Archive for the 'Globalization and Health' Category

Ebola in Liberia

Add a comment
 Volunteers of International Medical Corps (IMC) suiting up in personal protective equipment (photo by J.M. Souers)

Volunteers of International Medical Corps (IMC) suiting up in personal protective equipment (photo by J.M. Souers)

MONROVIA, Liberia — Though the Ebola epidemic that put the world on edge may be waning in parts of West Africa, there is much more work to do be done to ensure this underserved region of the world does not continue to suffer from a potentially endemic and devastating disease.

From the start of the Ebola epidemic in West Africa there have been almost 10,000 reported deaths and 14,269 confirmed cases in Sierra Leone, Guinea and Liberia, according to the World Health Organization (WHO). The U.S. Centers for Disease Control and Prevention (CDC) was here in Liberia during the initial outbreak but pulled out in May thinking everything was under control. In August, months after the CDC left, the real Ebola crisis struck Liberia.

In January, I applied to Adventist Health International (AHI) to work as a volunteer physician at SDA Cooper Hospital in Liberia. The hospital is run as a general hospital that has been providing health services during the epidemic to patients that are not suspected of Ebola while screening and referring patients with signs of the illness to Ebola Treatment Units (ETUs).

On February 9, 2015, I arrived at the hospital in the capital city of Liberia. Upon arrival I learned of a confirmed case at our hospital that had been transferred to an Ebola Treatment Unit (ETU) just a few days earlier. The hospital now had to shut down the inpatient services for decontamination and everyone who had contact with the case agreed to be quarantined for 21 days as a precautionary measure. Since I did not have contact with the Ebola patient, I continued working at the hospital in the out-patient department and continuous infection control and prevention training.

The hospital was soon overwhelmed by representatives of the WHO, CDC, Medicins Sans Frontieres (Doctors without Borders), International Medical Corps and the Ministry of Liberia. In a semi-coordinated effort, representatives of the different organizations came to our hospital to offer their advice and services.  We were pleased to see that these organizations were finally giving our hospital assistance and aid, but staff was frustrated that the offer had not come earlier during the actual crisis.

The situation in Liberia is now finally starting to stabilize. There was a period of more than 25 days with no confirmed cases, according to sources at the CDC in Monrovia. Though, on March 19th a patient presented to Redemption Hospital in Monrovia and was confirmed positive on March 20th. It is rumored that the patient contracted the illness from Sierra Leone, not unlikely due to the very porous border between the two countries. Another theory is that the patient contracted the disease through sexual transmission from her partner over three months after he had been released from an ETU. This reality does not heed well for the already pronounced stigma towards survivors.

It is concerning that many organizations are already talking about decommissioning the ETUs to redeploy aid and services to Guinea and Sierra Leone, where the situation is much worse. There is no doubt that the epidemic must be further addressed in these countries to ensure the safety of Liberians and all of West Africa, but it is important to continue to support efforts in Liberia to eradicate the illness. The health system still needs major improvement to reduce the risk of an uncontrolled and devastating outbreak in the future.

Community leadership seems to have had the most impact on curbing this disease in Liberia. Recognition of the disease, plus changing traditional practices and customs was more widely accepted and accomplished in Liberia than in Sierra Leone or Guinea. This shows how important it is for healthcare organizations to work directly with community leaders at the local level, educating the general population to cooperate in changing habits and customs (i.e. burial customs, consumption of bush meat, hand washing and sanitation) that propagate such an infectious illness.

Education is critical, which is most apparent when working with hospital staff that has very little basic knowledge of infectious disease prevention and control. This is in part because we are in a country with extremely limited health infrastructure including hospitals without running water, dependable energy sources or proper waste management.  What does exist is hardly adequate to provide even some of the most basic health care needs of the population. It is a shame that an epidemic like Ebola was necessary to bring this to international attention.  It is even worse that the short-term solutions are almost exhausted and very few long-term solutions have been established.

Volunteer of International Medical Corps (IMC) working in hospital triage at SDA Cooper Hospital in Monrovia, Liberia (photo by J.M. Souers)

Volunteer of International Medical Corps (IMC) working in hospital triage at SDA Cooper Hospital in Monrovia, Liberia (photo by J.M. Souers)

Focus has turned towards effectively training health care workers in the hospital setting with the proper equipment and precautions for infection control and prevention. Transitioning care from the ETU setting back to the hospital setting has been aided by the “Keep Safe, Keep Serving” curriculum provided by the Liberian Ministry of Health.  Still, there are too few properly established hospital protocols to protect staff and patients from another outbreak. This creates insecurity for the hospital staff.  Proper onsite training, triage staff, laboratory testing, contact tracing teams, supply chain availability, international support and local community education are still needed to continue to address this transition.

The international community can help by not allowing this epidemic to be just another news flash.  Instead, they should make it their long-term mission to help developing countries create sustainable healthcare reforms and infrastructure for long-term outcomes.  Their incentive should be to limit the spread of communicable diseases like Ebola that are no longer confined to remote areas of the world given our new global economy.  Unless these diseases are recognized quickly and controlled effectively at their source, they can and may spread rapidly and become an international pandemic that threatens everyone.

Joanna Mae Souers is a medical doctor, native of upstate New York, and graduate of the Latin American School of Medicine in Havana, Cuba.

SocMed Uganda 2015 Course Announcement – Reminder

Add a comment

Greetings all,

A reminder that our application deadline is quickly approaching at the end of June.  We welcome applications from all interested health professional students.


Michael Westerhaus


On behalf of SocMed, we are please to invite health professional students to apply for the fifth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience offered on-site at Lacor Hospital in Gulu, Uganda from January 5th – 30th, 2015.  Beyond the Biologic Basis of Disease merges unique pedagogical approaches including community engagement; classroom-based presentations and discussions; group reflection; theater, film, and other art forms; patient clerking and

SocMed Uganda 2015 Poster

presentations; and bedside teaching.  These approaches create an innovative and interactive learning environment in which students participate as both learners and teachers to advance the entire class’ understanding of the interactions between the biology of disease and the myriad social, cultural, economic, political, and historical factorsthat influence illness presentation and social experience of disease.

