Claudio Schuftan

I have to admit my columns are not always calming.

I here now ask questions and make comments about the rather big SUN (Scaling Up Nutrition) worldwide initiative endorsed by the World Bank and the pertinent UN agencies plus some international NGOs.

Our colleagues who are driving and steering SUN, some of whom I have known well for many years, call once again for nutrition to be mainstreamed in development work. This time the energy, declared commitment, and stated engagement of powerful players, looks stronger than ever before. I applaud this. All public-spirited professionals concerned with malnutrition should respect SUN; we should continue to engage with its process, make clear proposals for improvement and press for these, as well as be constructively critical when needed. A friend who is nothing more than a yes-person is not a true friend. Those who are driving SUN deserve respect; my column this month is written in that spirit.

I consider myself a nutrition activist. As such, I try to have my practical experience influence my theory. Our engagement in nutrition work should lead to a praxis in which profession, empathy, concern and political solidarity become one and the same. Without these bearings I fear that we will just go in circles. I fear that the SUN initiative does not – at least yet – have these bearings. In any case, we need to discuss it, as between colleagues and friends. Here, I call for us to build up our capacities as nutrition activists to motivate others to be equally constructively critical.

Box 1

SUN

The Scaling Up Nutrition (SUN) Initiative is, in one way or another, steadily engaging more and more public health nutrition and allied professionals throughout the world.  It is the most ambitious, highly-geared, integrated multi-actor programme of its type ever attempted.  Its vision is once and for all effectively to address undernutrition, food and nutrition insecurity, and their consequences, particularly in the most highly burdened countries. A recent issue   of the Food and Nutrition Bulletin linked here summarises some of SUN’s purposes and ambitions.

One of the concerns is that any programme initiated at top level may well not succeed in achieving the lasting results that only active community engagement  can make possible. There are other concerns too, like the state of the most vulnerable in many parts of the world. They also include concerns about the heavy external debt burdens, rapidly increasing inequity between and within nations, the collapse of public health services, and rising and volatile food prices, all suffered by the most vulnerable populations, any of which are liable to vitiate any form of development initiative. These oppressions are not  necessarily the responsibility of those who have devised SUN, granted. But they cannot be overlooked.

Now I proceed to ask some general questions, and also some questions addressed to the leaders of the SUN initiative. I hope this will generate a dialogue.

Here is my first question. Can we now at last, begin to shift our attention away from merely ‘reaching the poor with nutrition interventions’, towards deep understanding of the fundamental drivers of poverty and inequality, as these affect nutrition?  What ultimately counts, I contend, is our social and political accountability, and also carrying out our work in true partnership with populations and communities that happen to be impoverished.

It is political processes and issues of power that determine the content, direction and implementation of food and nutrition policies and programmes. As nutrition activists we can be strong political players, instead of – implicitly or by default – merely protecting narrow group interests. But we have to be mindful of the fact that we mostly work under the wings of governments, industry, or international agencies that are often unmindful of the real interests of those who are impoverished, despite their public statements to the contrary. We all know that the people who have the power are not the people who have the problems.

Our networked influence as public health nutritionists can and must contribute to realisation of the human right to nutrition; and also, to the reversing of violations of this right in all domains. So my second question to the SUN leaders is: Does the SUN initiative also mean and intend this? So far the drafters of its documents seem to skip the human rights dimension –at least explicitly. Is this my misunderstanding?

The processes that make people poor and malnourished are becoming more ingrained every day. So my next question is: Is the SUN Initiative fostering ‘survival’,  or sustained ‘better living’  Poverty changes people’s incentives and the constraints under which they operate; it causes a chronic sense of helplessness. Impoverished people are excluded from a share of their nation’s resources. That is why, to end protein-energy malnutrition, the distribution of wealth is as important, if not more important, as its creation. I am not sure that the World Bank, a backer of SUN, fully understands or accepts this point. Perhaps in pronouncements, but in practice?

People experience poverty and the violation of their right to nutrition differently, according to their gender, age, caste, class and ethnicity. For us, in nutrition work, poverty is multi-dimensional. It relates to powerlessness, to exclusion, to exploitation, to victimisation and to violence. It is also related to migration, to forced displacement, to rising urbanisation and to loss of livelihoods. Do the leaders of the SUN initiative see this at par value?

Let’s face a hard fact. Much of our work, such as that which involves micronutrients, remains a ‘nutrition repair industry’ of damage done by impoverishment. A sustainable approach to poverty reduction is complex. It requires three types of measure. These are to ensure that the ‘improving poor people’ continue to improve; that the ‘coping poor people’ graduate out of their precarious state; and that the ‘declining poor people’ have an opportunity to reverse their condition. I ask: How much of this do we really do in our nutrition work?

Poverty that is forced on individuals and on families who have no other choice, is unequivocally linked to injustice – and potentially to rebellion, uprising, and even wars. It is a denial of human rights on a massive scale. Should this fact not make a difference in our day-to-day work?  And so, to my next question is: Do those shaping the SUN Initiative, in their call for nutrition to be placed more at the centre of development, accept this, with all its implications? We need to engage in sincere dialogue on this and the other questions asked here.

The gap in policy processes towards better food security and nutrition interventions is not mainly a gap between knowledge and action. Food and nutrition issues generally have had little policy attention from decision-makers. The lack of action this entails is not due to a lack of knowledge. Ignorance is not the issue. It is more a matter of a deliberate choice not to attend to food and nutrition matters.

Crucial partners in the SUN initiative are food and nutrition research organisations, such as those associated with the UN and World Bank funded CGIAR consortium, originally named the Consultative Group on International Agricultural Research, These employ and engage thousands of highly trained and committed professionals. But as far as I can see, they have hardly engaged in the needed consciousness-raising about the structural causes of malnutrition.

If I am wrong in this, let’s have a response please. Most such organisations seem to think that if decision-makers have, or are given, more and better knowledge that they will indeed take the urgently needed decisions. But this is not how the political world works. People in power rarely go against their own interests. What is missing is something that SUN, by its nature, is not supplying. This is organised methodical intelligent, informed and energetic pressure from below, from empowered claim-holders.

I will now explore this somewhat further here, in a point-counterpoint fashion.

Point 1

Most nutrition colleagues will, I think, agree that the right food and nutrition policy decisions are not being made, in a world where malnutrition is still a serious public health nutrition problem, and where a host of options for action exist. Why is this? Why do decision-makers overall pay little attention to food and nutrition issues?

Counterpoint 1

Some researchers in the food and nutrition community are indeed looking for ways to reduce the gap between knowledge and action. As said above, the issue is deliberate overlooking and ignoring of the food and nutrition problem, as long as this does not get to the stage of social and political unrest and uprising, and thus jeopardising the stability of the system controlled by those who hold the power. Knowledge gaps most decidedly exist, but are of little significance. Policy is only minimally affected by knowledge alone. It is political factors that determine the policies that get priority. It is power politics that drive policy choices.

The communities most affected by impoverishment are usually not being engaged in the policy making process. They do not have a voice; they do not influence policy. They need to be empowered to do so in order to claim this right.  And thus another question: Will the SUN Initiative embark on this?

The more militant civil society organisations have indeed contributed to some real changes. There is much to be learned from them. We need to help budding civil society organisations to achieve the power to demand needed changes and to monitor their implementation.

Point 2

Existing food and nutrition research organisations like the CGIAR consortium often engage in attempts to influence policy-makers by communicating their findings to them and by contributing new information at conferences and other policy fora.

Counterpoint 2

But merely communicating and contributing new information to decision-makers will not achieve needed changes, unless this information addresses political issues. Furthermore, new information and ideas need to come not just from discussion with professional peers, but with the claim-holders themselves.  Just how often does this actually happen? Perhaps more often than I think, so examples please, from knowledgeable readers.

Point 3

These organisations claim there is a disconnect between the sphere of policy-making and the sphere of science-and-knowledge; that the need is to break ground methodologically, to engage policy-makers for decisions to be made.

Counterpoint 3

This has been one of the problems of these food and nutrition research organisations all the time. They try to connect policy with science-and-knowledge, and not with politics. Does any knowledgeable professional in these fields really still think that if decision-makers have more and better knowledge, they will make decisions that are against their political interests? In their guts, politicians already know what scientists want to tell them. They may not have quantified information, but they know. The need is not to break new methodological ground. The need is to break through politically.

