencies, professional and civil society organisations, and the beneficiaries. The language needs to be primarily based on social commitments to human rights, and on raising the level of responsibility of the different actors, as more active claim holders and as more responsive duty bearers.
Most governments unfortunately suppose that the recognition of the right to adequate nutrition would interfere with their current policy choices. But states have already signed covenants that guarantee respect of the right to adequate nutrition under any circumstance, irrespective of their resources. While certain aspects of the rights approach can be implemented progessively, governments need to be made to understand that there is a minimum core of rights that all states simply have to uphold.
A second challenge is to make the human rights approach concrete and to give it substance. The field of nutrition is, for sure, an inescapable candidate. For nutrition professionals, human rights objectives need to be better singled out, defined and refined. The right to adequate nutrition has yet to acquire a concrete meaning and reality. This is an immediate responsibility for all nutrition professionals. Effectively mainstreaming human rights in all nutrition activities remains a challenge of enormous dimensions. The challenge is political. First, nutrition professionals need to see that the human rights approach is crucial and fundamental. For many of us, this involves new thinking and recognition and acceptance of a new conceptual framework.
Personal illness, population health
The medical impediment
||HEALTH CARE IS INCREASINGLY USED AS A SUBTLE,
WIDESPREAD INSTRUMENT OF SOCIAL CONTROL
Nutritionists are not helped when, as is now usual, they are trained in the context of modern Western medicine. This treats disease at the individual level, rather than promoting community health. It attributes the causes of illness to faulty individual behaviour or natural misfortune, rather than to social injustice, economic inequity, and oppressive political systems that disregard people’s human rights.
Malnutrition packs the equivalent of the Twin Towers 11 September death toll every 3½ hours. Differences include that most of the victims are small children, and that practically all the deaths follow weeks of tortuous misery. A larger number of children do not die, but are left disabled or seriously ill. A substantial percentage of malnourished children are child labourers.
Currently, only about 10 per cent of overseas development aid goes to health and nutrition projects and programmes in lower-income countries. This means that external funding for health care and nutrition in all these countries amounts currently only to slightly more than $US 8 billion a year. Furthermore, health care in impoverished countries is increasingly used as a subtle, widespread instrument of social control.
The gaps in health and nutrition equity worldwide – in terms of numbers of those affected by many types of preventable ill-health and malnutrition – continue to widen. Health and nutrition are more about power imbalances, than about morbidity and mortality. They are more about control over the basic determinants of ill-health and malnutrition, than about the treatment of diseases and the rehabilitation of the malnourished.
The right to adequate nutrition
The fight for rights
||WE NOW NEED TO COMMIT OURSELVES TO THE NEW AGE
OF THE HUMAN RIGHT TO ADEQUATE NUTRITION
Making human rights basic and central to the work of nutrition professionals also involves the need to demand many things. Among these are:
- That economic and physical access to basic community-based nutrition
services be equally guaranteed for girls, women, the elderly, minorities and
- That steps be taken progressively to achieve all human rights (the right to
adequate nutrition being the point of departure for nutrition professionals).
- That the private sector (national and transnational) be made to comply with
human rights dispositions.
- That accountability, compliance and institutional responsibility be required
from relevant duty bearers in all processes aimed at improving nutrition.
- That administrative decisions in nutrition programmes are in compliance with
human rights obligations.
- That governments’ resilience to embark in meaningful nutrition interventions
be differentiated from their inability to comply.
- That, if unable to comply, governments be required to prove that there are reasons beyond their control that stop them from fulfilling their responsibilities.
- That national strategies on the right to nutrition be adopted, using and
defining clear, quantified verifiable benchmarks.
- That the implementation of national nutrition strategies or plans of action be
transparent and decentralised, and include people’s active participation.
- That the same plans progressively also move towards eliminating poverty,
the main determinant of malnutrition.
- That new legislation on the right to adequate nutrition be developed,
involving civil society in its preparation, enforcement and monitoring.
If the above demands are met, the added value of the rights-based approach to nutrition will be such that:
- Beneficiaries will become active claimants of their rights.
- Claims will be made more forcefully (making governments effectively liable).
- This will stress the international and national legal obligations of states.
- The right to adequate nutrition will be the foundation for relevant programme decisions.
- This will move discussion from charity/compassion to the language of rights and duties.
In short, the human rights approach enhances the scope and effectiveness of nutritional, social and economic corrective measures, by directly referencing them to what are already close to being universally accepted obligations found in related UN covenants.
These obligations are in competition with obligations stemming from other rights, especially when resources are scarce. But the duty to fulfil the right to adequate nutrition does not depend on an economic justification, and does not disappear when it can be shown that tackling some other problems is more cost-effective.
To put things in a historical perspective, in the basic human needs-based approach, beneficiaries had no active claim to their needs being met. The human rights-based approach gives such claims legal and political status and force.
We nutrition professionals all need to commit ourselves, in our teaching and our practice, to the new age of the right to adequate nutrition.
December 1st, 2009 by Matthew Anderson
Our colleagues at THE POINT, a South Bronx Community Development Corporation, sent us the following flyer for the South Bronx Food & Film Expo, this Saturday, December 5th (noon to 5PM).
Their announcement reads:
If you are interested in growing your own food, or having better access to healthy food, or getting involved with changing current food policies, this is the event for you! Our expo features groups that can help you do all this and more. Or if you simply want to come sample free local healthy foods, maybe learn a thing or two, and watch a few great films, you are welcome as well!
Rethinking the way we eat
This event will showcase some of the activism around rethinking the way we produce and consume food.
- Urban Farming, one of the sponsors, is an organization that promotes the use of urban spaces to plant gardens. They have developed the concept of vertical farming - “edible” food-producing wall panels mounted on walls of buildings, growing fresh produce (without the use of pesticides).”
- Bascom Catering will be providing free, locally-sourced Vegan lunches.
- Short films from the Bronx will be showcased. As an example, this link shows a shortened version of an urban farming video made at the Point.
- Two feature films will be shown. What’s on Your Plate? and FRESH! What’s on Your Plate? is a documentary that follows two eleven year old NYC girls as they try to figure out how food gets onto their plates. FRESH! focuses on the efforts of activists across the country to “reinvent the food system.”
- An interactive expo will feature groups from the South Bronx and beyond that grow and supply healthy local food, and fight for change in food policy.
Details: This event is free, but there is a $10 suggested contribution. Food/clothing donations are encouraged. Childcare will be provided. For more information, contact: Adam, email@example.com
For more information on local food activism, consult some of our earlier posts on food and nutrition.
posted by Matt Anderson, MD
June 30th, 2009 by Matthew Anderson
As a follow-up to our earlier post on nutrition in New York City (Feast or Famine) our colleague Renee Shanker sent us an updated list of Farmers’ Markets in the Bronx (see link). For a complete list of farmers’ markets supported by the New York City Department of Health visit this link.
posted by Matt Anderson, MD