The course curriculum places considerable importance on building partnerships and encouraging students to

reflect upon their personal experiences with power, privilege, race, class, and gender as central to effective partnership building in global health.  In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty andstudent colleagues.

In our annual Uganda course, thirty health professional students enroll each year, with half of the spaces filled by students from Ugandan medical and nursing schools, and the other half filled by international students from anywhere outside Uganda.  Credit for away-rotations can be arranged.

This course is offered through SocMed, a non-profit organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

More Information and Application Process

Further information and applications can be found in the Social Medicine Course Prospectus 2015 and on the SocMed website:   Please view short videos describing the course, publications related to the course, and advocacy videos created by previous students during the course by visiting the “Resources” tab on the website.

Applications are due June 30, 2014 and can be downloaded from the website.  If you have questions, contact us at

Please do not hesitate to contact us with any questions you have.


Amy Finnegan, Ph.D.

Phyllis Kisa, MB.Ch.B, FCS ECSA

Michael Westerhaus, MD, MA

SocMed Co-Directors

Key questions to guide the UN Post-2015 High Level Panel’s work and consultations on the future development agenda.

1 Comment


Suggested responses by Claudio Schuftan in a personal capacity.


I. Qs on lessons learned and context:

1. What have the MDGs achieved? What lessons can be learned about designing goals to have maximum impact?

The mix of MDGs achievements/shortcomings is by now well known. The question here is: Do we really want to set goals –in terms of outcomes? Or do we rather want to set (annual) benchmarks –much more related to processes (a central critique of the MDGs). Goals, in the past and in the present, aim at achieving national averages. By design, this leaves half of those affected below the average. To be consistent with the UN-sanctioned Human Rights Framework, setting goals will only make sense if these are applied at the sub-national level, i.e., district or municipality since only this allows focusing national efforts on those territorial units so far most neglected and discriminated. With this being accepted, the concept of maximum impact will have to be redefined in the new framework.


2. How has the world changed since the MDGs were drafted? Which global trends and uncertainties will influence the international development agenda over the next 10-30 years?

The world has changed plenty; but how much due to or despite the MDGs? Let us keep in  mind that the selection of MDGs was arbitrary and top-down with many of us having complained about issues left out and about the lack of consultations when they were set. The global  trends that will influence development are, for sure, peace, the progressive realization of human rights, and our success in making democracy more a local direct democracy (as opposed to the flawed representative democracy we, at best, have now). But keep in mind that the global trends will be made up of myriad local and regional trends –certainly not forgetting those due to both economic and climate-related migration– which the new framework will have to influence in a positive direction. The human rights framework is the most effective tool we have to achieve this. In the next development phase, let the human rights perspective, then, guide the deployment of human, financial and other resources.


3. Which issues do poor and vulnerable people themselves prioritize?

First of all, ‘vulnerable people’ I think is a euphemism. [It is the same as speaking of ‘people at risk’; we tend to think that people take risks but, beware, risks are also imposed!]. To avoid any sort of victimization, we must talk of marginalized people. Vulnerable has a connotation of ‘poor them…’; marginalized tells us our social arrangements have put them in that situation. Now to the question of which issues claim holders prioritize: The question has not been answered! Why? Mainly because we have not systematically asked them. Let us do that…and then heed their advice!  I have great hope that this time we put this question at the very center of what we do in the massive consultation that has now been launched. Should I be optimistic? For people to influence priorities, development work cannot only continue focusing on service delivery, on capacity building and on (depoliticized) advocacy; what is needed is a focus on empowerment and social mobilization (the latter also called practical politics). It is not easy to say what is really empowering in community development work. Any attempted operational definition will (always) carry a certain bias depending on the conceptual glasses one is wearing. What is clear is that –in a mostly zero-sum game– the empowerment of some, most of the time, entails the disempowerment of others –usually the current holders of power. Empowerment is not an outcome of a single event; it is a continuous process that enables people to understand, upgrade and use their capacity to better control and gain power over their own lives. It provides people with choices and the ability to choose, as well as to gain more control over resources they need to improve their condition. It expands the ‘political space’ within which iterative Assessment-Analysis-Action processes operate in any community. That is what we need to pursue.

4. What does a business-as-usual scenario look like?

The business as usual scenario paints quite a grim picture, I’d say. Take, for example, the poverty alleviation discourse in the MDGs: it displaced the poverty debate worldwide: from a political discussion about its causes to a technical, risk management scheme. (N. Dentico)

Bottom line, I am not sure MDG achievements will all be sustainable. We have raced for the outcomes neglecting the participatory processes to get there, and what we see does not bode well.

An equally important question is: What does a business-as-usual mode foretell?  As another example, take the following: if current trends continue, by 2015, 3.7 million more children in Africa will suffer from malnutrition than are today. My crystal ball tells me we will see more fundamentalism more ‘…springs’, growing frustration, more (understandable) explosive conflicts; perhaps some empowerment in the process, but empowerment in an unpredictable direction; some good, I’d expect. What this tells us is the urgency for the post-2015 agenda to address the real deep structural causes of widespread disempowerment of those that live in poverty/happen to be poor.

Perhaps the most crucial element missing in the MDGs was a conceptual framework of the causes of underdevelopment (or maldevelopment). In the 1990s, UNICEF pioneered the now widely accepted conceptual framework of the causes of malnutrition identifying its immediate, underlying and basic or structural causes importantly showing that addressing each level of causality is necessary but not sufficient. This omission of the MDGs cannot be repeated by the new framework we are all trying to come up with. An adaptation of the already well accepted UNICEF framework is perhaps the best way to address this omission. Are we up to the challenge?