Point 4

These organisations still often call for more interdisciplinary research.

Counterpoint 4

However, almost all the hurdles are ideological. Multidisciplinary teams of conservative researchers will produce conservative, ‘focused’ (meaning narrow) results and recommendations that merely tinker with the immediate and, perhaps, underlying causes, strictly consistent with the established order – or disorder.

What is needed, above all, are structural changes that address the basic causes of preventable hunger and malnutrition. It is definitely not a dearth of multi- or interdisciplinary work that has hampered progress. ‘Selling’ research findings to decision-makers is, I think, likely to bring more of the same disappointments. Policy makers tend not to listen, unless claim-holders put pressure on them.

Point 5

Many of these organisations call for setting up social protection and safety nets.

Counterpoint 5

Let us now, once and for all, stop talking about safety nets! This is what leads to mere tinkering within the system. The ongoing casino capitalism with its global restructuring, creates the problems, and food and nutrition professionals are supposed to pick up the pieces? Just so that poor and marginalised people do not revolt? Who is cheating whom here? We need to stop victimising poor people and them throwing them bread-crumbs. What about changing the system that makes safety nets for poor people necessary to begin with?

Point 6

The CGIAR and similar organisations have proven their ability to communicate effectively, to bring relevant actors together to promote action.

Counterpoint 6

True, but what are they communicating? Rice with added iron or vitamin A? The horrible impact of AIDS on agriculture, economies and social stability? The need for improved agro-forestry? Super new strains of staple foods? None of this is enough. In any case, do such proposals lead to policy-makers listening, acting, and going on to make structural changes? I think not.

Food and nutrition issues appear on the public policy agenda almost always only when it is in the interest of the decision-makers, or when international pressures become unbearable. Is the SUN initiative a response to such a pressure?

Only occasionally do leaders have a clear mind and determination about the importance of food and nutrition, in a genuine equitable and sustainable development process. But we need to remember that some governments do place a high priority on reducing hunger and malnutrition. Take Vietnam, China, Brazil, Costa Rica, Cuba, and Kerala state in India. The common denominator among them is political determination at the highest level, in some cases spurred by engagement and partnership with strong civil society organisations.

Ultimately, the crucial factor is organised pressure from below; thus the importance of empowering and mobilising beneficiaries. Current legislation and legal systems do not affect action to reduce hunger and malnutrition to any great degree. Laws may be passed, but are often not enforced. National leaderships often feel content with having made the laws, and do not care much about their enforcement. Legislation is also frequently in response to international pressures and not to a real felt need. So a similar question to the last one is: Is the SUN initiative a response to such pressure?

So how can all the actors allied and working together within the SUN initiative, create the conditions for actions that really will effectively reduce hunger and malnutrition in impoverished countries? In my view and that of many experienced colleagues, they will first need to go through a deep process of revising and redefining their vision and their mission. Above all, they need to incorporate the human right to nutrition in their policies and actions. Will the SUN initiative mark the end of the donor-driven, philanthropic and charitable approach to what actually are human rights? I hope so. I pause, for a reply.

Please cite as: Schuftan C. Let us hope that the SUN Initiative can really put nutrition at the centre of development. [Column]. Website of the World Public Health Nutrition Association, January 2012. Obtainable at www.wphna.org

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

This is to announce a new open-access slide show, “Overview of Economic, Health, and Human Rights Issues of Racial and Ethnic Minorities,” on the Race, Ethnicity, and Culture page of the Public Health and Social Justice website. The slide show, which can be found at http://phsj.org/wp-content/uploads/2011/08/Economic-health-and-human-rights-issues-of-racial-and-ethnic-minorities.ppt, begins with quotes from Christopher Columbus and Cecil Rhodes demonstrating attitudes of colonial exploitation which have carried over to the present day, leading to maldistribution of wealth, environmental degradation, wars, and economic and educational disparities. Racial disparities in access to health care and in processes and outcomes of care are listed, along with statistics regarding inequities in the criminal justice system. Other slides cover the global situation viz a viz U.S. foreign aid, the brain drain from developing to the developed world, and the developing world debt crisis. Some suggestions for combating racism and creating a more just world are noted.

This slide show is brief, so those desiring further information on these topics can turn to other pages of the PHSJ website at http://www.publichealthandsocialjustice.org or http://www.phsj.org, including those covering Activism and Education, the Criminal Justice System, Environmental Health, and Migrant and Seasonal Farm Workers.

I would like to add more content to the Race, Ethnicity and Culture page, so submissions are encouraged. Please send them to martindonohoe@phsj.org, along with any comments, questions, corrections, etc.

I hope readers are as inspired as I was, and energized to continue our unfinished quest for a right to health care for all (not ‘near’ all!).

Enjoy!

The Fight to Save the NHS, by Jacqueline Davis, Saturday October 29, 2011, Washington D.C.

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of ‘islands of excellence in a sea of misery’.

I’ve never been to this city [Washington D.C] before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president.   I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow [laughs in the audience].

I’ve been asked to speak today about our fight to save the NHS.  Who are we and why are we fighting?  We are the campaigning organizations I work with, in particular Keep our NHS Public which we started about 7 years ago in response to the Labour government’s marketisation policies for the NHS – the NHS which Tony Blair had promised would be safe in his hands.

Why is the NHS worth defending? The NHS was a great act of social solidarity when it was founded in 1948 in the aftermath of the Second World War. It’s ironic that we are told we can no longer afford it but it was created in a period when the UK had huge debts, but importantly when people believed in acting together for a common purpose, and that the state could intervene for the benefit of society.

The intention was that people should be freed from the fear of the financial consequences of illness and that good health care should be available to all regardless of wealth, the 3 core principles being:

1. Meets the needs of everyone
2. Free at the point of delivery
3. Based on clinical need not ability to pay

And by and large it has managed to maintain those principles

Of course the NHS faces the challenges that all health systems do i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost efficient and equitable health services in the world.  And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

S o if it’s so good why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale. A successful public service is an affront to the free marketeers.  They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

S o the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost effective integrated public service into a kite mark attached to a ragbag of competing private providers. For those who are interested in how this happened I recommend this excellent book (The Plot against the NHS). It’s enough now to say that since 2000 governments have pursued a policy towards the NHS that the electorate hasn’t voted for and doesn’t want, a profoundly anti democratic state of affairs

The process actually began under Margaret Thatcher with the internal market and was continued under New Labour with the Private Finance Initiative and policies which increased marketisation. It has now come to crisis point with Andrew Lansley’s Health and Social Care Bill. After Prime Minister Cameron’s specific pre election promise of no more top down reorganizations Secretary of State for health Andrew Lansley produced a bill the size of a telephone directory, and everyone knew it was going to be very bad news.

And so it has proved. In brief the proposed changes are

The current system of commissioning care will change completely, with 80% of the budget going to family doctors (GPs). And they will be responsible for commissioning services,

NHS services, rather than publicly provided by NHS organizations, will be provided by any willing provider i.e. anyone with a mop and a bucket. They will be coyly called the ‘NHS family’.

Competition will be paramount and (according to politicians) drive improvements. Anti competitive behavior will not be tolerated. This will be enforced by an organization called Monitor, chaired by an ex employee of Mackinsey, the management consultants.

Hospitals will all have to become Foundation Trusts which are in effect autonomous competing businesses. Their only remit is to make a profit and they don’t have to offer services on which they can’t make a profit

There will no longer be a cap on income that hospitals can make from private patients. This is likely to lead to private patients filling NHS hospital beds, with NHS patients going to the back of the queue and a two tier service

Personal health budgets are being rolled out

This has all been driven with the usual spin of ‘patient choice’ and ‘power in the hands of doctors’ but even so the vast majority of health professionals and the public don’t want anything to do with this Bill

What are our fears?

Most GPs don’t have the time, expertise or interest to get involved in commissioning health care. It will be done – is already being done in some places – by private companies such as UnitedHealth which has just signed a big contract in London. If the private sector is commissioning care and at the same time delivering it is tantamount to putting the thieves in charge of the jewelers shop.

