Ouadougou. I began this month’s column in Ouagadougou, Burkina Faso. How come I am here? Well, the government here is in the process of finalising guidelines for ministries to prepare their next mid-term plans. Demonstrating real vision, the government wants to make sure that the cross-cutting issues of gender, the environment, and human rights, are incorporated in these plans. In the area of human rights, they requested the help of an external consultant. The local UNICEF office was approached to find a francophone consultant. And this is how I became involved. I cannot yet tell how much the issues of macro- and micro-causes and of political, economic, and social determinants of ill-health and malnutrition will be taken up in the work I am doing right now here. But I am sure working hard on it… So see what follows.
Africa is a good continent to be in. I have done much work here; always going after what the real causes of malnutrition are (here meaning undernutrition and nutrition insecurity, or to speak plain, hunger).
Macro- and micro-causes
For many of us, undernutrition and hunger are nothing but the biological translation of a social disease with particular historical roots in each case. Their basic causes will here be called macro-causes. The more immediate and underlying causes will here be called micro-causes.
Macro-causes are conditioned by the overall policies that govern economies, both within any country and in foreign relations and trade. With many others, I contend that macro-causes explain most undernutrition and hunger in societies with capitalist modes of production. Nutritional vulnerability is a manifestation of a society’s inability to enable its poor populations to earn their livelihoods adequately and not an issue of overpopulation or of insufficient agricultural production. In short, impoverished societies struggle for their own livelihood while actually contributing to the livelihood of other societies (1).
Political and technical approaches
Macro-causes are not removed or even touched by the vast majority of conventional nutrition intervention programmes. The fight against undernutrition and hunger thus has to change, to become much more of a political struggle. Technical approaches simply cannot achieve the fundamental structural changes needed to end hunger.
Removal of a few (or even one) of the main macro-causes is more likely to alleviate undernutrition and hunger than acting on many micro-causes simultaneously. Macro-causes are now frequently mentioned and identified by planners analysing specific country situations, but the plans they devise seldom address these causes frontally.
Micro-causes impinge on the physiological condition of malnutrition. These include health, environmental, and biological factors. These are those most frequently identified and selected for direct intervention by Northern planners. They largely emphasise technical approaches, and justify Northern-trained experts who often come with ready-made off-the-shelf analyses…and ‘packages’. To many of us, The Lancet Series on Nutrition suffered, to a great extent, from such an outlook.
All experts bring their own view of development. Nothing new here. Their proposals for nutrition programmes will reflect their ideology, of which they may be unaware. Over the years, a focus on micro-causes has led to myriad packages of solutions or interventions that pretend to be apolitical and free of ideological connotations or influence. But ultimately one either bows to the system or objects to it, totally or partially. Is not this a political stance?
As nutritionists, we keep inventing new ‘more comprehensive’ or ‘multi-sectoral’ or ‘evidence-based’ approaches to old problems, as if these would change major contradictions and maldistribution of power in the system that is causing the problems of malnutrition to begin with.
How to get to the point
I contend we basically cannot agree on the content of needed nutrition interventions if we do not share the same understanding of why people are poor, undernourished and hungry to begin with. Different socioeconomic contexts call for different nutrition plans. This does not imply that only macro-causes should be identified and acted upon. An appropriate understanding of hunger and malnutrition will include consideration of and acting upon a mix of macro- and micro-causes.
The challenge here is to determine, in each national (or regional) context, how much and what kind of macro-changes are needed for micro-changes to have some chance of success. The connections between macro- and micro-causes must be made explicit so as to justify the needed macro-changes. Any plan or programme geared to ameliorating malnutrition as a public health and social problem will have to include a mix of interventions designed to affect change in both macro- and micro-causes. Technical measures in themselves are not tools for income redistribution; at most, they may have a partial redistribution impact as a side-effect – assuming that they reach the lowest income and marginalised groups.
In this context, our role is indeed delicate. Sensitisation and advocacy skills are perhaps more important than technical know-how. The strategy that is to follow a comprehensive diagnosis of the problem(s) at hand can either a) first, define a set of specific activities directed to address and remove or minimise the effect of micro determinants (the classical approach) followed by an estimate of the potential of such a package of interventions to solve or address the major problems of hunger and malnutrition, or, b) alternatively, invert this sequence).
So that anybody can understand these links, a list of the key macro-causes should be identified with beneficiaries (claim holders), and a summary made of why and how each one of them contributes to the persistence of undernutrition and hunger; a list of possible interventions should then be prepared also with beneficiaries’ participation. Through a process of ensuing social mobilisation, the list will become the basis for demanding the removal of some of the structural constraints that are ultimately determining the state of chronic hunger in identified sectors of the population.
Why populations are impoverished
Countries that are poor, and poor regions and communities within any country, are impoverished through similar pathways. Consider the following 20 macro-causes of undernutrition and hunger:
Undernutrition and hunger is indeed a social disease! It cannot be eradicated by medical interventions, not even if these are comprehensive. Nor can it be eradicated by a combination of medical and agricultural interventions.
