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

August blog

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

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

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

For more information, we invite you to please see our website at: 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

THE REAL POTENTIAL OF HUMAN RIGHTS LIES IN ITS ABILITY TO CHANGE THE WAY PEOPLE PERCEIVE THEMSELVES VIS-A-VIS THE GOVERNMENT.

Food for staging a thought

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.

Hormones in the Food Supply and Other Food Safety Issues

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

IPHU Day 2: June 6, 2011: The Social Determinants of Health

Today we start the day with a brief overview of the Social Determinants of Health (SDOH).  Before getting to the core of the discussion, Dr. Matt Anderson challenges us to rethink the category and concept of “race.” This is a concept we all grapple with in our work on social justice. Through a quiz, we learn revelatory bits of information, such as, that all institutions in the USA, it is the Office of Management and Budget that determines “racial” categories in its collection of statistics on discrimination! Race is not only a socially determined category, it is, as Matt puts it, a “faux category.”

The SDOH discussion starts with a historical overview, and this is not a new debate or concept.  William Farr, the 19^th century British epidemiologist and early founder of medical statistics, through his observation of the relationship of disease and social conditions particularly of tuberculosis, prophetically said, “disease is the iron index of misery.”  That is, today we still know that the poorest of the poor are still the sickest of the sick and share an unequal burden of disease.  How to frame the debate remains a central challenge in our work and move the public discussion from blaming the poor and individuals  to one which points at the structural injustices and inequity in the social/economic order.

Next, we view a short documentary (circa 1970) on the origin of community health centers (CHCs) in the United States, “Out in the Rural.” The CHC movement in the USA began in a rural, share cropping community in Mississippi which bore the legacy of the historical injustices of slavery, increasingly mechanized agriculture, and loss of land and livelihood in an already economically and socially disenfranchised community.  Launched by Dr. Jack Geiger who knew that human rights and justice are the foundation of health, the CHC movement sought to place the health center as part of the development of the community.  The founders and early pioneers of the CHC movement rightly placed the responsibility for a community’s health and well being back on society’s shoulders, not on the backs of the individuals.  This is a must viewing for anyone committed to health and justice.

The morning concludes with a discussion by David Legge on globalization and health.  Four questions he presents are worth sharing here and need to be asked of anyone working towards a health for all agenda:  1.  How is the global health crisis maintained and produced? 2.  How does historical change take place? 3.  How does deliberate human action contribute to steering historical change? 3.1. How does social movement activism contribute to social change? 4.  How to strengthen the PHM so it can be more effective in driving social change? For the next hour or so we discuss how the concepts of the “global village, ” the movement of capital/economic structure and global governance institutions (i.e. World Trade Organization (WTO)) not only affect health, but are the foundations of a global system of inequity that “requires the bottom billion to be in misery to support the top billion.”

After lunch, Amy Finnegan and Mike Westerhaus conduct the SDOH
“Game Show,” an innovative tool to explore how SDOH operates through the work and voices of our fellow participants.  Amy and Mike act as “game show hosts” and interview participants John “Eros” Lopeyok of Kenya; Eugenia Perez-Montijo of Puerto Rico; Hripsime Kalandarian of Lebanon; and John Ashmore of South Africa.  Acting as the “contestants” they eloquently answer questions about the social and political landscapes of their respective countries and how SDOH play themselves out in their communities.  While no “prizes” were handed out to the social champions being interviewed, we all “won” through being both outraged and inspired by their stories.  And Amy and Mike definitely have a calling to be the answer to the PHM’s version of the Regis and Kelly morning show.

The SDOH Game Show! L-R: Mike, Amy, Eros, Eugenia, Hripsime, and John

The afternoon concludes with an overview of advocacy by Lexi Nolen that prepares us to go back to our small project group discussions and develop our project proposals.  One way to sum up advocacy she presents is that it is “the process of using information to strategically to change policies that affect the lies of the disadvantaged.”  Advocacy needs to be central to our work on health and human rights, and as advocates, activists and practitioners, there is a spectrum of actions we can take to move the vision of health for all forward.  And we move onto our project groups with our task in hand:  to analyze the problem our projects seek to address/correct/explore; assess our organizations; and identify the goals and strategies we will use to move the projects, and ultimately, the PHM agenda forward.  These project groups proved not only to be useful for the sake of project development, but in harnessing the collective experiences, visions, and passion of the members our groups.

After another delicious dinner, John leads us through Theatre of the Oppressed and another visual, movement expression of our work as activists and our vision of both justice and injustice.  The night continues with the delightful task of getting to know our fellow participants, their stories, and fun…fun and laughter seem to be the fuel for what will turn out to be long, intense days.  And some of us have impromptu dancing lessons late into the night ala.  The Revolution will not be televised, but it will be filled with laughter and dancing…

Having "a ball" before dinner on the beautiful Mary Knoll grounds

Tonight's Theatre of the Oppressed

IPHU Bronx 2011: An Introduction to the PHM

Today we came together on this first day of the IPHU from all over our small planet:  Ghana, Guinea, Haiti, Kenya, Lebanon, Puerto Rico, Russia, Rwanda, Thailand and the United States.  The day begins with introductions that are more than asking this group of inspiring and eloquent agitators the bland recitation of names, organizations and what are you interested in; we are asked to speak of ourselves through our personal and social mandates, or, what is the change you wish to see in the world and how do you see it?  As  brothers and sisters, we respond with a passion born of being fed up with a global system that perpetuates inequality and injustice at the cost of the health of our communities, and speak of our hopes and common threads of the need for advocacy, speaking truth to power, and alternative models and ways of thinking about health and health care that is people centered, not profit focused:  “Health for all Now,” “Love Solidarity,” “Access,” “Health Activism,” “Meaningful Participation,” “Progressive Work,” “Mental Health,” “Englightening,” “Bright Future,” “Visual Healing,” “Cultivate Love,” “Health Education,” “Awakening,” “Education Action.”