II. Qs on the shape of a post-2015 development framework:

5. How should a new framework address the causes of poverty?

Based on the new conceptual framework on the causes of maldevelopment I plead be arrived at by consensus, the post 2015 framework will importantly have to work on deconstructing neoliberal globalization –the latest incarnation of raw capitalism. Why? Because it is not about the alleviation of poverty (much less about the chance of eradicating it); it is about a quantum reduction of disparity the world over –among and within countries. It is about working out new mechanisms of redistribution of wealth and power. And such a redistribution will only come through empowerment and social mobilization from below; with people going from having voice to exerting influence. I worry that all the good intentions of the UN to address the structural causes of poverty in the conceptual framework will lead to another 10 years of failure if it does not politicize this issue. The rich have no intentions to give up their power and privileges; non-violent counter-power has to be organized and applied. Dialogue has to become a dialogue of equals.

6. How should a new framework address resilience to crises?

Ultimately, the common denominator of most of the man-made crises can be attributed to the excesses of capitalism. (It is not really the excesses of capitalism but capitalism itself that cause the problems; those excesses are only the inevitable result of raw capitalism, more systematically implemented). Decisive steps must be taken by the new framework to foster the social mobilization needed to make sure effective disparity reduction measures are launched nationally and internationally. [ Internationally, this means giving accredited NGOs a seat, voice and vote in UN and in government deliberations. Environmental crises have both natural and man-made causes. As Rio and Rio+20 have shown us, we can effectively address the latter. The new framework must depart from this premise and thus, as a minimum, incorporate Rio+20 recommendations.


7. How should a new framework address the dimensions of economic growth, equity, social equality and environmental sustainability? Is an overall focus on poverty eradication sufficiently broad to capture the range of sustainable development issues?

The economic growth model has been shown to be unsustainable, mostly (but not only) on environmental grounds. Does the new framework have an option not to deemphasize economic growth as the main development goal? It actually needs to denounce it in no uncertain terms.

Reaching equity and social equality inevitably points to the fact that both need the processes of empowerment and social mobilization I insisted-upon earlier.

For environmental sustainability, the roadmap has already been worked-on by the experts in  Rio and Rio+20 so that the new framework has to adopt its recommendations.

As said, the focus ought not to be on poverty eradication, but on disparity reduction which has connotations for urgently needed actions both in rich and in poor countries including changes in many, if not most, aspects of ODA.

The disparity reduction approach is necessary, but not sufficient to capture the range of sustainable development issues. Rio+20 is clear about this.


8. What should be the architecture of the next framework? What is the role of the SDGs in a broader post-2015 framework? How to account for qualitative progress?

The broader architecture of the next framework must absolutely be based on the human rights framework. Enough of lip service. It is time for deeds (related, nothing less, than to the Universal Declaration of Human Rights and to the UN Charter). From now on, we have to look at the development process from the perspective of claim holders and duty bearers in their dialectic relationship. This language must be adopted and both groups have to be made more confident and assertive in their respective roles, i.e., claim holders placing concrete demands/staking claims and duty bearers abiding by UN Covenants, Conventions and General Comments. The concept of progressive realization is another one to be given center stage.

The role of the Sustainable Development Goals is also key. We only have one planet! Heed the recommendations from Rio!

Also related to the architecture, there will have to be a global UN body with executive powers following up on the implementation of the new framework. (The MDGs did not really have this; it was left to countries to apply them; there was no global accountability). This body must be endowed with funding. It must have some kind of an executive ombudsperson role on issues of implementation and must work towards influencing international financing mechanisms being made available.

To account for qualitative progress, yearly benchmarks have to be set by each country (especially for the poorest districts/municipalities) based on processes that must be implemented en route to the progressive realization of the different human rights. Civil society organizations are to be appointed as watch dogs for the achievement of these benchmarks; they need to receive funds specially earmarked for this.


9. Should (social, economic, and environmental) drivers and enablers of poverty reduction and sustainable development, such as components of inclusive growth, also be included as goals?

The word enablers is a rather vague one. So is inclusive growth. I had already suggested a) that we need to deemphasize economic growth as the main development goal, b) that the selection of outcome goals is likely to be less useful than the use, inclusion and of yearly processes-achievement benchmarks, and c) that disparity reduction, and not poverty reduction, is the term to be used from now on.

Indeed, the three drivers mentioned in the question need to be tackled –but absolutely not forgetting a fourth one, namely the political driver. Each is necessary, but not sufficient. [The UN being non-political is to be understood in terms of non-political-partisan, but, by God, it needs to act more decisively on issues political in nature it strongly stands for; therefore, when needed, calling a spade a spade. Some agencies do it more that others].


10. What time horizon should we set for the next phase in the global development agenda (e.g., 10, 15, 25 years, or a combination)?

I am more inclined for five years with yearly-interval benchmarks as yardsticks of progressive realization. Yearly achievements/shortcomings can thus be assessed and adjustments made accordingly, as needed, in a participatory manner. With the world changing as fast as it does, I am sure that major adjustments are justified every five years –at least at the country level.


11. What principles and criteria should guide the choice of a new set of goals?

The human rights principles of non-retrogression, universality and inalienability, indivisibility, interdependence and interrelatedness, equality and non-discrimination, participation and inclusion, and accountability and rule of law are, once and for all, to guide the new framework. The assessment of these principles being respected is to be built-in into assessing annual benchmarks.

The main criterion that must go with this is for countries to be mandated to participatorily draw-up long-term and annual plans for the progressive realization of human rights Human rights are all closely related to the development process. (Such plans could be a requirement for ODA as well). The new framework must demand these progressive realization plans be drawn up.