Serious fears for the doctor/patient relationship especially in primary care.  UK GPs are very effective gate keeper s to secondary care, one of the reason why the NHS is so cost effective, but it’s very important that patients trust their judgment and decisions. Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road is it because their wife has a financial interest in it? 25% of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

We fear GPs will be unwilling or financially unable to refer patients to hospitals and ‘care in the community’ is already becoming weasel speak for hospital closures

Hospitals will see their incomes reduced and will turn to private patients to make them up. Until now there has been a cap on private patient (PP)  income but that has been removed. If NHS beds fill with PPs then NHS patients will have to wait and we will see a 2 tier service develop

With services being provided by competing organizations we know there will be fragmentation of the care provided to patients and disruption of the patient pathway.

We fear that unprofitable services and patients will be quietly dropped

We fear the loss of public accountability with the private sector hiding behind commercial confidentiality (as they did with ISTCs)

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out of pocket payments and those who can’t afford it going without

And we really fear the arrival of the private companies, many of them from the US, whose behavior leaves much to be desired. They want to ‘cherry pick’ leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

The government was very clever with the Bill, which is about the deeply unacceptable break up and sell off of the NHS. They knew they would never get away with that so they sugar coated the bitter pill with GP commissioning. And GPs fell for it initially – many were excited by the prospect of holding the budget. Then they woke up to the fact that they would be doing this against the background of $30 billion to be saved over 4 years, and they would be made the scapegoats for cuts, closures and rationing. They would also have the private sector doing the commissioning, telling them what to do and probably ultimately employing them. Less than 20% of GPs now approve of the Bill and very few think it will benefit patients. But because the government have started to implement the changes before the Bill is law they have had to engage or see others do so on their behalf.

So, you see why we have to fight this. Because of the complexity of the Bill people, and in particular doctors, were either too busy to look at it or couldn’t understand it when they did. One of the problems we have had is engaging the profession because they didn’t notice what was going on, or trusted too much to our union to take on the problem or felt powerless given the lack of any visible sign of opposition.  There is also a minority of doctorpreneurs who see financial opportunities and never mind the long term consequences

Because the language used was about patient and doctor empowerment patients felt reassured by the thought of money and power in the hands of their local friendly family doctors and it has been hard work to expose the spin.

Another problem was identifying and co-coordinating all the bodies who were opposed to the proposed legislation, in particular working with the health unions who tend to be suspicious of other organizations.

Our organization was vociferous from day one, saying that the Bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10 point critiques of the Bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published. We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize on line petitions. We put a lot of energy into lobbying politicians. We have helped exposed the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster. We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within

As the Bill passed from the House of Commons  to the House of Lords the profession finally woke up and there has been a flurry of open letters, both to our union, the BMA, asking it to oppose the Bill, (published in the BMJ), to politicians in both houses and to newspapers. We, the NHS Consultants’ Association, wrote to the Academy of Royal Colleges, the umbrella body for specialist professional bodies, asking them to get involved. They are traditionally very conservative and excuse inaction by saying they are apolitical, but we pointed out that their remit is quality, training and standards, all of which are threatened by the legislation. They have since published a letter to the government stating their concerns.

Despite what amounts to a public outcry in the last couple of months the Bill is now going through the House o Lords with the prospect that it may emerge with little changed

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cosy relationship with today’s politicians.  It’s easy to lose hope but we mustn’t.  We have to take on this cosy configuration of politicians and giant corporations which have come to a ‘comfortable accommodation’ at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is.  We must collect evidence and use it to criticize and expose.  We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, ‘The NHS will last as long as there are folk left with the faith to fight for it’. We must be those folk because, personally, I am not prepared to let him down

drjcdavis@hotmail.com

Food for a wrongly chronicled thought

Human Rights Reader 275

-History is a lady with a slow digestion. (E. Galeano)

-Being human means knowing and judging the role that extremes of greed, of moral corruption, of prejudice and

of cruelty have played in history so as to effectively combat them. (M. Vargas Llosa)

Understanding history for what it is

1. As individuals, we do not really create the historical times in which we live-in. But what we have to do is to understand the problems posed and shaped by each historical time so as to try to come up with the most forward-thinking interpretation of them that eventually leads us to fair and just solutions applicable to our time.

2. Making sense of current and recent history is a subjective, value-driven activity; we do make historical errors of interpretation, i.e., judging what is true or false in history is a value-laden process. Myths have had and have the bad habit to conquer and dominate. There thus always is a historical relativity in the judgments people (and historians) make. The powerful can always boost their honor for posterity by buying themselves a good pair of historians and  making them deliver; it is just a matter of a good pay-off.  In this same vein, I like the quote: History negotiates its terms and collects its dues, i.e.,  a ‘history enlisted by commerce’. (A. Roy)  Historians, then, are the only individuals that can (and have) modify(ied) the past. (A. Gomez) Most probably, from the claim holders perspective, worse things than have been chronicled have happened…and keep happening.

3. Not even the educated public is prepared to face and correctly interpret history; I am convinced that, throughout history, the lack of universal progress in development-for-all is a fact, as much as people want to tell me that history is a progressive upward spiral. (P. Weiss)

4. Picture the history of the world as the history of a ten-thousand-year war of brains and of interests between the rich and the poor. Each side has forever tried to take-in the other side –and it has been this way since the beginning of time. The poor have won a few battles but, of course, the rich have won the war for ten thousand years: The inalienable fact is that, in order to make poverty history, the history-of-poverty-making needs to be understood. (T. Lines)

5. History already has a sufficient number of pages to teach us two things: never do the powerful elect the best among us, and policies are too often set up by bad  politicians who now, with hindsight, can be held responsible for historical inertia. (C. J. Cela) Too many politicians apply the word ‘history’ to any banality that suits their needs.

6. For instance, the price poor countries pay to sustain the rich countries is a historical fact. After all, colonies do not cease to be colonies because they are independent. (Disraeli)  In his Candide , Voltaire already had a black slave who had a leg amputated to prevent him from escaping say: “This is the price for the sugar that you eat in Europe”.

7. What we have to ask ourselves is: Is all history like this? Like the one we learn at school? Like the one historians write, i.e., a more or less idyllic, rationalized and ‘coherent’ fabrication of the hard and crude historical reality representing a mix of multiple interests?  The latter has been the forever-history, the never-ending-history we have been taught.  When historical (sociological, psychological and cultural) explanations are exhausted, there still is a vast grey area to get to the root of the perversity of human beings.

8. The history we are taught is made up of symbols giving them an aura of reality. But symbols do not always have to be seen as a sign of human irrationality*; they just show time-bound predominant elite-sanctioned beliefs, customs and discriminations that end up being chronicled by history. As a result, history rarely chronicles the setbacks of the largest part of its protagonists.

*: Climate change illustrates a case of irrational exuberance, of forgotten history and of widespread greed.

9. A certain continuity in history is undeniable; One cannot act ignoring it. For sure, more ‘modern’ visions cannot be adopted disregarding history. (M. Ovalle)

10. Some say history is a prophet looking backwards, i.e., based on what was and what was not, history announces what will be. (E. Galeano) Otherwise, it is said philosophers interpret history. After all, it is argued, philosophers are nothing but belated notaries that notarize what is happening in main street. (A. Gomez)

11. So, as you see, history is not lineal. It is made up of ruptures provoked by the accumulation of energies, of ideas and of projects that, at a given moment, cause a break, and thus the new erupts with enough strength to attain hegemony over all the old forces; thus another time is set up and a new history begins. (L. Boff) Revolution, although a violent break, is the most dramatic compromise with history.

12. Nothing is black or white in history; not even the glamorous chronicles of battles won or revolutions or a just cause succeeding; even there, we can detect those grey areas that cloud everything.

13. A final thought here is that, these days, we do not say or do anything that does not have numbers attached (statistics); judgment comes from the latter. More numbers, more graphs, more histograms with a % on the top and history thrusts forward defying anyone who contradicts (so often biased) statistics. But is this what we really want?

History and Human Rights

Isn’t it true that we often love and pay respect to our dead more than to those that are due respect and are alive? Take human rights pioneers, are they not too often ignored and ‘nobodied’. (A. Bryce Echenique)

14. For work in human rights (HR), being conscious of one’s responsibility in history means we cannot turn our backs to the compromises of history. From this perspective, what leaves me with a bad aftertaste is realizing that, as a group of HR activists, we still are in the periphery of history.