Next, David Legge gives a comprehensive overview and history of the People’s Health Movement, International People’s Health University (IPHU) and the People’s Health Charter (PHC).  We go over this radical document, a unifying, organizing vision that views health as a right for ALL.  This profoundly simple understanding is so fundamental, that some of us in our small group discussions ask, “Why Not?” Not “Why Not” as this is a good idea, but “Why Not” as in why is this socially, economically and just idea not implemented and what do we as advocates and activists need to do to push this forward, use this in our work, and what do we need to include (LGBT rights, more emphasis on gender inequality, and a suggestion to create a handbook on how to use the PHC)?

Laura Turiano follows with a presentation on using a Human Rights based approach to advocate Health for All Now.    Next follows participants’ big task:  group work on our projects that advance the idea of Health for All in our communities.  Our task at hand:  present our projects with our compadres in small groups where, over the course of the week, we will support each other to: analyze, re-think, re-fine, conceptualize, strategize, and put into action our vision of the world and communities in which we wish to live.

The “formal day’s agenda” concludes with a brief introduction of the Theatre of the Oppressed by John Sullivan.   Free form movement and human sculptures is what we are and mold ourselves into as we attempt to convey the fundamental values and concepts of the days proceedings:  Hope, Inspiration, Thinking, Motivated…all conveyed through our bodies, expressions, and movements.  The consensus over dinner discussions and late night debates, rabble rousing, getting to know you sessions, is:  this is going to be a great, learning filled, intense, memorable week.

A NEW VISION FOR WHO: MANY HUNDREDS OF MILLIONS OF PEOPLE HOPE THAT THE WORLD HEALTH ORGANIZATION WILL BE WISE AND COURAGEOUS, AND WILL ALWAYS GIVE FIRST PRIORITY TO FAIRNESS AND JUSTICE.

My dear friend and colleague Dr Ravi Narayan works at the Centre for Public Health and Equity, Bangalore. Beginning in 2003, he was the second global secretary of the People’s Health Movement (PHM) which, during his years in the post, started to monitor the activities of the World Health Organization and other relevant UN agencies.  A central criticism of WHO has been that, for many years, it abandoned its commitment to the primary health care approach in a number of areas, including nutrition.

PHM’s People’s Charter for Health calls on ‘people of the world to demand a radical transformation of the World Health Organization, so that it responds to health challenges in a manner which benefits the poor, avoids vertical approaches, ensures intersectoral work, involves people’s organisations views in WHO’s annual World Health Assembly, and ensures independence from corporate interests’.

My column this month is drawn from successive People’s Health Movement statements, agreed after extensive consultation. Ravi has always been involved in this work. Said statements have repeatedly criticised WHO for too strong a reliance on so-called ‘public-private partnerships’ with industry for a big part of its budget. This, despite a lack of objective evidence of the effectiveness of this approach in either improving public health and nutrition, or in improving access to care for those who happen to be poor. Despite real and active participation of civil society representatives in WHO’s work being crucial, civil society initiatives designed to work with WHO have become increasingly sidelined.  WHO’s attitude has to change from lukewarm to committed and enthusiastic in this respect.

Margaret Chan, Director-General of WHO, speaking in Mexico on the topic of prevention of obesity and chronic diseases, on 25 February 2011. Her point is enjoyed by Mexican President Felipe Calderon, and his Health Minister. Rates of obesity are rocketing in Mexico. One reason, as Mexican  politicians know, is unfair terms of trade with the US. These also increase poverty and create destitution among Mexican farming communities.

________________________________________________________________

The World Health Organisation, the UN agency most responsible for global health decision-making, has so far not fully lived up to the hope expressed in the heading above this section. WHO does not seem to be giving first priority to fairness and justice. To varying degrees, WHO and its leaders in the last decades have not succeeded in encouraging member states in many crucial ways. They have:

• Lacked a commitment (active, beyond pronouncements and some good reports) to equity, social justice and the human right to health and to nutrition.
• Lacked an action-oriented implementation of the principles and public health orientation of the Alma Ata Declaration on comprehensive primary health care, as well as a commitment to manage WHO on the basis of these principles, especially given the current still prevailing trend towards selective and vertical health care and nutrition programs.
• Lacked an ability to establish WHO as the acknowledged leader of global advocacy for the attainment of the universal right to essential health care and nutrition.
• Lacked an ability to forcefully stand behind an agenda based on the principles of equity, integration, inclusiveness and public service ethics.
• Avoided an inappropriate relationships with the corporate sector whose interests conflict with public health, particularly the pharmaceutical, alcohol, and processed foods and drinks manufacturers.
• Lacked the courage and readiness to stand up to the inappropriate influence of the major donor countries.
• Lacked a commitment to strengthening civil society’s involvement within WHO’s decision making process, especially grassroots organisations and particularly from developing countries.
• Lacked a real willingness to follow-up on the recommendations from the Commission on the Social Determinants of Health to tackle the social, political and economic determinants of ill-health, malnutrition and preventable deaths at global and national levels.
• Lacked a commitment to speak up and prevent the negative health and nutrition effects of policies pursued by the World Trade Organisation, the World Bank, the International Monetary Fund and the ‘G8’ richest countries.
• Lacked an ability to support and strengthen the weaker regional offices of the World Health Organisation, in particular the WHO African Regional Office.
• Lacked a commitment to fair in-house labour practices, the advancement of committed and technically competent staff and a more multi-disciplinary staff composition representing all regions of the world.