III. Qs on themes and content of a new framework:

12. To what extent can we capitalize on MDGs achievements and failures in developing our post-2015 development agenda?

To a great extent and to begin with, the agenda can not again be drawn top-down –a challenge that I still see unresolved. Opening up the consultation to development workers worldwide reading this is only a variance of a top-down model.  We not only can, but must capitalize on both the positive and negative lessons learned from the MDGs. Which lessons? Ask the recipients of MDG ‘benefits’! This calls for governments and local civil society the world over to jointly open, in the next year, a wide dialogue on post-2015 options. Seed funding is needed if we are serious about this.


13. What is the legacy agenda of the existing MDGs that will be inherited in the next framework? Which elements should be revised in the light of lessons learned, such as the importance of girls’ education and gender equality?

Positive points notwithstanding, the legacy of MDGs shortcomings, as I see them, is that they had donor over-influence; had a technical over-emphasis; paid no attention to acting on the underlying social and economic inequalities; they lacked a systematic long-term financial commitment; had a predominant focus on health and education; and overlooked the entire participation and political economy contexts. Furthermore, they did not quantify the obligations of the rich countries (this assumed that poverty is a problem of poor people only); actions to be taken in the rich countries must simply be part of the next framework.

Poverty was defined in the MDGs as a state in which people have to live in the equivalent of less than $US 1 a day (but inflation is likely to make the one dollar in 2000 worth around 60 cents by 2015); and China, Cuba, and Vietnam (where, by the way, I live, so I am in a position to know), have long focused on structural development concerns, but have not labeled them as ‘Millennium Development Goals’, i.e., not wanting to play the MDGs game.

These are all shortcomings we do not want to carry over to the next framework. Beware: the elements to be revised, such as the ones insinuated in the question, are not for us reading this questionnaire to decide! Additions and revisions are to come from consultations with claim holders and duty bearers down below in many little places giving this process the flexibility needed in terms of the participative selection of contents and the timing of their participative introduction.


14. Which issues were missing from the MDGs and should now be included? How to address inequality, jobs, infrastructure, financial stability, and planetary boundaries?

It is not for us to decide these issues. They must come from dialoguing with claim holders and duty bearers at national and sub-national level importantly including women and youth organizations, trade unions, social movements, parliamentarians, local civil society organizations, organizations of migrants (who cannot be ostracized as non-citizens!)…

Inequalities are a result of power imbalances so, obviously, the organization of a counter-power is the answer for the next period; rights holders have to become de-facto claimants through processes of empowerment and social mobilization.

Employment issues must be discussed directly with trade unions for inputs.

Nobody knows better the shortcomings in infrastructure than their daily users (and/or those who need it and do not have it); we have to reach out to get their inputs.

Financial instability is a trademark of the cycles of boom and bust of capitalism and, as we now know better, is caused by the reckless behavior of greedy megabanks and financial institutions and individuals. Global and national regulation –including people’s audits– must keep them at bay making sure taxpayers never again bail them out for the disasters they bring about. A Tobin-type tax is an issue whose time has (belatedly) come. People’s audits also must be introduced to look into the issues of odious foreign debt in poor countries.

For planetary boundaries, we should fall back on work done by UNEP and in Rio; but what is needed for the new framework is to set aside funding to educate the public at large, all over the world, about these boundaries so as to make this an additional  topic of their empowerment and mobilization.

All the above notwithstanding, remember the most crucial element missing in the MDGs was a conceptual framework of the causes of underdevelopment (or maldevelopment) alluded-to earlier.


15. How should a new framework incorporate the institutional building blocks of sustained prosperity, such as freedom, justice, peace and effective government?

I wish I understand what ‘institutional building blocks’ are. So I am a bit at a loss here. But anyway, first of all, the concept of sustained prosperity must be de-linked from the concept of economic growth with the latter having to be seriously questioned.

Freedom, justice and peace are all embedded in the human rights framework which will have to, once and for all, be the guiding framework for post-2015 development agenda. [It is a real pity (or a scandal? ) we are facing having to wait another 24 months for this to become true!].

As for effective government, I have always said that elected officers are as good as the people who elected them; electors deserve those they elect(ed). The problem is that (the often anachronistic and formal) representative democracy is made use of every 4, 6 or 8 years. “You made a bad choice? You are stuck till the next election”. Under these circumstances, nothing short of making the accountability/watch dog function a function of civil society (with commensurate funding) will be good enough in the new framework. Actually, the ultimate purpose of social mobilization is the application of local direct democracy to remedy the serious shortcomings of representative democracy.


16. How should a new framework reflect the particular challenges of the poor living in conflict and post-conflict situations?

I assume that by ‘the poor’ actually the question means ‘poor people’ (or people living in poverty). I hope I make my point…

If we are talking about ‘particular challenges’, can we expect the new framework to have general recommendations here? Is this a contradiction? Would global recommendations have any chance to work?

I strongly feel this is, par-excellence, a topic for South-South cooperation (with commensurate funding). Countries living in conflict and/or post-conflict can give better advice to others on what to do/not to do. The international community’s help should come in the implementation of the recommendations coming from such S-S cooperation –the help firmly based on the principles of their extra-territorial human rights obligations now recognized by ECOSOC.


17. How can we universalize goals and targets while being consistent with national priorities and targets?

The first question I have here is: Must we again universalize goals and targets? And then: Does the MDGs experience tell us universalization of national level targets was a good thing so as to follow it now? I have said that I personally prefer the setting of benchmarks over the setting of goals and targets (whatever the difference is between these two).

National priorities have to be based on a progressive realization of human rights long-term plan with annual benchmarks. The priorities must be disaggregated to the district/municipality level so as to first concentrate actions on the x% of the most marginalized ones. (Vietnam has done so with a hundred thirty some districts). [This applies equally to giving priority to marginalized groups in society; I do not need to name them here since they are well known]. This all is what the human rights based approach calls for! So, nothing new here. In this case, we are talking about a human rights principle that is not subject to progressive realization, but calls for immediate implementation, namely the principle of non-discrimination.