15. Today, we have to serve not those who purport they are making history, but those who suffer from the way it is made. We thus have to refuse lying about what we know to be true and in so doing resist oppression. (Albert Camus)

16. Historically, when HR have gained meaning beyond the level of rhetoric, it has always been as a result of political contestation, often long and bitter.

HR principles are thus intimately bound to values of solidarity and to historical struggles for the empowerment of the disadvantaged. (D. Tajer)   

17. A former UN High Commissioner for Human Rights described HR as “the closest thing we have to a shared-values-system for the world” (M. Robinson 2007). From such a historical perspective then, it is the mobilization of claim holders for the legal recognition of HR that will offer the most plausible route to (by nonviolent means) achieving the transformation of national and international institutions and practices that deny opportunities for good health and for a long life to literally billions of people. (T. Schrecker)

18. The rich are always one step ahead of activists, you would say, right?  Well, not anymore if we succeed in explaining key historic facts from a HR

perspective*; for this, for every step they take, we will take two. We are not the owners of history. But it is time we were. (Z. Acevedo Diaz)

*: Herein the thrust of this Reader.

19. In HR work, we are all bound by the unfair rules of history; the prevailing social order can only be subverted through international work. Motivation for change comes from the effervescence of the masses. (R. Luxemburg)

20. All this having been said, I contend that, in the era of HR, ingenuity will never again be an ingredient of history.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

_________________________

Adapted from Development in Practice, 19:8, 2009; F+D, 47:1, IMF, March 2010 and 47:2, June 2010; and from Mario Vargas Llosa, ‘El suenio del Celta’, Alfaguara, Santillana USA Publishing Co. Inc. Doral, FL, USA, Nov. 2010.

Postscript:

Beware: Mistakes of historical interpretation occur when one judges remote, past situations with the ethical, social or political values valid today. Therefore, rushing to historical judgment can be more damaging than lies. (A. Gomez)

Claudio Schuftan

Los Angeles. My main topic this month is the significance of the ‘new philanthropies’ and their impact on global public health, and in particular population nutrition in less resourced and impoverished countries. My context is this month’s UN Summit on the prevention and control of non-communicable diseases, which are now rampant in Asia, Africa and Latin America. A vital source for this commentary is an analysis by scholars from the Harvard School of Public Health and the London School of Hygiene and Tropical Medicine (1).

My pictured example is the biggest philanthropist in the world, whose interest is public health, and his foundation, whose budget is greater than that of the World Health Organisation, and which after the US government is the biggest funder of WHO. This is the Gates Foundation, about to become the largest single shareholder in the Coca-Cola company and in Kraft Foods (1), which, as stated on its website, is ‘driven by the interests and passions of the Gates family’.  Bill Gates, above, is speaking on the theme of ‘the new drivers of development’ at the 2008 World Economic Forum meeting in Davos.

People’s Health Movement

On to its world assembly in Cape Town

At the end of July I attended the annual meeting of the USA circle of the People’s Health Movement in Los Angeles. The setting was bucolic: the Loyola Marymount University campus, seen above in term time.  It was good to be with grassroots activists in the US who, suffice it to say, are having a hard time, because of the financial turmoil the US is going through. I brought with me the solidarity of the global People’s Health Movement.

Discussions were fertile and we all shared plenty of ideas on where the movement wants to go in its domestic US work over the next two years. Attention was also given on how to best contribute to the organisation of the Third People’s Health Assembly, to be held in Cape Town in July next year. This coming event is creating a great deal of excitement the world over, particularly among grassroots organisations working in health. What a great job they are doing in the US. Defending the right to health in this great nation is certainly not an easy task – let alone working against militarism and against big time polluters, as some militant groups here do.

The new philanthropies in world health affairs

Masters of our universe

Bill Gates is currently the world’s second wealthiest person. Among all the new philanthropists I have picked him because the Gates Foundation, with assets of $US 30 billion, is by far the largest foundation whose main interest is population health (1). He has become devoted to the UN Millennium Development Goals. Above (left) he is advocating them at the UN General Assembly in 2008. Also in 2008 he is (right) upholding them with colleagues UN secretary-general Ban Ki-moon, the late Nigerian president Yuma Yar-Adua, former UK prime minister Gordon Brown, Queen Rania of Jordan, and (far right) Bono. No people of the type shown in the photographs being held up were, as far as I know, present in Davos.

When we consider the significance and impact of the ‘new philanthropies’, it is fair and reasonable to think of Bill Gates and his foundation, because of its scale and his presence. But there are others.

Institutional relationships in global health are a growing area of study, but few if any previous analyses have examined private foundations. It is almost as if analysts feel that foundations are beyond criticism or even appraisal. Bill Gates certainly thinks so. The intentions and policies of the directors of foundations are rarely considered. This is now beginning to change (1-4).

There are broadly three different types of private foundation whose declared purpose is to protect and improve public health, including nutrition. Some were set up a long time ago, often by vastly wealthy US industrialists and which, over decades, have sought distance from their founders. These include the Rockefeller and Ford Foundations, for example. Some are similar, except that the founders are themselves alive and active in pursuit of influence on internal affairs in ways they see as akin to their view of the world. The Gates Foundation is the outstanding example, but there are others, for instance the Fundación Carlos Slim Helú, named after the world’s currently wealthiest person. Other foundations are obviously different; they are set up by and controlled by transnational and other giant food and drink companies. These include the Coca Cola Foundation, the PepsiCo Foundation, the Kraft Foods Foundation, and many others.

As I see it, the similarities between these types of foundation are actually greater than their differences. Corporations set up or fund foundations that support the corporation’s direct or indirect, tactical or strategic policies. Foundations that are historically or constitutionally distant from their founding funders still work within an ideology that is consistent with big business, particularly as seen by US industrialists. They rarely transfer money and resources to organisations that are  independent, democratic, and accountable to their members, or to voters and taxpayers.

The funders and directors of private foundations may well have altruistic motives, but it is also true that there is financial benefit in setting up a foundation. It also stands to reason that the policies of any foundation will support or at least be consistent with the corporate policies and personal ideology of the people who control the foundation.  Tax-exempt private foundations and for-profit corporations increasingly engage in relationships that can and do influence global health.

Where do foundations invest their money?

Many public health foundations have associations with private food and drug corporations. In some instances, they are invested in the stock of such corporations. Here below, for example, is a list of the main stockholdings of the Gates Foundation, taken from (1).

________________________________________________________________

Table 1

Gates Foundation stock portfolio, 2010. Some of its holdings (1)

________________________________________________________________

What this shows is that when the stock of Hathaway donated by Warren Buffett and now being transferred to the Foundation is taken into account, the Gates Foundation will be the largest single stockholder in Coca-Cola, the biggest manufacturer of sugared soft drinks in the world, and of Kraft Foods, the biggest manufacturer of confectionery in the world. Does Bill Gates think about this, when he makes decisions, or is on platforms with executive from transnational food and drink processors? Probably not, but it seems likely that they think about it, and it also seems likely that there is a basic community of interests here.

Does this help to explain the zealous attachment of the cash-strapped United Nations system to ‘public-private partnerships’ where in our field of nutrition and public health the private partners are mostly transnational food and drink processors, otherwise known as Big Snack?  This also seems rather likely to me.

Personnel move between food and drink industries, pharmaceutical houses and academia and to and from public health foundations. Foundation board members and decision-makers also sit on the boards of some for-profit corporations benefiting from their grants. While private foundations adopt standard disclosure protocols for employees in order to mitigate potential conflicts of interests, these disclosures do not always apply to the overall endowment investments of the foundations or to board membership appointments.

The extent and range of relationships between tax-exempt foundations and for-profit corporations suggest that transparency in grant making alone may not be preventing potential conflicts of interests between global health programmes and their financing.  The question of whether and how financial and institutional relationships shape foundation decision-making has yet to be properly addressed, let alone answered.

Further, it is surely fanciful to suppose that industrialists who are alive and active now, and who maintain control over foundations, are likely to change the core beliefs that made them immensely wealthy. The basic ideology that drives transnational corporations is going to be the same basic ideology that drives their foundations. Does this seem to you to be a cynical view? Surely it is common sense. But the implications are vast. It means that the strategic policies and practices of transnational corporations are pursued, albeit in a different guise, by the foundations set up in their name. Technological fixes ensue. But medical technologies make a relatively small impact on the broader social and economic determinants of health and nutrition; and the efficacy of technology cannot be guaranteed so that an over-emphasis on technology has been and is problematic.