Following the money

Civil society organisations expect WHO to be the number one international advocate for their most cherished principles, values and approaches. These include the ethics of nutrition and of public health, equity, primary health care, community-based health care and nutrition, community participation and empowerment, use of appropriate technology, and intersectoral cooperation. Civil society organisations also look to WHO as the standard bearer on health and nutrition issues.

But now this role appears to have been usurped by other organisations, particularly the World Bank. WHO comes with technical advice, the World Bank comes with money; national governments usually prefer the money –despite the indebtedness  involved.

Many non-governmental organisations have, from many years ago, formal relations with WHO and thus can have a voice at WHO meetings. Unfortunately these tend to be those that are relatively malleable, without a strong social consciousness. They usually do not actively lobby for agendas that more forcefully address the needs of the poor.

What WHO should do

Here is what PHM thinks the World Health Organization should do. The list below is ambitious. Some may say that WHO can do only what its member states instruct it to do. Formally this is true, but WHO still has a duty to set rational and progressive agendas and to guide and help member states to  address the social determinants of health, particularly in those countries with least resources. WHO thus should:

• Become a real strong advocate of poverty eradication (or, better, of disparity reduction) particularly in its interactions with the World Trade Organization, the World Bank, and the International Monetary Fund.
• Take a more forceful stand with the above institutions, to make them more responsive to greater equity; cancellation of foreign debt; fairer trade; more just intellectual property rights; promotion of comprehensive primary health care.
• Oppose the privatisation and commoditisation of health care.
• Resist vertical, overwhelmingly technical initiatives.
• Involve community and people’s organisations in evidence seeking and in the drafting and carrying out of action plans.
• Involve people’s organisations in WHO’s work at national, regional and headquarters levels.
• Advise and help member states to strengthen the public sector for health and nutrition.
• Prevent any agenda setting by corporate interests.
• Ensure that transnational corporations (particularly those whose activities impact health and nutrition) are effectively regulated.
• Promote more participatory, relevant and transparent public health and public health nutrition policy processes and initiatives by giving civil society a greater voice in the annual WHO World Health Assembly.

The mighty meet to save the world at the World Economic Forum, Davos,    28 January 2011. Left to right: Josette Sheeran, head of the World Food Programme; Melinda Gates of the Gates Foundation (on-screen);       Margaret Chan of WHO; Bono, the pop star and champion of ‘Make     Poverty History’; Muhtar Kent, CEO of Coca-Cola; and Lars Sorensen,     CEO of Nordisk. They hear one another. Are they listening to the people?

__________________________________________________________________

He also said: ‘It seems so strange for WHO staff in Geneva to be talking about poverty, destitution, misery and hunger, as they pay 2 Swiss francs (equivalent to $US 2) for a cup of coffee, while millions struggle to survive and sustain their families on the equivalent of $US 1.25 a day’.

It is time now for WHO to take a new direction. It currently is moving in the wrong direction, towards its control by corporations. The call to the leaders of WHO, beginning with its current Director-General Dr Margaret Chan, is as follows: (Many more points can really be added…)

• Reaffirm the principles of comprehensive primary health care approaches and translate them into concrete activities in all WHO programmes.
• Review the Millennium Development Goals, and the recommendations of the Commission on Macroeconomics and Health, in terms of their compatibility with the principles of primary health care as stated in the Alma Ata Declaration; moreover, health and nutrition are to be taken for what they are –human rights– rather than primarily inputs to economic development.
• Evaluate different approaches to primary health care by both governments and NGOs in order to improve their implementation worldwide.
• Instruct WHO personnel in WHO headquarters in Geneva,  and in WHO regional and in country offices, to engage actively with both government and NGOs primary heath care initiatives, and to determine their capacity gaps so as to face and overcome demographic, epidemiological and socio-economic challenges.
• Continue to support countries that are improving the quality and quantity of health personnel in order to improve access to comprehensive services, especially for people who happen to be poor.
• Emphasise implementation of locally determined models of primary health care that are flexible and well adapted.
• Monitor global policies in trade, development and economic restructuring for their effects on the health and nutrition status of those who happen to be poor.
• Identify and oppose policies that are having an adverse impact on primary health care.
• Organise a series of periodic meetings on future strategic directions for primary health care that capture grass roots experiences, and involve grassroots organisations such as the People’s Health Movement.

Needed: attention to the people at the grassroots

In a meeting with the People’s Health Movement, the immediately past Director General of WHO, Jong-Wook Lee, further said that ‘WHO urgently needs to listen to the people and their movements have to say. Many of these organisations have for too long felt powerless.  But by uniting forces, they have now reached a critical mass, in part through the People’s Health Movement.  WHO must now listen to voices from communities’. And he was right.

Needed: new accountability and transparency

Today, WHO’s accountability is no longer mainly owed to national governments, who in the UN context are preoccupied with their own status, the trading of favours, and continental rotations of top posts, including that of the director-general.  Accountability is primarily owed to the people, legitimately represented by civil society organisations. We in civil society now should demand an open dialogue, to discuss WHO’s policies and programmes in all its areas, including public health nutrition.

You are invited please to respond, comment, disagree, as you wish.  You are free to make use of the material in this column.

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

March blog: Claudio Schuftan

EQUITY: UNLESS WE ALL BECOME PARTISANS IN RENEWED LOCAL AND GLOBAL BATTLES FOR SOCIAL AND ECONOMIC EQUITY, WE SHALL INDEED BETRAY THE FUTURE OF OUR CHILDREN AND GRANDCHILDREN.