The only way another set of universal goals is going to get us further in the next phase is to mandate those goals be achieved in each district/municipality and not as a national average.


IV. Qs on partnership and accountability for development:

18. How will a new framework encourage partnerships and coordination between and within countries at all stages of development, and with non-state actors such as business, civil society and foundations?

If the framework should encourage partnerships and which partnerships is the first question to be asked here. We need to know which partnerships the question refers to. Partnerships with whom?

‘Partnerships’ between countries have a very sorry historical past in the realm of neo-colonialism. Partnerships in traditional ODA do not have much to show for either in terms of each partner wielding equal weight in decision-making (this includes partnerships with often non-transparent/non-democratic mega philanthropies and foundations).

South-South partnerships are an upcoming potentially promising avenue the new framework should definitely refer to, explore and foster.

A special worrisome ‘animal’ here are public-private-partnerships that have been plagued by devastating conflicts of interest and by claims of white-washing the conscience of participating TNCs. Quite a bit has been written about this and I will not go into more details. (I call your attention to seminal work done on this by IBFAN and by Judith Richter).

[It would be desirable the new framework calls for greater transparency of mega philanthropies with an opening-up of their internal decision making processes].

The new framework simply has to put in place mechanisms through which governments together with representatives of civil society have a controlling stake in all partnerships. Governments and civil society organizations have learned (and suffered) by now and are now up-to-the-job, from now on, to take this mandated role.

At global level, PPPs are also a big worry at the UN in general (Global Compact) and in UN agencies. The People’s Health Movement has been active in denouncing this state of affairs in WHO calling for concrete and definitive measures to be taken. The question also calls for  coordination between countries and within countries. The latter, I understand well. But does ‘between countries’ refer to foreign aid? If yes, I have made my point. If not, this coordination will have to be further explained.


19. How specific should the Panel be with recommendations on means of implementation, including development assistance, finance, technology, capacity building, trade and other actions?

I would say the Panel should not be specific on such means, but perhaps propose a range of options. It is for the participatory country and sub-country level to work on them and gain full ownership of the ones finally selected. There should be a specific time period and funding set aside for this.

As regards development assistance, foreign aid has to be made to abide by the human rights framework and by the principles of extra-territorial obligations.

The transfer of technology is a key additional issue. At grassroots level, the technology has to be appropriate, as decided by its direct future users. Otherwise, we have witnessed how TNCs transfer second hand technology to developing countries –technology they have replaced by a more advanced one in rich countries. This perpetuates underdevelopment and must, therefore, be countered.

Capacity building: my experience is in health. I have seen the proliferation of aid-funded vertical programs, be they for TB/HIV/malaria or for family planning… They all duplicate in big part the training offered with the same service provider at the point of delivery being called out for yet another training. Add to this that often different donors repeat the very same training due to a total lack of coordination. The service provider attends mostly for the sitting allowance provided and returns home not applying what has been learned. I call this disease ‘workshopitis’. The remedy? In health, we need roving multidisciplinary provincial teams that go facility by facility, stay 2-3 days in each, observe how services and extension/outreach work to the community are provided, correct deficiencies, add new knowledge, leave a list of to-dos and return in three or six months to check on changes only to make yet a new round of recommendations, and so on.

Trade is also a big problem. Rich countries have stayed away from using WTO as a vehicle for their international trade deals and have opted for bilateral free trade agreements where they can better use their muscle to extricate more favorable conditions. The negative human rights consequences of most of these FTAs are nothing short of appalling. The rich in the poor countries may benefit, but not poor people. The new framework cannot possibly ignore this fact at the risk of coming up with a ‘robbing Peter to pay (rich) Paul’  agenda of development. [Not coincidentally, this also applies to poor countries servicing their odious foreign debt].


20. How can accountability mechanisms be strengthened? What kind of monitoring process should be established? How can transparency and more inclusive global governance be used to facilitate achievement of the development agenda?

The answer is: Through civil society organizations specifically funded to act as watch dogs.

The monitoring should be based on annual benchmarks so as to check if on processes set in motion to assure the progressive realization of human rights are on course. (This presupposes each country prepares a long-term progressive realization plan of action with a, say, ten years horizon. The new framework must explicit this).

If a more inclusive global governance is to be understood as participatory governance, then the issues pertaining to governance transparency are included in the watch dog function.

What this question does not touch-upon is the issue of providing accessible redress mechanisms. The obligation of States is to take steps to prevent, investigate, punish and redress any abuse through effective policies, legislation, regulations and adjudication. States must ensure that those affected by business-related abuses or other human rights abuses have access to a prompt, accessible and effective remedy including, where necessary, recourse to judicial redress and non-judicial accountability and grievance mechanisms. The new framework must address this issue.

It is well known that CSOs are active in many countries in preparing shadow reports for the UN Human Rights Council. The framework must explicitly encourage CSOs to participate. Once the Council engages in the universal periodic review of the human rights issues of each country it issues recommendations which, unfortunately, are not binding. Mentioning this fact, may help the new framework creating greater consciousness about this shortcoming which could result in some corrective action on this in the future.


21. How can a new framework tackle the challenge of coherence among the organizations, processes, and mechanisms that address issues that are global in scope?

[I saw the concept of ‘poverty of ambition’ being used in these post 2015 discussions; I think it fits nicely here].

Since Paris has, for all practical purposes failed, I think the in-country coordination of donors and local organizations should be made mandatory for multilateral and bilateral agencies and for non-governmental donors both on general aid and aid by sector. Central in the coordination process will be addressing the global issues that the new framework will suggest be prioritized worldwide with the specific mandate to adopt/adapt them to the local realities and priorities. Coordination meetings are to be chaired by two government representatives ideally from the ministries of planning and finance and must have a representative participation of CSOs. More human and financial resources have to be specifically allocated by donors for such a coordination function.