As David McCoy says, the ways in which much private philanthropy works are hugely inefficient. For example, there are many transaction costs related to vertical top-down initiatives, and there is much collateral damage along the way. We could achieve better long-term health and nutrition improvements using an approach that tackles the social determinants.

Foundations are not all bad

David McCoy also thinks the issue is less straightforward than ‘condemning private philanthropy out of hand’. For example, he asks some important questions:

• Private philanthropy can include some expressions and actions of social

solidarity for ordinary people, but we do not condemn that, do we?

• Do we need to make a distinction between post-tax and pre-tax private

philanthropy?

• Many of us work for organisations that are funded in part by private money –

do we condemn all that private money as well?

• Is all private philanthropy worse than public aid? Are US government aid and

the World Bank loans and grants associated with structural adjustment programmes better than all examples and sources of private philanthropy?

• Are there better and worse forms of private philanthropy – in terms of the source and the spending of that wealth?
• Is there a need for us to differentiate a moral/political position from a

tactical/strategic position on private philanthropy?

• Given the pre-eminence of Gates in the global health field, what is our strategy towards the Gates Foundation? Have we ever called for a debate or discussion with the Foundation? And should we?
• Do we seek to reform, or to lead a revolt on all of the above?
• Much philanthropy used in ways that prevent the radical and structural

changes required to set up a fairer and more progressive economic system. What is our stance here?

• Aren’t private foundations not only unaccountable, but hasn’t their power grown through the ‘capture’ of other institutions, including the UN?
• Their rise is linked strongly to the relative reduction in public financing with a concomitant rise in the public-private partnership paradigm. Is there any monitoring of the revolving door syndrome between United Nations-foundations-corporate sector-governments?
• Are there adequate checks and balances to prevent the capture of public

financing and policy making by the private philanthropy/corporate sector?

I think there is much agreement on the historical analysis of the rise of these institutions, their minimising the tax liabilities of their corporate funders, and their capture of the UN (and many other public bodies). But the issues are complicated, and are only beginning to surface and to be understood (1-4).

My friend Alison Katz, on the other hand, thinks philanthropy is never positive. Her view is that the right to health and to nutrition are incompatible with private philanthropy. Private philanthropy and the diseases of poverty go together: They result from, and characterise, gross economic inequity – the root cause of preventable malnutrition, ill-health and deaths.

She believes that as nutrition professionals, we must fight for economic justice as the precondition for the right to nutrition. This implies denouncing private philanthropy.

I am on her side. These things were clear already over ten years ago when philanthropies became prominent.  Since the 1980s, most of all, big corporations have successfully fought to pay very little tax and even no tax at all. In doing so they have succeeded in destroying the tax base which is the basis for public services of all kinds, including health and nutrition.

Of course they prefer not to pay taxes, but instead to ‘give’ money (even lots of money) to health (much less to nutrition). In doing so, they open up the area of health and health services to privatisation. They thus make what should remain public goods actual tools of capital with all that implies. The implications include rapidly widening gaps in equity, and the terrifying prospect of destitution when chaotic fluctuations in the money markets occur, such as those we are once again experiencing as I write this column.

Please, do not tell us that health services in faraway lands would collapse, were it not for private foundations. It is not a question of abandoning services in Africa and leaving people adrift. It is a question of what we are fighting for in the long run, and a question of values, principles, equity and justice.

.

  Box 1

A letter to Margaret Chan

   In 2007, Alison Katz sent a letter on this to Margaret Chan, director-general of WHO. She wrote it at a time when she worked for WHO, but under notice of dismissal. Nothing has changed since and conflicts of interest are still pervasive.  Here is part of the letter. It never received a response. You can access the full letter here.

‘It has become fashionable to focus attention on the poor, but to meet and establish partnerships with the rich. In order to address the fundamental problem  of inequality, this pattern must be reversed. It is time to focus attention on the rich and powerful, because they are the experts in the mechanisms of unequal power relations and the architects of policies and strategies which produce, reinforce and accelerate inequalities. Those systems must be closely examined by WHO and opened up to public scrutiny and democratic control. To clarify, this is not a discourse on good and evil; the issue is one of antisocial and sometimes violent systems manipulated by a handful of individuals.

‘Poor people do not attend G8 summits, board meetings of the latest Global Fund or philanthropic foundations, let alone the World Economic Forum – where Chief Executive Officers of transnational corporations are offered even more privileged access to political leaders than they already enjoy. But poor people also hold meetings and they are represented – if imperfectly – at the World Social Forum  (and in national and regional social fora), in trade unions, social and political movements and elsewhere.

‘As Director-General of WHO, you are committed to “the people of Africa who bear an enormous and disproportionate burden of ill health and premature death” and you have made this “the key indicator of the performance of WHO”.’ Katz goes on to say that the presence of the WHO director-general at meetings of the World Social Forum ‘would represent real hope and inspiration for the world’s people and an essential counterbalance to high level meetings with government leaders and their corporate backers/advisors – who are increasingly one and the same’.

‘You have gone on record saying that “the landscape of public health has become a complex and crowded arena for action with a growing number of health initiatives” and you reminded us that WHO is “constitutionally mandated to act as the directing and coordinating authority on health”.  As you know, public-private partnerships have become the policy paradigm for global health work despite the evident conflict of interest which would have outlawed such arrangements thirty years ago. Agencies and organizations with public responsibilities are partnering with the private  sector for one reason: It (appears to have) become the only source of funds. This situation has arisen, because under neoliberal economic regimes, public sector budgets have been slashed and tax bases destroyed. Those developments are themselves the result of the influence of transnational corporations (TNCs) and the international financial institutions on governments’.

‘The solution to this problem is not for public bodies to go begging to the private sector, nor to the foundations of celebrity philanthropists with diverse agendas. The solution is economic justice, including an adequate tax base, both nationally and internationally, to cover all public services, as well as proper funding of public institutions such as WHO through regular budgets so that they  may fulfil their international responsibilities unimpeded by corporate interests’.

‘You have further argued that “the amount of money being made available by foundations, funding agencies and donor governments is unprecedented”.  This will be entirely positive if you are able to use these funds to pursue your vision and priorities, as is your right and your duty.  It can be argued that, if WHO had operated exclusively on a regular budget, even with a significantly smaller workforce, but one that was dedicated to WHO’s constitutional mandate, far more progress towards Health for All would have been achieved’.

‘As you have said “Primary Health Care (PHC) is the cornerstone of building the capacity of health systems. It is also central to health development and to community health security”. PHC will remain mostly rhetoric if it is not supported by a solid, equitable tax base and other forms of redistributive justice (debt cancellation and reparation, fair trade, abolition of tax havens, democratic control  of TNC activities, etc.). WHO itself needs to set targets for the level of core funding, starting perhaps at 70% of total expenditure, and increasing annually until undue influence is removed. The private sector has no place in public health policy making at global or national level. This does not, of course, exclude responsibly designed interactions as in the past. But it does exclude partnerships, because partners  must share the same goal’.

Private philanthropy is always interested in something. Does it seem that I am being facetious when I suggest that this is furtherance of its own interests? Private philanthropy exists because of gross inequities. Diseases of poverty and philanthropy in health and nutrition will always go hand in hand. When the right to health is achieved – even partially – who will need philanthropy? Philanthropic giving is the antithesis of the rights-based approach to health and nutrition.

Private philanthropy has no place in a social justice approach to human rights, including the right to nutrition. A right cannot depend on charity, or even on expressions of top-down social solidarity. That is the nature of rights. Private philanthropy only exists because of large inequalities. It almost always confers yet more power on the giver and thereby further widens those inequalities. It is truly a vicious circle and our aim ought to be to move out of it.

This does not mean abandoning people to their suffering. It means working on a transition to a human rights-based approach at all times. In all our strategies we have to move towards the standards and principles of human rights and away from charity.

The People’s Health Movement position

The People’s Health Movement has had lengthy debates on public-private partnerships, and has protested Bill Gates opening the World Health Assembly in 2005 and again speaking there in 2011. We have vehemently and vocally opposed the privatisation of health services and have denounced the UN Global Compact. Our   entire raison d’être relates to issues of conflicts of interest, the rule of money, and the capture of WHO by industry.