Halfdan Mahler is a cherished friend, and a member of the People’s Health Movement. He was the Director-General of the World Health Organization for 15 years, from 1973 to 1988. He is now 87 years old. During his period of office, WHO co-sponsored the 1978 Alma Ata conference, where the bold goal of ‘Health for All by the Year 2000’ was proclaimed. How sad, that some 30-plus years later, this expansive vision of health, founded on the principles of primary health care and social change, has been replaced by the miserly and narrow-minded Millennium Development Goals (1).

In May 2008, Dr. Mahler addressed the WHO sixty-first World Health Assembly. He called again for an integrated approach to health, and what he said was followed by a standing ovation from the delegates of all member states present. Two statements he made were for me outstanding. The first was:

So now, as a tribute to Dr Mahler, and in recognition of the truth of what he says and stands for, and of his vision for a more equitable world, I present some thoughts and ideas about the role of health and nutrition in the context of development.

Solving the problems of malnutrition was for many years considered primarily a health activity and prerogative. Unfortunately in many circles it still is. But there is much more to malnutrition than that.

After having witnessed the failure of many attempts to solve malnutrition through health and other specialist sectoral interventions alone, it is time that we all approached malnutrition as a human rights issue. As soon as we do this, we are directed towards looking at what are the basic causes of malnutrition and their resolution.

The food and nutrition chain is usually seen as a series of linked processes that food follows from its production (or import) to its consumption and utilisation. The links in the food chain are the following:

At each link in the chain there are weaknesses that directly or indirectly contribute to malnutrition. One of the tasks of the human rights-minded nutritionist is to identify these weaknesses, together with the claim holders, so as to strengthen as many of them as possible.  In such an analysis:

• Political, economic, infrastructural, manpower, agricultural, educational,

environmental, health and other constraints all need to be considered.

• Solutions often far removed from strict nutrition interventions are       indispensable to succeed in the battle against malnutrition.
• Primary health care, agricultural, and rural development activities, all require a

human rights focus, as demanded by organised claim holder groups.

Rural/urban imbalance

One of the weak links in the food chain is migration from rural to urban areas. The downside of this is that cities will continue to deteriorate if the countryside does not prosper. Every urban-migrating young adult is two less arms to produce food, and one more mouth to feed in the city. Those who stay behind increasingly are older women, children and elderly men.  Given the current and projected massive urbanisation trends, increases in food supplies are liable to be only moderate in the future.

The traditional agricultural sector will, for years to come, continue to be the first driving force in many countries. Overall, it produces more than three-quarters of all food consumed. Availability of productive employment, revenue and food – in particular, staples – is often seasonal in rural areas. This compounds problems of health and nutrition during the hungry season.

In most lower-income countries, a sizeable proportion of the population – those of low income or subsistence status – get less than the recommended average daily calorie intake specified by the Food and Agriculture Organization of the UN (FAO). Urban averages are often higher than the FAO recommendations, but income disparities are widest in cities. It is safe to assume that 30 or more per cent of urban dwellers are also short of calories. Further, a minimum cost diet for an average family of five or six people is often above the minimum wage of unskilled urban workers. In most countries the overall purchasing power of the more impoverished proportion of the population will improve only very slowly, if at all – hence, malnutrition.

How to alleviate hunger and malnutrition.

The list of determinants of malnutrition is extensive, intricate, and interrelated. Here follows a list of policies and interventions deemed necessary to move towards the eradication of malnutrition.

The capacity of any system to alleviate hunger and malnutrition depends on the concerted efforts government officers and political leaders at all levels make to address the basic, underlying and immediate causes of malnutrition. This is in turn related to whether those responsible are really actively and ongoingly pushed towards their obligations in this field by active groups of claim holders demanding greater equity and social justice.

Even if willing and capable, I contend that governments and other individuals or institutions in duty bearer roles will fail to do anything significant about malnutrition, unless a significant number of the following actions are planned and carried out in any national development programme:

• Strong encouragement of organisation of claim holders to secure their participation in development activities at all levels.
• Measures to slow down urban migration, such as increasing rural employment opportunities, making food crops more profitable to producers, and providing a minimum of infrastructural services in rural communities. These entail a change in investment priorities towards overall rural development.
• Measures to curb urban unemployment.
• Explicit incorporation of women into the development process, for example by making them eligible for agricultural extension, bank loans, and credit.
• Fair market prices for producers of cash crops.
• Agricultural banks to strike a fairer balance between cash-crop and food-crop credit allocation, favouring the latter.
• Minimum wages to be based on the results of balanced food-basket cost studies.
• Higher import duties to be levied on luxury items, especially luxury foods and drinks.
• Subsidies for selected durable inputs for small farmers, such as tools and small machines.
• Subsidy of fertilisers and pesticides. A fair balance to be struck between the proportion of these inputs going to food production as distinct from cash-crop production.
• Adequate logistical support for agricultural extension workers and community development workers.
• Priority given to home and school gardening programmes and small dry-season irrigation projects.
• Measures to improve farm-level food storage practices, in order to decrease food losses.
• Primary school enrolment to be increased especially for girls, and more teaching of work-related skills within school curricula.
• Adult literacy campaigns, with emphasis on women, to be intensified.
• Organisation and financing of a network of day-care centres in the country.

This list is by no means complete. It probably includes most of the more rights- and equity-oriented actions duty-bearers should embark on. It is essential that all such actions are monitored by claim holders.

The bottom line is as follows: Improving the nutritional status of vulnerable groups in the population remains closely related to the alleviation of poverty. It also requires specific interventions in several sectors. Only some of the determinants of malnutrition can by partially or totally corrected by explicit health interventions.