Underlying the actual willingness and commitment of all involved agencies to work in a coherent manner will, in many cases, call for a profound exercise of revisioning and remissioning of what they do based on an honest question: Are we part of the problem or of the solution? The new framework can no longer condone silo mentality, vertical programs, each donor for himself in development work. Service delivery work is not enough; technical capacity building work is not enough; advocacy work is barely enough. Remissioning is about these institutions funding and engaging in empowerment an social mobilization work in the countries they work in.

Globally, it would be highly desirable that the new framework proposes ways to be worked out for the United Nations Committee on Economic, Social and Cultural Rights also to be involved in coherence, in processes and in mechanisms issues.

Furthermore, it seems indispensable that in the post-2015 period the UN special rapporteurs be allocated adequate budgets to allow them to have proper small staffing and more travel funds to do their (excellent) work.


22. How can we judge the affordability and feasibility of proposed goals, given current constraints?

Affordability is strictly a country by country matter. Being a cautious optimist, I think the current constraints will be overcome. Therefore, to be prominently kept in mind are the provisions of the extraterritorial obligations of rich countries. This means that countries showing well justified shortcomings to embark in the progressive realization of human rights will go to donor agencies for help. Given that the progressive realization is based on yearly progress marked by benchmarks –and countries will have ad-hoc plans– donors will be able to commit resources long-term, in tranches, based on the budgeted official progressive realization plan of each country. Coupling this with CSOs participation on accountability issues gives us some hope for (cautious) optimism on feasibility.

Affordability/feasibility issues can be and have been addressed successfully in several instances through participatory budgeting initiatives. These ought to have an important place in the post-2015 recommendations.


V. Qs on shaping global consensus for the goals:

23. How can we build and sustain global consensus for a new framework, involving member states, the private sector and civil society?

Global consensus has to be built from the bottom up, i.e., starting from the sub-national level up. This is why this consultation period up to 2015 is so crucially in need to go to the level of claim holders and duty bearers at district level. (Keep in mind that duty bearers to claim holders in the community are, in turn, claim holders to duty bearers at the national, often ministerial, level….and those, in turn, claim holders to duty bearers in the international context, i.e., there is a chain of oppressed oppressors). Thinking loud: Can a worldwide 1-2 weeks period of national debate be agreed upon and set sometime in 2014? Can we then imagine a global process of some kind of formal ratification of the new framework by parliaments, social movements, CSOs, private sector without conflicts of interest (?) and governments the world over?

Sustaining the consensus will depend on progress being made. Annual benchmarks can give us year-to-year reports of progress as perceived by representatives of the wider society. This national annual taking of stock has the additional advantage of giving the new framework flexibility to change tactics within the same strategy (…or change strategy if needed).


24. How can our work be made coherent with the process to be established by the intergovernmental Open Working Group on the Sustainable Development Goals?

All efforts have to be made to secure such a coherence. Moreover, in all issues pertaining the SDGs and pertaining to this post-2015 framework the principle of one country one vote is non-negotiable in all instances when such consultations are deemed necessary. We all are born to live in this planet as equals. [I see no problem in isolating the rich countries often voting in block against the poor countries and thus formally obstructing this or any coherence. They are already doing so! So what is left for the poor countries is to continue blaming and shaming them, remotely hoping for a future break through. In the meantime, as much as possible, the poor countries ought to act on issues as per their majority vote].



Having come to the end of this reflection, I know I have opened only a small additional window that adds to the equally important contributions of many many others. I am afraid I have often been normative (and even possibly wrong). There are too many shoulds and woulds in my comments.

The risk we face is coming up with a more radical new framework than the MDGs framework was only to see it watered down by the powers that be –as has always been the case in end negotiations.

I ask you: Why has consensus always to be pulled to the side of those who feel they have something to loose in this pathetically unequal and unfair world?


I was looking at the November 30 note the High Level Panel of Eminent Persons on the Post-2015 Development Agenda just made available and had a couple to-the-point short comments.


Is there a way we can get away from the use of the maligned term ‘stakeholder’? Stakeholders stake claims, right? The simple replacement of the word stakeholders by claim-holders or duty bearers, as appropriate (to use the correct HR parlance that we and the UN are finally trying to instill in post-2015), just might provide us with the hint of the sort of framework we are interested in fostering in the new era. Claim holder/duty bearer are in the original UN language. Stakeholders is originally business language. To have or to hold a stake in something is the same as having an interest or holding shares!!! (A. Katz)

As regards the section on human development, the second bullet talks of raising the bar and of several members focusing on the need for quality of outcomes. The MDGs have shown us that a focus on outcomes does not assure sustainability of the respective goal being kept up. It is not only the quantity and the quality of outcomes that counts; it is the participatory processes to achieve them that will matter in the long run. (Note that here sustainability is used in a different sense than in the environmental connotation of the term).

The fourth bullet tells us that many panel members pointed to the importance of rights and equity. I ask, do we have some panel members that ought not be there if this is not the unanimous outlook of the panel? Furthermore, there are still too many among us that consider HR and equity, gender…as crosscutting issues; they are not. They are core issues (!) and we have to build sectoral or other interventions around them.

As regards the section on jobs and livelihoods, the sixth bullet talks about safety nets. I feel strongly we ought, instead, to be talking about social protection mechanisms. Universal social protection is the new political and cultural horizon where health rights must be placed. Social protection is the fundamental measure to pursue redistribution of wealth. It includes social security, social assistance, labor rights, the right to public services and environmental rights. (F. Mestrum)

Safety nets take the issue of poverty as a fait accompli. So since ‘they’ are poor, we throw them a few crumbles of bread since it is morally reprehensible to us to let them starve. In reality, safety nets somehow come up with measures that avoid social discontent that could flare up into protests and thus a challenge to the status-quo. Or put another way: Safety nets are nothing but a way to manage poverty and ‘ill-being’ (as opposed to wellbeing) by attenuating social unrest. Am I very wrong?