We do not condemn private philanthropy action as a temporary measure to stop immediate and medium term suffering. As a way of achieving our aim of health as a human right, yes, we do condemn it. It has no part to play in the structural processes to achieve the human right to health and to nutrition. We are about creating the conditions for human rights, not to dole out goodies to salve consciences, quelling popular uprisings, and preventing real change.

My own reflections

Here is what I think, based on working for over 30 years as a nutrition and health professional mostly concerned about impoverished people in all continents apart from Europe.

Ordinary people understand well that charity is an integral part of systems of inequity. If it is to be effective, and in order to improve the situation of people, social solidarity has to take the form of political action. Hence the famous phrase of Dom Hélder Câmara the Brazilian archbishop of Olinda and Recife: ‘When I give food to the poor they call me a saint, when I ask why they are poor, they call me a communist’. When impoverished people protest in the streets, you do not hear them calling for more philanthropy. They are demanding their rights.

A solid tax base, redistributive tax systems, and economic justice are the answers.  Transnational corporations are skilled at avoiding tax. Some pay little, some pay none. Rich people generally pay far less proportionately than poor people. Over the past 30 years, the tax burden, like every other burden, has shifted massively onto the backs of the poorest.

Do we really want to put nutrition decision-making in the hands of the wealthy much of whose money comes from avoidance of taxes, which is to say not contributing to the public purse, so that the public has to come begging for money that is rightfully theirs in the first place? Or, do we want decision-making to be public and democratic including those who pay taxes? That’s the choice: rule by money – plutocracy – or rule by people –  democracy. We already condemn the ability to pay as a criterion for access to health care and to good nutrition. We should also condemn the ability to pay as a criterion for access to decision making.  When we work in health or nutrition or any public service addressing human rights, our funding should be public; we should not depend on private funding.

The more I think about this, the more it seems to me that private philanthropy provides a respectable front to the much larger hidden face of powerful and exploitative forces. We want health and nutrition for all through social justice. It is a matter of appreciation whether social justice is a revolutionary project. Compared to the current neoliberal dogma, it probably is.

People are naturally compassionate, and empathy is a human trait. When ordinary people are told the truth about how international aid or private philanthropy works, they understand very well that human rights and charity are not the same thing. People will always need to help out other people in emergencies, because human beings are like that. But in a fair world, it would be just as likely for Haiti to help out Belgium, as it would be for Australia to help out Mali.

Private philanthropy’s espousal of ‘creative capitalism’ or ‘responsible capitalism’ or ‘win-win capitalism’ or ‘markets that benefit the poor’ (there are many more warm phrases) surely is obviously absurd at a time of chaotic market failures. Such phrases are surely fatuous when we find that foundations are doing nothing or little to stop systematic corporate tax evasion, and are aware that international property rights laws now promote monopolies and hinder innovation and scientific development. The very least that private foundations could do, is to address the many inequities and causes of market capture, market failure, barriers to market entry, and so on and on. These issues are crucial in the health and nutrition sector, because of its particular susceptibility to market failures. If families are thrown out of their houses, or have no money to buy shoes, usually they manage somehow. If they have no food, they die.

As Alison Katz so eloquently argues and David McCoy rightly concludes, private philanthropy has become a powerful and insidious presence in our midst. Ventilating this topic now is timely, in the month of the UN Summit on prevention and control of non-communicable diseases.

Transnational corporations and foundations are deeply implicated and involved in this global pandemic. Soon, I predict, private foundations, some directly controlled by transnational food and drink companies, others with less direct links with that part of industry whose products are a cause of the pandemic, will enter big-time, into the prevention of non-communicable diseases arena. But why am I saying ‘soon’? This is already happening now. At the very least, we professionals need to become more aware of what is going on, where philanthropic stakeholders are coming from, and why.

References:

1          Stuckler D., Basu S., McKee M., Global health philanthropy and institutional relationships: how should conflicts of interest be addressed? PLoS Med 8(4): e1001020. doi:10.1371/journal.pmed.1001020

2          Anon. What has the Gates Foundation done for public health? [Editorial]. The Lancet 2009; 373, 9675: 1527.

3                Piller C, Sanders E, Dixon R. Dark clouds over good work of the Gates

Foundation. The Los Angeles Times, 7 January 2007.

4                Wiist B. Philanthropic foundations and the public health agenda. Corporation

            and Health Watch, 3 August 2011.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Schuftan C. The new philanthropies in world health affairs. [Column] Website of the World Public Health Nutrition Association, September 2011. Obtainable at www.wphna.org

I owe the analysis in the commentary to many years’ experience and many discussions with countless friends and colleagues in the People’s Health Movement. Many thanks to David McCoy and Alison Katz; and also to David Stuckler, Sanjay Basu and Martin McKee, whose extensive review cited above is a vital resource. This column is reviewed by Geoffrey Cannon.

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

At this time of social unrest and growing protests over corporate power and corruption, I offer this reminder that the public health and social justice website at (http://www.publichealthandsocialjustice.org or http://www.phsj.org) contains many articles and open-access powerpoints covering corporate malfeasance as it pertains to the U.S. and world economies, health care (including the insurance and pharmaceutical industries and health professions education), the environment, public education, drug laws, the tobacco industry, food safety (including GMOs, biopharming, the overuse of agricultural antibiotics, and obesity), and the military industrial complex.

Material in the slide shows can be shared with and presented to colleagues, activists, students, the media, and the general public (with appropriate citation).

The activism and education is a good place to start, as it contains slide shows which provide a general overview of the breadth of corporate malfeasance. The most comprehensive is at http://phsj.org/wp-content/uploads/2007/10/Corporate-Control-of-Public-Health-Case-Studies-and-Call-to-Action12.ppt.

The activism and education page contains contributions from Matt Anderson and colleagues/residents from Montefiore, Nick Freudenberg (whose website Corporations and Health Watch at http://www.corporationsandhealth.org/ is a treasure trove of material), Bill Wiist (author of the comprehensive The bottom line or public health: tactics corporations use to influence health and health policy and what we can do to counter them), Josh Freeman (writer of the Medicine and Social Justice blog at http://medicinesocialjustice.blogspot.com/), and many others.

One can also access links to many websites working to combat corporate corruption. New submissions are always welcome.

Contact Martin Donohoe at martindonohoe@phsj.org.

Claudio Schuftan

My column this month comes in two parts linked by one word. This is ‘target’ in two of its meanings. These are ‘targetry’ and also ‘setting targets’. The concepts that I want to get across to you are self-evident as you read along.

In the name of greater equity, many currently proposed approaches to resolve the problems of nutrition still very often favour and select actions covering, for the most part, strategies that target services to the disadvantaged and malnourished, such as the measurements of weight and height of little children as shown above. This strategic approach, it is purported, represents a move towards equity. But is it really? Many of us rather think that what is needed is to mobilise a strong popular movement that demands a comprehensive, truly equity-oriented nutrition policy (1).

TARGETRY AND EQUITY    ‘FIXING THE WORST CASES’ DOES NOT AND CANNOT ADDRESS THE BASIC ISSUES’

Many of us also think it is wrong to propose targeting as an alternative to making nutrition an integral part of primary health care – applied in its full Alma Ata spirit. Individual targeting is a variant of the ill-reputed ‘selective primary health care’ approach we all saw rise after Alma Ata. Its motto was: ‘Go for the worst cases, fix them, and improve the statistics’. But this does not and cannot stop recurrence of the same problems.

Unfortunately, individual targeting is now seen as a central option by the World Bank and other major funding agencies, together with geographical and other types of targeting.How can this be fair? In an era of fee-for-service delivery systems promoted by free-market proponents, one of the key issues for individual targeting – to keep a semblance of equity – seems to be the exemption from user fees for the poor. Unfortunately, these waiver schemes, in all their variants worldwide, have proven to be mostly catastrophes. They simply do not work. Perhaps they are meant not to work. They are often implemented insincerely, only as a political manoeuvre to make user fees more palatable to the population when first introduced.

In my view, and that of many others, individual targeting cannot be made to work equitably. Nor is it effective. Weeding-out and providing the needed services that actually do target individuals or groups is a time-consuming and costly administrative process.