Halfdan Mahler gave his address to the 2008 World Health Assembly sitting next to the current WHO director-general Margaret Chan, as you can see below. Above is the second statement made by Dr Mahler on that occasion that I especially cherish.

Inspired by Dr Mahler and what he stands for, it is fitting for us nutrition workers to explore the special role of primary health care in the battle against malnutrition.

The vision of universal primary health care

Primary health care is the most viable, logical and best possible approach to progressively reach the goal of health for all. Whenever it has gained a real commitment beyond lip service in the allocation of resources in a country, it has improved the health and nutrition of its people, especially through the active community involvement it calls for.  By doing so, it addresses the host of local health and nutrition problems as felt by the users of health and nutrition services.

Primary health care goes beyond conventional health care as it organises claim holders around activities aimed at addressing the three levels of causality of ill-health, malnutrition and poverty. In the spirit of Alma Ata, it actually can mobilise claim holders to change some of the determinants of their neglected condition. Happily, 2010 has seen a revival of the call for primary health care, and also for universal health coverage, from WHO and also from civil society organisations (2).

A real emphasis on primary health care involves the shifting of priorities away from urban-biased, hospital-centred and physician-centred approaches. Interventions that indicate primary health care goals are being seriously pursued include:

• Construction, staffing, equipping and opening to use of more primary health care centres.
• Training of relevant paramedical personnel, village health workers and traditional birth attendants.
• A higher percentage of the national health budget shifted to preventive services, including nutrition.
• Ensuring the required national vaccination coverage is attained and maintained.
• Expansion and extension of the coverage of overall maternal-child health services including nutrition and child-spacing (family planning).
• Ensuring preventive and curative approaches to, malaria, tuberculosis and HIV and AIDS, not forgetting respiratory infections, intestinal parasites and diarrhoeal diseases.
• Increasing the number of deliveries properly attended by trained personnel.
• Expansion of the pre- and post-natal supervision of mothers, to include monitoring maternal nutrition during pregnancy and lactation, and provision of iron and folate supplements, plus tetanus vaccination and malaria prevention during pregnancy.
• Promotion and expansion of latrine construction programmes through self-help.
• The number of households with access to safe and sufficient drinking water to be increased through community-managed projects.
• Introduction and use of growth monitoring and nutrition counselling in all communities, to include the training of personnel and of community members.
• Retraining of field health personnel with emphasis on nutrition and preventive health activities.
• Development of nutrition protocols for the treatment of malnourished children, to standardise the therapeutic approach at the national level.
• Mechanisms put in place to record and periodically report birth weight data.
• Review and improvement of the nutrition curriculum in all university health related courses.
• Introduction of health and nutrition education through the radio.
• Introduction of health and nutrition modules in the science curricula of primary, secondary and technical schools;
• Marketing controls of baby formula and of baby weaning foods. Banning of promotion of these products through the media and directly to mothers.

This list is also not exhaustive and, as said, includes some actions that are not strictly in the realm of primary health care. But all of them, and other more, are related to the problem of malnutrition and how to ameliorate it. Assessing national health plans to see if they incorporate these activities, and to what degree, will help to determine the capacity of the health sector to tackle the social determinants of malnutrition.

Implementation of all these interventions will be expensive and maybe beyond the capacity of poor countries in the short run. Nevertheless, progressive realisation strategies for health and nutrition, with measurable benchmarks for claim holders to monitor, have to be set.  The alternative would be to relegate primary health care to a token programme within the national health strategy – a policy that should be fiercely opposed by claim holders.

Resources, dependency and power imbalances

To be effective, policies need to be rational and technically feasible. But this is not enough. There is also the question of human, financial and other material resources.

Can the rightful demands of claim holders be met, with existing primary care resources in a country?  If no, then strengthening of primary health care capabilities needs to become a key national priority. Too often this has been overlooked and otherwise well-conceived nutrition components of primary health care programmes have remained and remain on paper only. Inventories need to be made of existing available resources. This done, the missing resources, and the needs and areas for improvement, can be identified.

Foreign aid, such as World Bank loans, in part intended to alleviate hunger and malnutrition, has created dependency. The foreign debt this kind of aid generates is a constant reminder of the neo-colonial domination by countries of the North. Part of such borrowed money is used to maintain consumption levels, mostly for urban populations, while the prices of impoverished countries’ export commodities generally fall.  Little of such borrowed money has contributed to equitable economic growth and food self-sufficiency.

Yes, much more investment is needed in better health and nutrition programmes. But there is another issue here. Governments are likely to feel threatened by empowered and autonomous  and driven claim holders, as much as this is exactly the purpose of universal primary health care. So here, maybe, is the greatest challenge faced by committed health and nutrition workers: to be aware that they are engaged in shifting the power imbalances between the governing and the governed.

We ought to be advocates of the poor. Are we? Putting nutrition into primary health care programmes is of itself not enough. There are bigger issues, such as land mal-distribution, low farm gate prices, lack of investment in the peasant sector, and in health, in education, in water and in sanitation. More specifically, the control of food production and the value of food produced is still taken off the hands of food producers.  Further, peasants are pressed by their governments, in turn pressed externally, to favour technically advanced, large-scale agribusiness, which will never reverse the impoverished countries’ food shortages.

Poverty – and to be more precisely the process of impoverishment – is the main issue here. Emphasis on more production of food fails to address the issues of why people in rural areas are poor, are in poor health, and are malnourished. These people are not fatalists or short-sighted or lazy and unimaginative. They are oppressed. Food and nutrition are political issues, and we professionals need to recognise this and act accordingly. One way forward is to insist on equity, on the human rights-based approach, and on universal primary health care, with what can then be an effective nutrition component.  This is what Halfdan Mahler believes and stands for, and he is right. I sent him this column in draft, and in his response he quoted a verse of Halfdan Rasmussen:

I fear
not execution,
not torture and not hate,
not death from rifle barrels or
the shadows on the gate,
I fear not restless nights
with shooting stars of streaking pain,
I fear but blindness from a World
indifferent and insane.

