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

1. You may often have asked yourself as to whether your individual contribution in the field of health and/or nutrition makes or is making any difference.  This, of course, depends.  Alone, each of us is indeed helpless to change very much.  Standing alone to-right-the-world’s-wrongs is a false ideal. We have thus plenty to learn from the lessons of mutuality or even of militancy.  Individual concern (let alone compassion…) is just clearly less powerful than organized solidarity. (Tikkun)   Or, to use an old adage, ‘divided we beg, united we demand’.

2. Sporadic, collective grassroots-organized acts are happening all the time   –mostly the result of non-political and personal leadership initiatives. To make these acts really count and add-up to something, they need to be progressively channeled into new patterns of higher political meaning and political impact. Human rights activists are needed to lead the way in such a transition.  This, because without continuity and follow-through actions, popular struggles will remain a heap of toothless words. (S. Ophir)

3. In the human rights (HR) context, two questions arise here: Are the fields of health and nutrition legitimate and good ports of entry for HR activism? And if the answer is yes: Are we ready for such a challenge?

4. If the answer is again yes, new forms of progressive HR learning and HR action are then needed in our line of work. Actually, to act effectively in the time before us, we need to first develop a more widely shared strategy that unequivocably points in the HR framework direction.  When adopting such a strategy, we cannot merely denounce; we must also announce a new order –an order with more empowering-health-and-nutrition-alternative-actions.  We must thus strive to become proactive, not merely reactive.

5. Today, together with the victims of health and nutrition rights violations, the inescapable challenge before us is to redefine the strategies we use in order to combat preventable ill-health, preventable malnutrition and preventable premature deaths. This invariably entails (simultaneously at the global, national and local levels) addressing and combating the social, economic and political determinants of the violations of the UN-sanctioned Right to Health and Right to Nutrition.  Only thus will we be able to overcome the present crisis in overall development thinking and praxis we now are stuck-in in these two domains.  (R. Boyte)

6. As an avant-garde, we not only need to reflect on new institutional ways of supporting grassroots HR initiatives, but we also need to become more proactive in organizing them, as well as helping generate new forms of HR knowledge and of practices-of-direct-democracy in local government. In the process, we also need to reassess the pertinence and the role of foreign aid and of private (non-official) international development cooperation in the fields of health and nutrition. This, to either reject both or to help redefine them so that they, once and for all, fit the demands of local communities.  (S. Padron)  If the latter cannot be done, yes indeed, it is high time poor countries begin considering turning down foreign aid.

7. Still proactively, we first need to help create a shared critical awareness of the immorality of the prevailing social, economic and political system responsible for the violations of the Right to Health and the Right to Nutrition we are basically left to deal with as health and nutrition professionals. For this, among other, we need to bring people both in the rich and the poor countries to a point where they become more vocal in their demands to change the mechanisms that lead to the conditions perpetuating ill-health, malnutrition, poverty and injustice. And this can only be achieved by creating a growing discontent that leads to a ‘constructive anger’ and to commensurate actions that address such injustice. Action along these lines is desirable (preferably preemptive rather than reactive), and should even be made an inescapable outcome of effective health, nutrition and development learning. The HR activist/educator thus has a key role in our midst.

8. If we are to be consequent with effective people’s empowerment, we will have to foster an authentic people-centered development (in our case using health and nutrition as a port of entry to HR issues). For this we will have to further:

i) move away from coercive or top-down practices involving any kind of ‘acceptance-as-a-fait-accompli’ (e.g., in family planning?), and move into consensus-building practices involving legitimate beneficiaries’ approval; ergo, do things departing from the-way-people-see-them in their own environment;

ii) revolutionize people’s expectations helping them to move away from fatalistic outlooks;

iii) help define a new type of collective, community sense of responsibility that replaces the prevailing individual identity;

iv) help legitimize and enforce all UN-sanctioned people’s rights;

v) increase the negotiation and bargaining capacity –or at least the defense capacity– of claim holders;

vi) as needed, aim at overcoming constraining local political structures (formal and informal);

vii) concentrate on changing the local inter-generational dynamics when required, and very specially concentrate on changing the role of women (our main contact in health and nutrition work) in overall development work;

viii) work with people towards the goal of ultimately controlling their own community resources, fighting for the resources they need from outside, and taking initiatives to shape their own future through a strengthened, militant organization;

ix) make sure people get access to relevant information, especially the type of information that will help them hold their government officials accountable; *

x) help redefine the roles and methods of so-called ‘participation’ shifting them towards methods of ‘empowerment’ –in our case in health and nutrition;

xi) constantly re-gather groups becoming marginalized, trying to make sure their special interests are accommodated in the general strategy;

xii) secure concrete short and long-term positive results for claim holders (with an initial emphasis on short-term results to foster self-confidence);

xiii) together with claim holders, monitor and evaluate said results, especially with regards to the degree of  popular empowerment being achieved, as well as probing the equality of the benefits accrued; and

xiv) promote self-education with the aim of achieving faster results.

*: Information given to people for use through the fashionable ‘social marketing’ approach is definitely not the type of information conducive to any meaningful participation; social marketing simply does not bring about the needed sustainable structural changes –at best, it allows people to tolerate and cope-with an unjust situation. Social marketing tells people what to do, but not what for  and why…

9. Only through the constant practice of such people-centered development activities –often through trial-and-error– will we overcome the limits of existing flawed development models and theories. (L. Padron)

10. In short, starting with/from our work in health and nutrition, we should all contribute, to the best of our abilities, to generate popular alternative development strategies with the corresponding set of tactics to implement them.  But to make a difference, remember that standing alone changes little; so: Network with other like-minded activists in the HR field!

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

Using Google Earth as an Innovative Tool for Community Mapping

SYNOPSIS

Maps are used to track diseases and illustrate the social context of health problems. However, commercial mapping software requires special training. This article illustrates how nonspecialists used Google Earth^TM, a free program, to create community maps. The Bronx, New York, is characterized by high levels of obesity and diabetes. Residents and medical students measured the variety and quality of food and exercise sources around a residency training clinic and a student-run free clinic, using Google Earth to create maps with minimal assistance. Locations were identified using street addresses or simply by pointing to them on a map. Maps can be shared via e-mail, viewed online with Google Earth or Google Maps, and the data can be incorporated into other mapping software.

Authors: Theodore B. Lefer, Matthew R. Anderson, Alice Fornari, Anastasia Lambert, Jason Fletcher and Maria Baquero

Source: Public Health Reports, July-August 2008, 123: 474-480, Available at www.publichealthreports.org

Sources of Food and Exercise around the Montefiore Comprehensive Health Care Center; Legend: Red cross = Comprehensive Health Care Center; Grocery cart = Grocery Store (n =10); Fork and Knife = Restaurants (n=16); Red dot = Fast Food outlet (n=32); Yellow dot = Bodegas (small variety stores, n=44); Green tree = Exercise site (n=11). Note the old Yankee stadium on the lower left of the map.

Food stores around ECHO Free Clinic, ranked by variety and quality of produce for sale; Legend: Red Cross = ECHO Free Clinic; Small red icon of shopping cart = “no variety” (n=33) ; Yellow cart = “Poor variety” (n=67); Blue cart = “Limited variety” (n=50); Darker green cart = “Better variety” (n=11); Larger, lighter green cart = “Good variety” (n=15) ; Blue -shaded area = Study area

If you are interested, you can also download the original KMZ file.

posted by: Matt Anderson