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.

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?

References

1          UNICEF. Progress for Children: A Report Card on Nutrition, 2006.

             www.unicef.org/publications/index_33685.html

2          Department for International Development (DFID). Child Mortality, 2007.

            www.dfid.gov.uk/pubs/files/mdg- factsheets/childmortalityfactsheet.pdf

3          UNAIDS. Global Report on the AIDS Epidemic, 2008.

www.unaids.org/en/dataanalysis/epidemiology/  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 www.wphna.org

SOME REFLECTIONS ON THE STATE AND HEALTH. (Pedro Luis Castellanos).

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

    markets.

  – 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

   people.

 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

    democracy. 

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

  decisions. 

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. 

xxx

For more information, we invite you to please see our website at: https://sites.google.com/site/socialmeduganda/ . In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011: http://www.youtube.com/watch?v=Z2UCUFcXAas.

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

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

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.

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 www.wphna.org

Please cite as: Schuftan C. Fundamental public health nutrition: Nutrition is a social science and nutrition is nothing but politics on a grand scale, Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

For more information, we invite you to please see our website at: https://sites.google.com/site/socialmeduganda/. In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011: http://www.youtube.com/watch?v=Z2UCUFcXAas.

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

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

Dr. Binayak Sen

On 24 December 2010 the court of Raipur, state capital of Chhattisgarh, India, rewarded the health and social justice life of pediatrician Dr. Binayak Sen not with honors, medals or an honorary degree, but with a sentence to life in prison.

The message from the Government of India: if you work as an advocate with the poor, you are against the government and will be punished severely. It is a message to any who would work toward a more just world, in accompaniment of the marginalized, stigmatized and poor.

Dr. Binayak Sen, who is vice-president of the Indian Human Rights organization PUCL (People’s Union for Civil Liberties) and is the recipient of the 2008 Jonathan Mann Global Health and Human Rights Award, was accused of transporting letters for a jailed Maoist leader who was under his medical care. Though the prosecution showed nothing but circumstantial evidence (better said, no evidence at all—all visits of Dr. Sen with the prisoner were attended by prison guards, none of whom saw any letters, and two of whom were declared “hostile” by the court when they testified that it would have been impossible for such an exchange of letters to happen), the judge ruled—using as the Lancet editorial (see below) notes “a section of the penal code first introduced by the British to quell political dissent and later used to convict Mahatma Gandhi”—that Dr. Binayak Sen is guilty of “sedition.”

Outrage at such treatment of a man many consider mentor, hero and teacher resounds globally in journals such as the Lancet (Lancet 377:98 on 8 January 2011, “Binayak Sen’s Conviction: A Mockery of Justice”) and British Medical Journal (BMJ 2010; 341:c7438 “Civil rights groups decry conviction of Indian paediatrician who pioneered community health”) and within the press in India.

See: Facts about the Dr Binayak Sen case – The Times of India http://timesofindia.indiatimes.co. m/india/Facts-about-the-Dr-Binayak-Sen-case/articleshow/7125220.cms#ixzz1AbSIjDmn

Physicians for Human Rights (PHR) has called for Dr. Binayak Sen’s release.          http://physiciansforhumanrights.org/library/news-2008-05-20.html

Dr. Binayak Sen has worked for many decades with the poorest of the poor. He is well known as an advocate for health and social justice, an outspoken critic of police brutality. Apparently, his effectiveness is such that the Indian Government feels the need to silence him.

Go to http://www.binayaksen.net/ to learn more about the intricacies of the case and the condemnation of the court ruling, including a recent article concerning Nobel Laureate Amartaya Sen in the Times of India, in which he is quoted as saying: as an Indian citizen and a human being, I must exercise my own judgment to ask if this is correct. Sedition means pulling the state down by violence. It cannot be suggested that Binayak did this. On the contrary, his writing indicates violence is wrong. There is a deep moral argument against sedition here [in Binayak Sen’s book]. Amartaya Sen goes on to say of the ruling against Binayak Sen: It has a threatening nature and seems to have political motivation. Any intelligent person would find that the judiciary acted very peculiarly. I hope the high court or Supreme Court quashes this.

Dr. Binayak Sen is a member of Jan Swasthya Abhiyan, the PHM (People’s Health Movement) India. He has touched the lives of many—and this is perhaps considered his greatest crime, the crime of being a positive example.

Dr. Binayak Sen was first arrested in 2007. Though he has severe cardiac disease, he was kept without adequate treatment for two years—until an international campaign, including several Nobel laureates, achieved his provisional release on bail.