References

1          Editorial, Social Medicine, Vol. 3, No. 2, May (2008).

2          World Health Organization.  Health Systems Financing: the Path to Universal Coverage. World Health Report. Geneva: WHO, 2010.

You are invited please to respond, comment, disagree, as you wish.  You are free to make use of the material in this column.

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

February blog: Claudio Schuftan

GLOBALISATION: IT’S THE RICH THAT GET THE GRAVY, IT’S THE POOR THAT GET THE BLAME. AIN’T IT ALL A BLEEDING SHAME.

January blog
Claudio Schuftan

I start this month by quoting some views of the prominent Uruguayan journalist and essayist Eduardo Galeano, written some 40 years ago, but still salient today. Yes, it is not me, but him pictured above. He is well known among many of us for his always sharp-as-a-whistle incisive social commentary.
Reviewing his reflections prompted me to ask myself what our role as ‘nutritionists-helping to-shape-society’ ought to be. In rather strong terms, I here argue for what our obligations should be, beyond liberalism: I call for a greater engagement in political action as the true test of our values as nutrition professionals.

As you may know, I am originally from Chile, and I am indebted to my fellow Latin American Eduardo Galeano and his book The Open Veins of Latin America, for the eight reflections that follow. The book was banned in the 1970s by the military dictatorships in Argentina, Brazil, Chile and Uruguay.
One. The international labour division consists of some countries specialising in winning, and others in losing. The latter continue to work as servants of the former.
Two. The defeat of the have-nots has always been implicit in the victory of the haves. The labour of the have-nots has always generated their own poverty, since it has fed the wealth of the haves.
Three. The strength of the globalised system rests on the necessary inequity of the parties that make it up. This inequity assumes ever more dramatic proportions. The dominant classes in poor countries have no interest in finding out whether patriotism could be more profitable than treason, or if begging and dependence are the only possible way for their countries’ international politics. Countries thus end up mortgaging their sovereignty, because, we are told: ‘There is no other way’.
Four. The globalised system is very rational from the point of view of their foreign owners and of our ‘hamburgeoisies’ that have sold their soul to the devil.
Five. The globalised system has a thorn in its side. We have too many people. And people reproduce. They make love with enthusiasm and without precautions. More and more, people are left on the verge of the road, jobless. So the empire gets worried: unable to produce more bread, it does what it can to get rid of those sitting around the table. ‘Fight poverty! Kill a beggar!’ a master of black humour wrote on a wall in the city of La Paz.
Six. The globalised system thus convinces poor people that poverty is the result of not avoiding having children. So it now proposes, in panic, measures to resolve the problem. Population control measures are the preferred policy.
Seven. We have social classes, and the oppression of one class by another. The system calls that ‘adopting a Western lifestyle’.
Eight. Poverty is not written in the stars. Underdevelopment is not the result of an obscure will of God. People are waking up, and are demanding changes.