Redistribution of resources and wealth, and the consequent increase in purchasing power of the needy majority, are necessary to reduce undernutrition and hunger. But not even these are sufficient. Poverty has many masks, such as cultural and educational deprivation, poor health, and inadequate sanitation and housing, each with its own features. We should not think that improvement of the features of such masks will have any lasting effect. The real face of poverty is socioeconomic deprivation and gross power imbalances in society.
How far can we go?
Many among us have divided the remedial actions finally proposed into two groups: ‘recommendations’ and ‘interventions’. Recommendations often concern macro-causes and the need to change or remove them; they are usually worded in very vague, general terms and have no specific implementation budgets or deadlines set aside. Interventions often concern micro-causes, are prepared in more detail, have a fixed implementation deadline, and usually have budgets.
How outspoken are we prepared to be in proposing corrective measures directed to the macro-causes? This will depend on the political environment in which each of us works. Political and professional risks are usually high (2). Many colleagues feel that their positions in academe, government, or international or private organisations might be jeopardised if they demand radical solutions. They take a ‘survivor’s’ attitude. This is disturbing.
We need to stop thinking that we cannot contribute much to the selection and implementation of non-nutritional interventions that are outside our immediate field of expertise.
Macro-causes can be exposed in a number of ways. Not all of these need to be dramatic or sensationalistic. For example, the possible interventions that flow from the analysis of macro-causes could be listed under a soft yet realistic title, such as: ‘Conditions under which interventions addressing the more immediate determinants of malnutrition will have a better chance of having an impact’ (3).
This should be followed by an estimate of the realistic potential of each macro- intervention to ameliorate undernutrition and hunger. This should include, and be based on, the demands that mobilised groups of claim holders will place in front of authorities. This kind of presentation is meant to show that, if macro-causes are removed or minimised, interventions that follow, geared towards removing micro-causes, are more likely to have a real and lasting impact.
Political and ideological constraints, as well as the attitude and commitment of decision-makers towards eradicating hunger, will determine how far any planning team can go. Beware though that such constraints can be overcome; social mobilization is the key that unlocks the Gordian knot.
The main problem with taking a ‘macro’ approach, is that it will look ‘too politically radical’ to the governments addressed. If so, they are probably not genuinely interested in solving the problems at hand. We often underestimate this. Sometimes it is hard to tell, given the lip service governments pay to their commitments.
Analyses of the type summarised here hopefully have an educational value, especially if they are documented with some hard evidence about issues that politicians and decision makers already know well, but choose to ignore.
We tend to assume that decision makers are rational and righteous, and will accept hard scientific evidence and react to outrageous injustice. Such assumptions are usually mistaken.
Colleagues who participate in the planning process may gain a new consciousness as a consequence of using this approach. This alone makes the effort worthwhile.
1. Makhoul N. Agricultural Research and Human Nutrition: A Comparative Analysis of Brazil. Cuba, Israel and the US. International Journal of Health Services 1983, 13, 1:15-24
2. Chossudowsky W. The Neoliberal model and the mechanisms of economic repression. Coexistence 1975, 12, 1
3. Schuftan C et al. Recommended national food and nutrition plan for Liberia. Mimeo. Interministerial technical committee on food and nutrition planning. Monrovia, 1982).
Ho Chi Minh City. I am back home now in Vietnam. After reading an exceptionally long list of emails I have just received, I fell into a pessimistic mood. I was thinking of roads paved with good intentions. This is what came out:
1. So we organise, expose, rationalise, denounce, analyse, network, liberalise, accuse, mobilise, study, decentralise, communicate, prioritise, implement, point a finger at, develop, monitor, evaluate, (reanalyse), measure, research, publish, present, advocate, persuade, correspond, orient, contribute to a list server, meet, declare, assess, legislate, decree, (reorganise), define, negotiate, devolve, fund, train, invest, capacitate, (reorient), build, seek answers in the internet, strengthen, deliver services, educate, give credit to, (redefine), provide literacy, procrastinate, lose our temper, despair, dismiss, reform, impose conditionalities, …or throw money at…
2. And then do all the above some more…
3. But what does this really do to stop the relentless march towards pauperisation, polarisation, violations, globalisation, desperation, exploitation, conglomerisation, monopolisation, transnationalisation, ‘IMFisation’, depreciation, masculinisation, centralisation, global speculation, devaluation, degradation, privatisation, depletion, erosion, deforestation, malnutrition, corruption, unfair competition, pollution, domination, oppression, repression, growing gaps, fundamentalism, authoritarian regimes, mergers, ill-health, disempowerment, growing inequities, free market excesses and abuses, maldevelopment, social unrest, trade imbalances, displacements, refugees, tribalism, and nepotism ?
4. So what? Who are we really failing, serving, fooling, satisfying, helping, cheating, speaking for, representing, defending, misleading, pleasing, empowering, condoning, letting get away with, supporting (by design and by default)?
Does anybody out there care to add to this list… or make it rhyme… or help me out of this terrible mood? Where has the big picture gone? And what are we doing about it?
Request and acknowledgement
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. Hunger: In search of the big picture, and another item. [Column] Website of the World Public Health Nutrition Association, December 2010. Obtainable at www.wphna.org
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