When a government punishes work dedicated toward health and social justice, it is making a statement that is global in nature. Its action must then be denounced globally. Please consider acting now in solidarity with Dr. Binayak Sen. Address the government of India with its own shame, by signing the petition directed to The President of India, Rashtrapati Bhavan: http://www.petitiononline.com/sen2010/petition.html

Consider expressing in print your disappointment that this sentence, egregious and wrong, has happened. Inquire into the health, not just of Dr. Binayak Sen, but of the patients who he has not been and will not be able to attend to because of his sentence. Demand that, in the name of justice, as well as health, the sentence be refuted (still legally possible by the Supreme Court of India) and his work instead granted the affirmation it deserves.

Please share what is happening to Dr. Binayak Sen with colleagues, local community members and your own government representatives, no matter where you live. Consider writing to him yourself, to express your solidarity and your appreciation of his example.

2. The defeat of the have-nots has always been implicit in the victory of the haves; the labor of the have-nots has always generated their own poverty since it has fed the wealth of the haves.

3. The strength of the globalized system rests on the necessary inequality of the parties that make it up –and this inequality assumes ever more dramatic proportions. The dominant classes in poor countries have no interest in finding out whether patriotism could be more profitable than treason or if begging and dependence are the only possible way for their countries’ international politics. Countries thus end up mortgaging their sovereignty, because we are told ‘there is no other way’.

4. The globalized system is very rational from the point of view of their foreign owners and of our ‘hambourgeoisies’ that have sold their soul to the devil at a price that would have shamed even Faust.

5. But the globalized system failed to foresee a minor thorn in its side: what we have too much of is people. And people reproduce. They make love with enthusiasm and without precautions. More and more, people are left on the verge of the road, jobless. This systematic violence, not always apparent, but real, is mounting: its crimes cannot be read in the red press, but in UN statistics. So, the empire gets worried: unable to produce more bread, it does what it can to get rid of those sitting around the table. “ Fight poverty! Kill a beggar!”, a master of black humor wrote on a wall in the city of La Paz.

6. The globalized  system thus convinces poor people that poverty is the result of not avoiding having children. So it now proposes, with more panic than generosity, resolving the problems: Population control measures are the preferred policy.

7. We have social classes, and the oppression of one class by another; the system calls that ‘adopting a Western lifestyle’.

8. The ‘order of the day’ is the daily-humiliation-of-the-masses –like it or not, an order nonetheless, we must say.

9. But Poverty is not written in the stars; underdevelopment is not the result of an obscure will of God. People are waking up, and are demanding changes.         (Eduardo Galeano, Las Venas Abiertas de America Latina)

We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:

Course Invitation 2011
We invite you to apply for the second 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 10, 2011 through February 4, 2011. 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 also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).

For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

Sincerely,

Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115

Discussion in 2010 Course

Leadership Development: Developing Skills to Lead as the Landscape of Health Care Changes

From national health care reform to community advocacy to clinical practice, physician leadership and engagement has never been more vital to the health of the nation. Recent successful examples have also demonstrated the benefits of physician leadership, advocacy, and engagement with community partners. This track will provide resources for communication, management and advocacy skills, civic engagement, community collaboration, and other tools that physicians can apply in a variety of settings. Community members are welcome to join and learn more about physician engagement. Session to include:

Advancing Health Care Through Civic Engagement
Kim Alexander, President, California Voter Foundation Carmela Castellano-Garcia, President CEO, California Primary Care Association Marc Wetherhorn, National Advocacy Director, National Association of Community Health Centers

Messaging, Media & Communications
Bob Crittenden, MD, MPH , Executive Director, The Herndon Alliance

Effectively Engaging with Your State Legislatures & Its Members
Progressive States Network – Speaker TBA

Educating State Legislators, Advancing Health Care Reform: Tools Physicians Can Use to Engage & Inform State Legislators About Federal HC Reforms
Progressive States Network – Speaker TBA

Models for Physician Leadership and Community Engagement
Bill Jordan, MD, MPH, NY Action Network – National Physicians Alliance
Aaron Fox, MD, MPH, NY Action Network – National Physicians Alliance

Issues on the Horizon: 2010 & 2012 Elections
Kim Alexander, President, California Voter Foundation
Serena Kirk, Senior Policy Advocate, California Primary Care Association

Practice Innovations: Practicing Medicine in a Changing World

What will the practice of medicine look like in ten years? How will reform change the way the average physician will practice medicine? This will be an instructive and interactive track will address these complex questions and many others by focusing on the following three areas: 1) Evidence Based Medicine (EBM), 2) Practice structure and financing, and 3) Information and Communications Technology. Sessions to include:

Evidence-based Medicine & Clinical Guidelines
Colin Kopes-Kerr, MD, JD, MPH, The Permanente Medical Group

Healthcare Planning and Strategy
Kevin Fickenscher, MD, CPE, FACPE, FAAFP, Perot Systems

Approaches in Chronic Disease Management
Susan Snyder, MD

High Quality Care for Disadvantaged Populations
L. Gordon Moore, MD

National Health Policy: Avenues for Involvement in Advocacy to Enhance our Country’s Health

With the potential passing of federal health care reform legislation a “wave of change” will alter the landscape of public health and healthcare in America. The National Health Policy Track aims to educate and mobilize physicians on the healthcare reform debate of 2009 and future directions for reform. Sessions to include:

Reforms that Reduce Costs Without Reducing Quality of Care
Thomas Rice, PhD, Professor, Department of Health Services; Vice Chancellor, Academic Personnel
UCLA School of Public Health

Political Solutions to the Obesity Epidemic
Deborah Cohen, MD, MPH, Senior Natural Scientist, Rand Corporation

Outcomes of Health Care Reform: Review of the Policy Debate
Josh Derr, Manager, Mayo Clinic Health Policy Center

Health Care Reform: Impact on Women
National Women’s Law Center – Lisa Codispoti, Senior Counsel

Federal Health Care Reform: How Physicians Can Help Their States Access Upcoming Opportunities & Resources
Progressive States Network – Speaker TBA

Global Health: Workforce Issues in an Ever-Evolving Global Health Landscape

The world has never been smaller, nor have global issues of health been more of a concern for physicians and advocates alike. With health care workers migrating to the Unites States for better opportunities, a shortage in these critical areas ensues. What can physicians do to ensure that we are thinking globally in our efforts to improve the health of our patient, our community and our world? Sessions to include:

The Global Workforce Crisis-Is US the Problem or Solution?
Richard Scheffler, PhD, University of California, Berkeley
Kate Tulenko, MD, MPH, Deputy Director at Capacity Plus/ IntraHealth
Health Policy Specialist at World Bank

International Health Workforce Issues
Amy Hagopian, MHA, PhD, Health Alliance International, University of Washington

In the Wake of the Storm: On the Ground in Haiti
Susan Partovi, MD, Professor UCLA School of Medicine
Director Homeless Healthcare Los Angeles

Trade and Health: The Impact of Health Worker Migration
Michelle Forzley, JD, MPH

Nuclear Non-Proliferation: The Physicians Role in Advocating Peace
Bob Dodge, MD, Physicians for Social Responsibility, Los Angeles

California Health Policy: Experiences & Experiments in State Policy and its Nationwide Influence

California has long been at the forefront of the ever-changing face of healthcare. Its struggles are often those of other states around the country, and the innovations and experiments in health care delivery have offered guidance to the rest of the nation, whether in success or in failure. With the ongoing budget crisis in the state and the potential impact of impending national health legislation, adding to other internal debates about border health, malpractice, medical marijuana, and disaster preparedness, now as ever, California will be watched by the nation. In the California health track we hope to stimulate learning, debate and exchange of ideas around these and other issues relevant to patients, providers, and policy-makers. Sessions to include:

Issues facing Community Health Clinics and the Underserved & Minority Populations
Michael R. Cousineau, PhD, Director Community Health and Family Medicine University of Southern California Castulo de la Rocha, JD, President & CEO AltaMed Medical Services

A ‘Reformed Single Payer’ in the Current Reform Era
E. Richard Brown, PhD, Director, UCLA Center for Health Policy Research Professor, UCLA School of Public Health, Principal Investigator, CHIS

Border States and the Uninsured: Immigration Issues for Health Care Reform
Michael Rodríguez, MD, MPH, Sr. Researcher, UCLA Center for Health Policy Research Professor, UCLA Department of Family Medicine
Krysten Sinema, MSW, Arizona State Legislator
Progressive States Network – Speaker TBA

Addressing Disparities Through Health Reform
National Women’s Law Center

Healthcare Crisis in a Bankrupt State: Can California Still Lead?
Herb Schultz, MPP, Senior Health Policy Advisor to the Governor
Sara Rogers, Health Legislative Advisor to Senator Mark Leno

Coordinating Across State Lines: Opportunities Presented by Health Care Reform
Progressive States Network – Speaker TBA

posted by Matt Anderson, MD