NUTRITIONISTS
OF THE WORLD, UNITE!
WE HAVE NOTHING TO LOSE
BUT OUR SELF-SATISFACTION!
Are nutritionists as intellectuals a class apart, responsible only to their own inner urges, and to their own vision of human needs? Are we not duty-bound to immerse ourselves in our respective societies to foster a higher level of social consciousness? Are we assuming our role as natural leaders, destined not only to provide key ideas that can reshape society, but also to make sure that these ideas become actions?
The public health nutrition congress held in Porto last September was a gathering of such selected intellectuals. But did they act as ‘a class apart’ or as bona-fide duty-bearers? There was some criticism reported on the Porto meeting on the home page of this website earlier, so I add no more. A reason for hope is our Association’s promise of a totally different type of meeting in Rio 2012.
So what role should we all play, in our troubled early 21st century world?
Intellectuals too often do bend the rules of discourse to suit their own interests; too often they do argue for what they want to believe. Their theories do end up justifying the status-quo. Nutritionists in higher education too often do not question the privileges of certain groups in society -privileges that ultimately end up perpetuating hunger and malnutrition.
Intellectuals are part of the system
But scholar intellectuals do not float somewhere above the economic system; they – meaning we – are part of it. Few scholars can resist the pressure of the scholarly tradition in which they work. Only by expunging that tradition’s false preconceptions can they break from its grip. This is possible only by challenging the ideology behind that tradition that many of us find abhorrent. Are we thus guilty of perpetuating passivity – the ‘passivist’ position of Geoffrey Cannon’s November column? An intellectual rebellion is difficult to achieve; many of us are prisoners of our own past training and other peoples’ thoughts (1).
We often use statistical illusions palatable to our own academic elites that do not really reflect the real world. Measuring poverty in detail can often be a substitute or an excuse for not acting in response to clearly visible needs (2).
To avoid discord or conflict, too many of our peers and too many international organisations take the politics out of the political economy of hunger and malnutrition in their daily decision making process. Using the economists’ yardstick only leads to a non-political bias… The abolition of slavery, or child labour laws, never would have passed a cost-benefit test (3).
Separating nutritional from political analyses, results in a reluctance to call a bean a bean. There is a tendency to stop the analysis where ‘politics’ begins, with formulations like: ‘This, however, is a political question’. But that is where the analysis should very often start. Our task is not merely to reflect the world, but to do something about it! Recognising trends and acting promptly at the right time, differentiates the politician from the theoretician (4).
The complex nature of the problems of hunger and malnutrition complicate our policy making. The essence of the problem transcends looking at it from an interdisciplinary view. A new world view, and a set of values into which all the determinants of hunger and malnutrition blend, is needed. The development of such a philosophy has been avoided by too many of our peers, because it raises larger issues and challenges the current system. We need effective tactics, yes, but first we need innovative strategies.
We need to move from our perennial critique to actual concrete actions. We need to plan for positive alternatives. These need to go beyond the expedient goal of obtaining the type of lowest common denominator results whose real purpose too often is to alleviate guilt feelings (5).
Our inherent obligations
We must not retreat into helpless passivity, watching the biological, ecological and social systems around us deteriorate. We can alter trends and avert catastrophes if we recognise and exercise our own power to make a difference. (6).
The greatest challenge we face today is to meet the inalienable human rights of poor and marginalised people. Past and present nutrition research too often has little or no relevance to our concern for the right to nutrition of the people. Furthermore, international and national nutrition conferences too often become exercises in futility, organised and orchestrated by the same conservative groups, year after year (7, 8).
Meeting the right to nutrition of the people will, in most countries, require political solutions that are likely to need technical inputs. But the political solutions are not dependent on first making the technical inputs available (9). Devoid of a clear ideological orientation, the right to nutrition does not clarify, but mystifies; it does not mobilise, but manipulates.
Not everyone who says ‘human rights’ supports human rights principles. These include: empowering participation in decision-making, social inclusion, rule of law, non-discrimination, dignity and accountability. The Roman emperors provided ‘bread and circuses’ for the masses. Authoritarian regimes present modern variants, such as beans and football stadia. Human rights defined in material terms, planned by an elite and delivered by a bureaucracy, create client groups, demobilise mass organisations, and create new patterns of dependency.
Technocratic models, like those proposed in The Lancet Series on Nutrition (to be found at.http://www-tc.iaea.org/tcweb/abouttc/tcseminar/Sem6-ExeSum.pdf) assume that the problems are largely scientific, and can be solved by closing management gaps found in decision-making groups (10).
There is no easy or short-term solution to the syndrome of underdevelopment, of which nutritional status is an important indicator. Too many non-solutions are proposed as answers. For instance, the provision of primary health care alone will not bring about better nutrition. Primary health care is necessary, but not sufficient. Ultimately, levels of health, nutritional status and living standards are determined by national development strategies and the international economic order. Straight public health and nutrition programmes, while aiming for greater equity, do not contain interventions that move towards more egalitarian societies (11).
Many of us are content to take life as it comes when things go reasonably well, preferring to evade the troublesome question of life’s purpose or meaning. In times of trouble, however, problems force themselves on our awareness and our consciousness. (12).
As scientists, technicians and intellectuals we are restless, often dissatisfied and critical, and in urgent need of an ideology. At the same time we are doing quite nicely: we have a vested interest in the status quo. And what is the ideology to be? Just a vague consensus for equal opportunity? We are good at exposing unintended consequences of well-meant measures. But this can be downright dangerous. This position threatens to give legitimacy to conditions set by corporate elites, where gross inequities are rationalised as a fact of life (13).

LIBERALS
BELIEVE IN ‘WIN-WIN SITUATIONS’
BUT IN THEIR WORLD THE
DISPOSSESSED ARE ALWAYS LOSERS
With a liberal ideology, we are committed more to stability than to justice and to fairness. As liberals, we have connections in the Establishment. We do not address fundamental questions. We are experts (technocrats). We think we are ‘reform professionals’, but more often actually are ‘stability professionals’ (13). We may make powerful diagnoses, but then offer feeble therapies.
‘Positive-sum games’, in which everybody or almost everybody wins something, are next to impossible when applying the radical therapies needed. That is why we now speak of disparity reduction instead of poverty alleviation. The rich simply have to give up some of their privileges! They are good at allocating gains, but horrible at sharing out losses. Honest rationality and self-interest frequently clash. Can we then stall indefinitely on needed policies and changes (14)?
Much of what has been called liberalism in the last half century has been merely an accommodation to historical change –to circumstances. It represents a triumph of circumstance over ideology. Liberals make a virtue of adjustment, of a kind of adaptive pragmatism. The disparity between what liberals say in public and what they do in private, is why it is so easy for young people to unmask the hypocrisy of their parents (15).
In the world that liberalism finally made, the world of the welfare state and the transnational corporation, liberalism itself has become politically and intellectually bankrupt. The welfare state of liberalism absolves individuals of moral responsibility, and treats poor and malnourished people as victims of ‘social circumstances’. It still condemns the lower class to a second rate education, yes even in the USA, and thus perpetuates the inequities it is supposed to abolish (16).
In the liberal tradition of the West, individual rights are valued more than social rights, and civil and political rights are deemed more important than economic, social and cultural rights. In socialism, on the other hand, the right to work, and to acceptable levels of nutrition and education, outweigh the importance of personal freedoms. To socialists, freedom from hunger, from ignorance and from disease is more important than freedom of expression (3).
It is no surprise that liberals believe in the globalised ‘free market’ and in competition. Liberals now seldom see trades unions as valid actors in the market or as institutions to be backed. Liberalism has no operational political economy at its core. It expunges any real perception of the nature of political and economic conflict perceived in terms of interest groups or of class.
Socialists espouse equality as an absolute, and measure injustice by distribution of wealth. But the right and the left do not occupy two extremes with a middle made up of liberals. Liberalism is another dimension altogether. It is empty of standards (17). It is often easy to see what liberal groups are opposed to or worried about. But what do they stand for? This is often an unresolved puzzle (13).
The core issues
So, here comes the question modern liberalism has always ducked. Why is the wealth of any self-proclaimed ‘egalitarian’ nation distributed so unjustly? The long march of liberal solutions to social injustice evades the more fundamental questions about wealth and its gross maldistribution.
The liberal mindset, well-intended as it may be, avoids confronting harsh realities. One of these is that in the final balance, welfare states care most for the prosperous, not the poor (18).
For a long time now, including in countries not really committed to genuine social development, health and nutrition programmes have become popular. These suggest a political adherence to the ‘ideals of health and nutrition’, without real commitment to deal with the deep-rooted social problems behind them (19).
Do liberal planners, programme officers, administrators and advisors really have anything relevant to offer in this world in 2011? The technocrats among us dodge the political issues behind undernutrition: “We are afraid to confront the hard-nosed reality of nutritional issues, because they come down to political questions and are non-scientific and hard to grapple with – so we shy away from them” (20).
Our predilection for nutrition education interventions comes from our believing in a concept of society in which there are ‘practical difficulties’ and ‘obstacles to desirable changes’, but ‘fortunately there are also various services or facilities available to overcome them, so in the end everything will be fine’.
But the way the world is going now, everything will in the end not be fine. We now need to analyse and expose the impact of systemic barriers to good health and nutrition. For instance, in the US, where I am now writing this column from, the strategy of ‘life-style policies’ for correcting deficits and imbalances in the diets of the population, by individually changing the food consumption patterns of individuals, avoids the political question of why those individuals consume that diet as they do. It ignores the enormous power and the economic interests of the gigantic corporations that determine food systems and thus dietary patterns (19).
We are in for a period of agonising reappraisal if we are to contribute to a world that is changing with remarkable speed. We need to make governments conscious that health and agricultural production interventions alone do not solve nutritional problems, and that the answer is not to be found in small projects, or with a few experts running around (20)