The ninth bullet pertaining to providing accessible and affordable basic needs to the poor closely relates to what I say above. It just, in a way, replaces safety nets by targeting the poor (note the use ‘the poor’ in the bullet; should it not be ‘poor people’? We have to be careful with depersonalizing the billions of  the affected). [I want to caution you that the same is true for when programs and projects speak of ‘targeting the poor’]. The bullet goes on to infer that nutrition, health, education, housing, clean water and sanitation will eventually cut the vicious circle of poverty. I thought the inter-generational vicious circle of poverty could only be uprooted for good with structural changes in the political and economic system that rules most of the world.  Am I very wrong?

I want to take the opportunity to express my thanks for the excellent 24 questions the panel released on this same occasion. They have the right food for thought and I hope to be able to spend some quality time pondering over them.





Reminder: Social Medicine Course in Northern Uganda – Applications Due June 30th

Add a comment

SocMed invites students to apply for the fourth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience conducted on-site at Lacor Hospital in Gulu, Uganda from January 7, 2013 to February 1, 2013. This unique immersion course incorporates innovative teaching methodologies to merge teaching of clinical tropical medicine with understanding the socioeconomic, cultural, political, and historical underpinnings of illness. Through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions, the study of clinical medicine in a resource-poor setting is intersected with social medicine topics such as the social determinants of health, globalization, war, human rights, community-based health care, and narrative medicine. Enrollment is open to fifteen 3rd and 4th year medical students from across the globe, and includes equal participation of Ugandan medical students, and credit for away-rotations can be arranged.


This course is offered through SocMed, an organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging medical students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

SocMed utilizes a curriculum that places great importance on building personal partnerships and encouraging students to reflect upon their personal experiences with power, privilege, race, class, gender, and sexual orientation as central to effective partnership building in global health. In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty and student colleagues.  Please feel free to visit our website,, for more information about the course, its directors and guest lecturers, and SocMed.  Applications are due by June 30, 2012.


Please do not hesitate to contact us with any questions you have at




Michael Westerhaus, MD, MA

Amy Finnegan, Ph.D.

Course Directors

The Millennium Development Goals, and the Scaling Up Nutrition Initiative




  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.







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





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?










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.  2008reportontheglobalaidsepidemic/ 


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




Add a comment


What are we talking about here?

  -Of health, of a healthy living, of a life lived in wellness.

  -Of the state:

     -Of power.

     -Of the legitimized use of force; of domination; of exploitation.

     -Of the hegemony of one social group that has given itself legitimacy, i.e., of the

      legitimization of the rules of the economic and the political game.

     -Of a situation of conflict and of a consensus with multiple contradictions around the

      decisions of what is public, i.e.:

         -re public and private; private vs social ownership; public goods and private goods.

         -re general interests and particular interests.

         -re what are national and what are international interests.

         -re class conflicts.

Some points upfront:

  – Do we live in an era of change or are we witnessing the change of an era?

  – An era of grave simultaneous crises: economic, financial, social, political,

    environmental, climate, food, cultural, techno-scientific…

Capitalism in its neoliberal phase:

  – Dominance of the financial capital over productive capital;

    speculation in the area of production.

  – Subordination of corporations to banks and speculation on stock and commodity


  – Exacerbation of the worse traits of capitalism.

  – Weakening of the status of nations; globalization.

  – Nature at its limits.

  – Humanity in danger of extinction.

  – Greater uncertainty; the future is a crystal ball. 

The Washington Consensus:

  – The state is the problem. Deregulate. Liberalize. Open markets.

  – Free markets are the solution and are ‘rational’.

  – Minimalist, focused and temporary social policies.

  – Dominance of the financial system. 

Consequences of it are economic, social, political, ecological and an expansion in the numbers of the excluded groups in society.

Towards a new discourse:

  – Again, do we live in an era of change or are we witnessing the change of an era?

  – Returning to common sense; returning to the same basic questions, but to arrive at

    new responses.

  – A new way of understanding the world and humanity is needed. 

The transition:

  – New historical anti-neoliberal blocks are joining in and coalescing.

     -What Unites us: a confrontation with neoliberalism, decolonization, a new culture of

      equity and solidarity together with a re-insertion in nature, defense of the national

      productive apparatus, direct democracy and participation as protagonism.

Three major tasks facing us:

  – Disengage countries from the neoliberal locomotive.

  – Address the historically accumulated social debt.

  – Advance towards a greener and better future.

Transition towards what? Need to clarify this.

How does health fit in this scenario and in the transition? 

  -We have to make our discourse succeed and become the lead paradigm. 

Struggles for health during the transition:

  – Recognize the complexity of the task ahead; recognize the consequences for theory

    and for practice.

 – Dealing with very different and heterogeneous groups.

 – Contesting neoliberalism is fighting against capitalism.

 – Contesting neoliberalism is actually much more, i.e., defending the national state,

   defending the public sector (the common interest as opposed to the private interest),

   regulation of the agents of the market through public economic, social and institutional

   policies, through democratization, through fostering the free determination of

   people, through having politics taking an interest in the every day life of common


 Setting the stage to advance towards a new form of state and a new society:

  – confront neoliberalism in its financial complex version as applied to health.

  – Pay back the historically accumulated social debt.

  – Foster and coach new social actors to be mobilized as protagonists of change.

 – Democratize, decentralize and strengthen local government; move towards direct


Some common objectives of health policies: 

   -Health as a human right, universal coverage, inclusion, equity….

   -Comprehensive social policies pointing towards quality of life, towards social

    solidarity and full citizenship rights.

Escape from the trap of single-track thinking:

 -Creativity and diversity; the new paradigm is not arrived at through bureaucratic


An open future:

  -Uncertainty, need for legitimization and for the resolution of contradictions in the

   neoliberal system and also within our anti-neoliberal groups. The latter can only be

   resolved when we set it as a priority to resolve our internal conflicts; otherwise we

   play into the hands of capitalism.