Geographical targeting, for instance of the most impoverished districts probably has more potential, and the more so if being made part of a comprehensive primary health care approach. But impoverished communities usually have little political clout to fight for their share. But even at somewhat higher cost, this type of focus on the poorest clusters of poor people makes sense in terms of equity – and of human rights.

Throwing crusts to the hungry

Individual targeting is a dangerous path to follow. It pursues a ‘mirage of equity’ that basically leaves the perennial determinants of the rich-poor gap untouched. It is like throwing a crust of bread to the hungry.

What’s needed now is to compare the effects on long-term equity and on nutrition indicators of selected individual targeting interventions with a host of already tried direct poverty alleviation measures. The data for this may already be there or may be still missing.

Overall poverty reduction (or better, disparity reduction) is a theme yet again getting growing attention these days. So nutrition colleagues have a golden opportunity to work harder to influence overall development strategies towards equity in health and nutrition. We should not miss the opportunity. All the more so, because the health/nutrition sector cannot, by technical actions alone, make significant improvements in the health/nutrition conditions of impoverished populations.

The limits of data

Breaking down health and nutrition data by income quintiles, by gender and by ethnic background, as is now proposed by some donors, is a welcome first move. This can be used to consolidate credible national and international databases and thus track equity issues. Results of analysis of these data could usefully be published annually in a publication with the stature of the annual UN Development Programme World Development Report. Countries could be ranked according to their respective performance. Such a publication could further analyse existing gaps, and minimum performance objectives could be set for improvements for the immediately following years.

Using such data to tackle the inequities at sub-national and especially local level is where the real challenge lies. Donor agencies will have to be more forceful in advocating equity-promoting, human rights-based, participatory, bottom-centred interventions. They will also need to be more responsive to government-initiated requests from low-income countries for funding to prepare and execute policies specifically addressing what is the fundamental issue of equity.

Governments and donors will need to enter into binding commitments, perhaps with signed memoranda of understanding, in order to move in the direction of disparity reduction and greater equity. Close monitoring of progress will also be needed. These binding commitments should be a precondition for continued support. Funds could then be released in tranches based on the achievement of negotiated verifiable indicators of progress along the line of project implementation. At the same time, donors should develop formal relations with national and local civil society organisations. In the case of non-responsive or non-performing governments, donor funding should be progressively reallocated to what by that stage should be known to be a competent and trustworthy civil society organisation network.

All this may only add up to a start –and from the top at that. But it is a start.

SETTING TARGETS     HEY DIDDLE DIDDLE, THE HYPE AND THE RIDDLE: THE GAP BETWEEN WISHING AND DOING

There is a big difference between the excitement and the expectations generated by setting goals and targets, on the one hand, and on the other hand, being able to claim that they actually work. Setting targets is typically not a participatory a process, and usually does not admit of public expressions of dissent. Further, in affirming goals and targets like those of the MDGs, countries pledge, but whether they really commit and comply is a whole different matter (2). More often than not, the processes to achieve the targets are left in the air (or only on paper).

Getting from where we are to where we want to be, requires quantifying where we want to be at a given time, and also requires specifying the process we are going to get there. Targets address the former. Processes are typically left to planners and implementers, and usually exclude any representation of those who are supposed to benefit. But it is the processes that contain the seeds of sustainability. Unfortunately, we nutritionists are good at setting targets, but not much good at prescribing sustainable processes – let alone denouncing processes we know do not work or are not working. Nor do we spend much time and energy on considering and agreeing what measurements can gauge progress towards fulfilling the right to nutrition. such as people’s participation, mobilisation and empowerment. Instead, we spend so much time and money proposing and monitoring outcome targets that medicalise the nutrition problem. Think about it.

The need to get real

Some targets we set before and during the 1990s called for a number of pretty unrealistic measures. These could not be afforded by most lower-income countries, let alone by impoverished communities. The result has been low coverage rates and low compliance – ineffective and also wasteful.

It seems to me and many others that this basic mistake has been and is being made with the MDGs. Already in 2011, we have no assurance that the goals are really mobilising national governments beyond lip service. And to repeat what I have said in previous columns, political and economic ‘business as usual’ will not and cannot achieve targets for anaemia, stunting and underweight, and at present rates, it will take way beyond 2015 to halve the prevalence of child malnutrition.

Moreover, three serious concerns arise here:

One is on who should be the judges of what is realistic. Certainly these should not be only us, the technicians. Also, realism can no longer be based on targets set at national levels. National averages hide huge disparities.

Two is the quality of the data used to monitor progress towards achieving targets. If progress seems to be poor, this may reflect poor quality of the numbers from which the goals are derived.

Three, I keep hearing colleagues say that this or that target ‘may be’ too ambitious. The time has passed for ‘maybe’. (A poster hanging on the wall of my office reads ‘I said maybe, and that’s final’). It is only through setting up processes of democratic consultation that we can expect to get realistic bases for concrete, feasible goals.

An issue not often considered is the convergence of the various goals and targets we technicians set, from the top down.

Actions to overcome specific aspects of malnutrition can be and are additive. For example, improvements in vitamin A status positively affect nutritional anaemia; improvements in iron status can positively affect the appetite of a child. Our actions to address micronutrient deficiencies and chronic malnutrition are thus complementary and impact on overall well-being of populations and families. But we need always to remember that they live in imperfect societies that ultimately cause them to suffer from the different forms of malnutrition. Yes, we can get the retinol levels of a child up to normal, but then the child may go on to die from malaria. So, to what avail our efforts?

BACK TO TARGETS AND RIGHTS: WHO SHOULD SET TARGETS, AND FOR WHAT? HOW CAN WE REALLY BE PART OF THE SOLUTION?

How can we make change sustainable? As always, we need to address the underlying and basic causes of malnutrition. We can start by de-medicalising our goals and targets, and by focusing both on processes and on outcomes.

The whole process of setting targets is, in a way, antithetical to human rights. The human rights principle is that we cannot rest until the rights of all are restored or instated, not 15 years ahead (and then another 15 years ahead), but in the present. We should be setting progressive, verifiable targets to be achieved year by year, in the process of progressive step by step fulfilment of human rights for all. A compromise position is to start working on targets in reverse. We could express targets as an expected year on year decrease in the number of malnourished at all including sub-national levels. Also, applying all specified interventions firstly to the easier to reach near poor – say, the second lowest income quintile – can move towards achievement of national average targets on schedule and also to reduction of inequity.

I disagree with colleagues when they say that consultation with beneficiaries (claim-holders) need to begin only when targets requiring direct action at community level begin to be achieved. To me, the idea of ‘just some amount of community action’ being needed is wrong. It implies a shift in the responsibility for doing something for the malnourished children in the community to the community itself. This victimises people who have been historically marginalised.

Donors: Fatigue or bad attitude?

More generally, why is donation of support for reduction of maternal and child malnutrition not working well?

Is this because of ‘donor fatigue? Or have targets for reduction of malnutrition having been set too high? And if so, are we responsible for having set ourselves up for failure? On the whole I think that the answer to these questions is, no.

In the eyes of donors. and also of many among us, chronic malnutrition is more messy to deal with than iodine deficiency disorders or vitamin A deficiency disorders. With bigger issues such as protein-energy malnutrition (and perhaps also iron deficiency anaemia), it is obvious that bottom-up, community-driven action is needed, and that issues of equity are involved, as well as longer time horizons. Donors pay plenty more lip-service to what needs to be done than, so far, working hard on solutions for these bigger and broader issues.

This is not fatigue, it is not a lack of will. It is a political choice. Internal and external resources allocated to under 5 malnutrition have thus remained a pitiable and disgraceful pittance. And there is nothing in sight that tells me that this is changing soon, notwithstanding the World Bank inspired SUN Initiative (Scale Up Nutrition)

In the selection of targets and processes, and in the steps needed progressively to achieve them, donors and many among us have been and continue to be undemocratic. Thus we fail those whose nutrition rights are being violated. As long as we consider the strategies needed to tackle the basic causes of malnutrition to be outside the realm of our professional scope of work, we are part of the problem and not of the solution.

The poverty alleviation connection

Will a global shift of donor agencies towards strategies that really are design to alleviate poverty and reduce inequity, ever happen? I have my doubts.