What it is that makes me tick

People ask me why I subject myself to the daily ordeal of spreading the
word on the right to nutrition. Perhaps the most honest response is that it
has long dawned on me that I am addicted to gambling. I play the ghastly
everyday power game. Anything else my peers want to convince me about is
an illusion. If questioned further I might say that I have no wish to say
any more about it.

References

1 Ul Haq. M.: The fault is ours. New Internationalist, No. 32, Oct., p. 19 (1975).
2 Lehman-Haupt. C. reviewing The Mismeasure of Man by Stephen Jay Gould. International Herald Tribune, Oct. 31/Nov. 1 (1981).
3 Exact reference to these quotes lost to the author.
4 Galtung, J.: What is a strategy? IFDA Dossier 6, April (1979).
5 Hetzel, N.: A sustainable development strategy. IFDA Dossier 9, July
(1979).
6 West. M: Washington Post, Jan. 14: E-2 (1979).
7 Mattis. A.: Science and technology for self-reliant development. IFDA Dossier 4, Feb.(1979).
8 Schuftan, C.: Do international conferences solve world problems? PHP, vol. 7, No. 11, Tokyo 1976.
9 Adapted from Kirkpatrick, J.: De-westernizing medicine: concepts and issues in the literature, mimeo. Proceedings of the 10th International Congress of Anthropology and Ethnographical Sciences, Pune, 1978.
10 Green, RH.: Basic human needs: a strategic conceptualization toward another development. IFDA Dossier 2, Nov. (1978).
11 Mangahas, M.: Why are we reluctant to set numerical equity targets?. Nutrition Planning, 3: 102 (1980).
12 Adapted from Bettelheim, B.: Surviving and Other Essays. (Knopf, New York 1979).
13 Adapted from Geyelin, P.: Book review of The neo-conservatives by Peter Steinfels. Book World, Washington Post, April 27(1980).
14 Adapted from Lekachman, R.: Book review of The Zero-Sum Society by Lester Thurow. Book World, Washington Post, April 27 (1980).
15 McWilliams, W.C: Liberal dialogue: Do you want to talk about it? Book World. Washington Post, Dec 21: 9 (1980).
16 Lasch, C.: The Culture of Narcissism: American Life in an Age of Diminishing Expectations, as reviewed by William McPherson, Washington Post Feb. 4: E-1 (1979).
17 Lowi, T.J.: Where is liberalism, now that we really need it? Washington Post, Oct. 31: C-8 (1982)
18 Greider, W.: A radical idea as old as Lincoln. Washington Post, March 11: C-3 (1979).
19 Bantje, H.: Constraint mechanisms and social theory in nutrition education, mimeo. BRALUP, University of Dar Es Salaam. Tanzania. Proceedings of the 11th International Congress of the IUNS, Rio de Janeiro 1978.
20 Navarro, V.: The industrialization of fetishism or, the fetishism of industrialization: a critique of Ivan Illich. Social Science and Medicine, 9: 360 (1975).

Slide show on land mines and cluster bombs

While much attention has been focused on WMDs over the last ten years, it is important to remember how much damage to human health, the environment, agriculture, and local economies results from the widespread and indiscriminate use of land mines and cluster bombs.

Despite a global treaty to ban land mines and an international convention on cluster munitions, to which a majority of the world’s nations are parties/signatories (although not the United States), production and deployment continue.

For a slide show from Oregon Physicians for Social Responsibility, see http://phsj.org/wp-content/uploads/2007/10/Landmines-and-Cluster-Bombs-Oregon-PSR.ppt on the “War and Peace” page of the Public Health and Social Justice website (http://phsj.org/war-and-peace/), where you can find many other open-access powerpoints and articles on other relevant issues.

For further information and to see what you can do, see the website of the International Campaign to Ban Land Mines at http://www.icbl.org/.

As always, submissions of new material are most welcome.