  -Empowerment of social actors. Participatory management style. Participation and

   mass mobilization. Foster the creative energies and a creative anger of the people as

   political actors towards a truly new historical wo/man. 


Reminder: Social Medicine Course in Northern Uganda – Applications Due July 31st


We invite medical students to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as the social determinants of health, globalization, global health interventions, war, human rights, community-based health care, and narrative medicine. This highly interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.

For more information, we invite you to please see our website at: . In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: and 2011:

If you have any questions or are interested in applying, please email us at Applications are due July 31, 2011.

Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA

2011 World Health Assembly & Global Health Governance


From May 16th to the 24th the World Health Assembly (WHA) met in Geneva to review proposals by the WHO Executive Board (EB).  The WHA is composed of delegations from the WHO member states and is the highest decision-making body in the organization. It choses the Director General, decides on the budget, and supervises the management of the organization.

This year was marked by a particularly controversial proposal by the WHO’s Director General to create a new World Health Forum. The forum would serve as a consultative body and – among other members – would include representatives of private industry.  Many see this one more in the process of privatizing the WHO.  Already most of WHO’s funding comes from private sources and it has been argued that WHO has fallen too much under corporate influences.

As usual, the People’s Health Movement was very active at the WHA promoting the agenda of health for all.  Here is a selection prepared by PHM describing their activities at the Assembly:

*  *  *  *  *  *  *

People’s Health Movement (PHM) is committed to a stronger World Health Organization (WHO), adequately funded, with appropriate powers and owning the leading role in global health governance. PHM follows closely the work of WHO, through the initiative ‘Democratizing Global Health Governance’ which was launched by the PHM and several international civil society networks in May 2010.

Within the framework of this initiative, the PHM has established a ‘WHO Watch’. The watch aims primarily at building capacity in supporting the WHO to regain its leadership role in global health governance according to its Constitution. WHO Watch mobilises a large number of health activists, civil society networks and academics to provide resources and evidence-based critiques related to the secretariat reports, draft resolutions, and other materials during the preparations to the WHO governance meetings especially the Executive Board (EB) meetings and the Assemblies. 

From the beginning of May 2011 and during the 64th World Health Assembly (WHA) of WHO, held from 16 to 24 May 2011, 30 members of the ‘WHO Watch’ group from over 20 countries have been working through the agenda of the 64th WHA with the assistance of high level experts from a number of collaborating networks and NGOs. The following letters and statements on some of the agenda items of the 64th WHA were drafted.

PHM letter to the 64th WHA
Distinguished delegate to the 64th World Health Assembly,
[…] The following comments on some of the agenda items of the 64th WHA were drafted for your kind consideration. More: EnglishEspañol

Statement to the 64th WHA, on agenda item 11: The Future of Financing for WHO
PHM calls upon WHO for accountability to people not dollars
The WHO is facing a financial crisis: programmes, projects and staffing face the prospect of being disbanded; the dominance of tied donor funding is having a terrible effect on administration. The WHO is also suffering from a crisis of identity and legitimacy; its role and mandate have been diluted and usurped by the proliferation of new actors in the field of global health. Inefficiencies within the organisational processes remain unresolved. More: عربى |EnglishFrançaisEspañol

Statement read by the PHM at the 64th WHA on future financing of WHOMoreHear it on Youtube

Statement read by the PHM at the WHA on infant and young child nutrition
Both under-nutrition and obesity are linked to the increasing dependence of poor countries on high-income countries for food security, which has been reinforced by trade agreements, climate change, and biofuels. Nutrition strategies should address the complex socioeconomic and political determinants of malnutrition. Governments and international bodies, like WHO, must advocate for the regulation of the trade and marketing of unhealthy foodstuffs, so as to protect the health of populations – and of children in particular – from aggressive corporate influence. More >>

Statement read at the 64th WHA on Non Communicable Diseases
Statement by Medicus Mundi International (MMI) and PHM
The NCDs initiative is too narrow in particular we believe it should include mental health. It is disappointing that there is no reference to the work of the CSDH in the report. Unhealthy behaviors do play an important role in determining NCDs however there are structural determinants like education, income, gender and ethnicity which are underlying causes of NCDs and behavioral risk factors. Clearly there are important equity dimension of NCDs as emphasized by CSDH and these variations are closely linked to the social and environmental factors; not just individual behaviors. More >>

Statement read at the 64th WHA on Substandard/spurious/falsely-labelled/falsified/counterfeit medical products
Statement by Thirld World Network (TWN)
We believe that every individual has a right to access safe, quality and efficacious medicine and steps do need to be taken to ensure the safety, quality and efficacy of medicines. More >>

Time to untie the knots: the WHO reform and the need of democratizing global health
Delhi Statement, coordinated by Medico International
Health is a common good that demands collective responsibility. Instead, structural violations of the right to health are produced by the dominant market dynamics and the uncontrolled influence of profit-driven transnational corporations, supported by the policies of international financial and trade institutions – the International Monetary Fund, the World Bank and the World Trade Organization. Such violations are often unmonitored, unmeasured, and are too numerous to quantify. As they form part of a process of systematic violations of other rights – to gender equality, to water and food, to work and income, to housing and education – any commitment for the right to health cannot be conceived in isolation from a broader approach of universal social protection as a key policy to human development. More >>

More information at:

* * * * * *

The video below offers more whimsical picture of the Assembly.

Posted by Matt Anderson, MD



Add a comment



April  blog

Claudio Schuftan


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.







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.

Ultimate causes

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.







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








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

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




Social Medicine Course in Northern Uganda (2012)


We invite you to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.

For more information, we invite you to please see our website at: In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: and 2011:

If you have any questions or are interested in applying, please email us at Applications are due July 31, 2011.

Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)