38. Equity in an inequitable world

Ho Chi Minh City. Two new years are now behind us: the Western and the Chinese, both of which we celebrate here in Vietnam. These traditionally are meant to bring a new sense of calm and hope to people’s lives. But not all is calm in the world of 2012 so, in the oriental tradition, I write with an ounce of optimism and two ounces of realism, in the hope that some of you take what I suggest here as part of your own new years’ resolutions.

Much of the inspiration for this column comes from my hero of the month, Pedro Luis Castellanos (above). For 19 years he was on the staff of the Pan American Health Organization. He is currently with IDESARROLLO, the Institute for Social Development in his home country the Dominican Republic.

I often ask myself what we could all do or do better to achieve greater equity, given that we most often work in countries with appalling social inequities. I guess that you do, too.
Here is how I see things. I believe that our role in helping to put in place the needed social processes and mechanisms that will drive sustainable policies in health and nutrition, is inseparable from a will and intent to change the underlying structural inequalities. We can realise and grasp this will and carry out this intention coming from either of two ideological positions: One is ethical, the other is political. I see the challenge for us being to graduate from the first to the second approach.

Top-down ethics mostly linked to charity
What is termed the new development ethic calls for working with impoverished populations and communities as protagonists and not merely as recipients. But I am afraid this approach still remains mostly top-down. It represents primarily the view of international bureaucrats, foundation executives, academics, intellectuals, church leaders, and a few politicians. Claim holders have remained mostly absent in this approach, rather counted as the ‘object’ of the process. This ethics-led process assigns key roles to ‘moral advocates’ who are to advance the cascading process shown below:

The inherent weakness of this process is that to have rights ultimately respected, people other than the impoverished ‘subjects’ take the responsibility at each step to steer the process from entitlement to enforcement.

Bottom-up politics linked to rights

This more bottom-up political approach, in which commitments are needed beyond ethics, better accommodates and represents the perceptions of needed development actions as seen from the perspective of the beneficiaries of development. In this approach, beneficiaries are clearly the protagonists of the process. The process is mostly politically motivated and assigns a key role to ‘social activists and political advocates’ who are to advance the cascading process shown in Box 2.

The ethically and politically led approaches, as simplified in Box 1 and Box 2, represent different paths. Both can, to different degrees, contribute to sustainable changes in the health and nutrition of those who happen to be poor. The two approaches complement each other, and will be even more synergistic when the ethically led process gets more proactive civil society inputs and gets more politically savvy.

It is in the political realm that I see a real chance to influence the choice of needed investments in health and nutrition and also to affect the redistributive and social protection measures and priorities that address the poverty underlying the preventable ill-health and malnutrition we professionals are left to deal with. It is also in the political realm, with added strength coming from organised communities inputs, that I see us effectively influencing how the public sector allocates its resources and how, in the process, the governments favour programmes that are under strong community control.

Finally, it is also in the political realm that I see greater potential for success. It is how we can best help to re-establish a will and intent to change structural inequalities underlying preventable ill-health, malnutrition and deaths. Strength will come from building the new constituencies that do have a vested interest in pushing real changes. Further strength will come from changing the currently entrenched system that repeats the structural inequalities generation after generation, and that determines the parameters within which we (as professionals) are ‘allowed’ to intervene.

This naturally brings me to Rio2012, our congress at the end of April, for which we all have high hopes. What should we be thinking about, in preparation? The big picture, I’d say, i.e., things like:

We should be thinking about:

• Health and ill-health
• Good nutrition and malnutrition
• What is healthy living?
• What is a life lived in wellness?
• What is the role of the state?
• How is power distribute in the world and at national level?
• How is the use of force legitimised?
• Patterns of domination and exploitation we encounter in our work
• The supremacy of one social group that has given itself legitimacy
• The multiple situations of conflict around the world, and
• Class conflicts.

We should come prepared to reach agreements on:

• What is public and what is private
• What is private and what is social ownership
• What are public and what are private goods
• What are common and what are particular interests, and
• What are national and what are international interests.

Does this seem altogether too much? Maybe. But I really do feel that we need to ask ourselves at least some of these big questions before Rio2012. Furthermore questions like:

• Are we contributing sustainable changes to the era we live in?
• Where is this era of grave simultaneous crises –economic, financial, social, political, environmental, climate, food, cultural, techno-scientific– taking us? and
• How will they affect nutrition?

How is it that Capitalism in its current ‘casino’ phase has taken us to:

• Dominance of financial capital over productive capital
• Devastating speculation in food commodities
• Subordination of corporations to banks and speculation in stock markets
• Exacerbation of the worse traits of Capitalism
• Weakening of the status of nations through the process of globalisation
• Nature being pushed to its limits
• Humanity being pointed to the brink of extinction, and
• Greater uncertainty about the future.

Why did we accept the tenets of The Washington Consensus that said:

• The state is the problem: deregulate, let corporations un wild
• ‘Free markets’ are the solution and are ‘rational’
• Apply minimalist, focused and temporary social policies, and
• Let the bankers solve our major problems.

And there are yet bigger questions:

• A public health nutrition professionals, are we part of the problem, or of the solution?
• What will be needed to return to common sense policies in health and nutrition, and their structural determinants?
• Are we not returning to the same basic questions when we are really in dire need to arrive at new responses to old and current questions?, and
• What are we saying? Are we saying that a new way of understanding the world and humanity is indeed needed?

Can we acknowledge that:

• New progressive forces are merging – Arab Spring, Occupy movement?

And that what unites us – or what we should do – includes:

• Confronting a world system that amounts to neo-colonialism
• Adopting the emerging culture of equity and solidarity
• Embracing a new understanding of the links of what we do with nature
• The defence of public goods, and
• Fostering direct democracy with claim holders as protagonists.

Three major tasks are thus facing us. They are:

• To disengage countries from the casino capitalist juggernaut
• To address and pay the historically accumulated social debt, and
• To advance towards a greener, sustainable future.

As we prepare for Rio2012 we have to think how to make our public nutrition discourse central to new enlightened public policies and actions. We need to:

• Recognise the complexity and consequences of the task ahead
• Deal with very different and heterogeneous groups
• Fight against the worst of capitalism
• Defend national states, and
• Defend the public sector and common goods.

We need to be part of the setting of new rational regulations in the public interest, through fair and sustainable economic, social and institutional policies, through greater democratisation, through fostering the free determination of people, and through having politicians taking a true interest in the everyday life of common people.

Some common objectives of future health and nutrition policies ought thus be to:

• Address health and nutrition as inalienable human rights
• Work towards universal health coverage, towards greater inclusion and equity
• Aim for comprehensive social policies, better quality of life and dignity, social solidarity, full citizenship rights
• Escape from the trap of single-track vertical thinking, and
• Foster greater creativity and diversity.

First and above all we need to put our own houses in order. We need to:

• See in what ways the current system’s shortcomings are reflected in our own current work
• Resolve our internal conflicts (ethics/politics) as health and nutrition professionals
• Help empower the social actors we work with;
• Use participatory management and mass mobilisation in our work
• Bring out creative energies and give free reign to ‘creative anger’ in the people we work with, and
• Make the social actors we work with true political actors, truly new historical women and men.

Does this seem to put too heavy a load on your shoulders? Maybe. But as they say, if not now, when?

Acknowledgement and request

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

Please cite as: Schuftan C. Equity in an inequitable world, and other items. [Column] Website of the World Public Health Nutrition Association, February 2012. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Geoffrey Cannon. It has been greatly influenced by the writings of Pedro Luis Castellanos.