Reduction of maternal and child malnutrition is selected in the MDGs as a key outcome indicator to measure progress in poverty alleviation. Yes, a decrease in poverty will improve nutrition. But, this does not automatically translate into greater advocacy, more actions and more donor resources for the prevention of malnutrition. Being an ‘indicator’ does not translate into anything much, let alone being the object of concerted new efforts and investments directed at halving malnutrition.

Finally, perhaps there is no such thing as realistic across the board targets. Perhaps targets can be proposed by us for participatory consideration, based on some technical grounds, together with an outline of possible processes to attain them. Rational and realistic consensus for targets and processes must be painstakingly built in many, many places with both bottom-up and top-down inputs. There are no short-cuts.

References

1. Schuftan C. Can significant major equity be achieved through targeting? abstract, Health Action, CHAI, India, 13, 12, December 2000.
2. Schuftan C. Aiming at the target: What’s left for the devil to advocate?, SCN News 22, July 2001.

Please cite as: : Schuftan C. Targetry and equity. [Column] Website of the World Public Health Nutrition Association, August 2011. Obtainable at www.wphna.org

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

Human Rights Reader 266

Human rights are intrinsic values that give all human beings dignity.

1. Human rights (HR) are a foundation of the UN. Therefore, the UN has a core mandate to institute international HR mechanisms worldwide. “HR are foreign to no culture and native to all nations”. (Kofi Annan)  HR are legally guaranteed by HR law. Governments are thus obliged to do certain things and prevented from doing other. Yes, but are they faring well at this?

2. In 2000, the Millennium Development Declaration was signed by 189 member states. But the MDGs that came from it, stripping it to the bone, do not underscore HR sufficiently thus absconding from one of the main purposes of the United Nations. Since HR and the MDGs both clearly confer obligations on governments –but do not fully succeed in it yet– they are to be considered two sets of interdependent and mutually reinforcing commitments: I wish I could say they were.

3. Readers should be aware that, in the UN 2005 World Summit, Member States in the General Assembly resolved and agreed to mainstream HR into their national policies and that UN agencies were to assist them to do so.*

*: More than 20 multilateral HR treaties have been formulated since the adoption of the Universal Declaration of Human Rights. What HR treaties have done is to put into legal language the obligations of states (principally) and other duty bearers to do certain things, as well as to prevent them from doing other. The full body of international HR instruments consists of more than 100 treaties, declarations, guidelines, recommendations and agreed principles. The 1993 UN Vienna Conference recognized all rights as equally important; there is thus no hierarchy in HR: all HR have equal status.

4. To instrumentalize all the above, the HR-based Approach to Programming was born. [Together with some others, I personally prefer to speak about the HR-based framework, but we are in a minority. In this Reader, for once, I will yield to the majority].

So, what is the Human Rights-Based Approach (HRBA)?

5. At its simplest, the HRBA is defined as the process furthering the realization of HR, being guided by HR standards and principles and developing the capacities of claim holders and of duty bearers to change the approach to development programming. In short, today, it is the right approach to follow –both morally and legally. Given the complexities involved, the HRBA prompts claim holders and duty bearers to think differently and to ask a different set of questions. But it does not automatically give them the ‘right’ answers as, often, in fact, there is more than one right answer.** Conversely, what the HRBA is not is a panacea to the world’s development challenges.

**:The HRBA offers us a process and guides us towards which questions to ask; it does not provide easy answers; to some degree, we are still left with the challenge of embarking in trial and error.

6. So, what are the Human Rights-Based Approach’s attributes:

• The HRBA alters the way that programs are designed, implemented, monitored and evaluated –it is a veritable new roadmap.
• It moves development action from benevolence into the mandatory realm of law.
• It considers the individual as an active agent.
• It recognizes each development challenge as a HR challenge –or as several unfulfilled or violated HR that need redress.
• It provides a mechanism for renaming problems as violations making it clear that violations are neither inevitable nor natural, but arise from  deliberate decisions and policies. (!)
• It exposes the hidden actors and structures behind violations and sets out to change them face-on.
• It focuses on analyzing the unjust power relations that are the root cause of HR violations and of maldevelopment. It thus gives insights into the unfair distribution of power. (!)
• It imposes limits on excessive power and addresses all economic inequalities and their causes.
• It is the prime vehicle for governments to fulfill their HR commitments.
• It is directed at reducing the vulnerabilities of the most marginalized, i.e., it has a special focus on groups subjected to discrimination and suffering from disadvantages and exclusion. It thus gives the disadvantaged special priority.
• It sets out to impact prevailing norms, values, and structures –thus the development workers’ practice– and it shapes their relations with partners in a new way.
• It entails consciously and systematically paying attention to HR and HR principles in all aspects of program development.
• Making the needed situation analysis HR-based, it identifies the primary claim holders and duty bearers and their corresponding rights and obligations. i.e., it asks who is affected and who needs to be involved in solving the problem(s). Ergo, it looks beyond just the numbers (i.e., on what, how, who, why, and not just how many).
• It can invigorate NGOs by helping them recognize their roles as duty bearers as opposed to seeing themselves as strictly charitable institutions.
• It takes concrete steps to identify and combat social stigmas.
• It requires devoting time to capacity building activities (HR Learning) for both claim holders and duty bearers (includes forming HR trainers and mentors on how to use and teach the HR framework).
• It involves addressing areas that are highly political. (!)
• It opens up space for public dialogue, and
• It is not a rigid plan; it is an extremely flexible approach that consists in asking key questions, applying key HR principles to the program’s processes and outcomes, and in framing the program being designed around the realization of HR –a realization that governments are legally obliged to secure.

7. The caveat here though is that there is still little solid evidence to fully demonstrate the HRBA’s effectiveness; it has, so far, been difficult to measure success and widely shared indicators are still in their development phase. (But a growing body of evidence is indeed amassing).

You may think you are already applying the HRBA, but are you really?

8. Among other, this begs the following questions:

In your work,

• do you identify the HR claims of claim holders and the corresponding HR obligations of duty bearers, as well as the structural causes of the non-realization of HR?
• do you consistently assess the capacity of claim holders to claim their rights and of duty bearers to fulfill their obligations?
• do you design programs around strategies and plans to build these capacities?, and
• If you are a donor, are you according the highest priority to addressing the needs of the most vulnerable in the least developed countries?

9. Bottom line, the HRBA is a process with a myriad of different challenges –all of them surmountable with the right attitude, the right programming tools and the right determination.

We can truthfully talk of ‘the art of staging HR-based initiatives’.

Claudio Schuftan in Ho Chi Minh City

cschuftan@phmovement.org

____________________

Adapted from UNFPA’s  A HRBA to Programming: Practical implementation manual and training materials, 2010.

Postscript: In typical HR-based programming:

• People are recognized as key actors in their own development and not as passive recipients of commodities and services.
• Participation is treated both as a means and as a goal.
• Activities planned are empowering, not disempowering.
• The situation analysis to be carried out includes all stakeholders and is used to identify the immediate, underlying and basic causes of development problems.
• The program focuses on the marginalized, the disadvantaged and the excluded groups. It demands accountability of all stakeholders and aims at reducing disparity.
• The development process proposed is, in last instance, locally owned.
• Top-down and bottom-up approaches are used in synergy.
• The capacity-gaps of all stakeholders is assessed and support is given to fill these gaps.
• Measurable goals and targets are used in the programming.
• Strategic partnerships are developed and sustained.

Want to know more about the risks to human and animal health posed by the use of Recombinant bovine growth hormone, aka recombinant bovine somatotropin/rBGH/Posilac (Monsanto) in milk production, or about the use of other hormones in meat production. Visit the Food Safety Issues page of the Public Health and Social Justice website at http://phsj.org/food-safety-issues/.

Here you can read the APHA’s resolution calling for precautionary avoidance of hormone growth promoters in beef and dairy cattle production. Also available are articles and open-access powerpoints on rBGH and hormones in the food supply and the health and environmental risks of the overuse of agricultural antibiotics and about genetically-modified crops, biopharming, food irradiation, and mercury in seafood. Learn about the activities of Monsanto (and its infiltration of the USDA) and other agricultural biotech firms, many of which also manufacture and sell pharmaceuticals. Many external links will take you to other sites involved in food safety.

As always, submissions and corrections are welcome. Contact Martin Donohoe at martindonohoe@phsj.org. Visit and explore the entire website at http://www.publichealthandsocialjustice.org or http://www.phsj.org

Happy summer.

martin