The situation: The macro and micro levels.
The actors : institutions, social groups and individuals
The methods and solutions
Epilogue
References
CLAUDIO SCHUFTAN
schuftan@gmail.com
When focusing on the political economy of ill health and malnutrition we are tackling a problem that is bound to be subjective and controversial in its interpretation. I urge all readers to take this opportunity to bring to the surface their own subjectivities about these topics -a practice we too often skip, sometimes even in the name of a scientific imperative. We all need to face these controversies head-on and try to examine some of the unresolved contradictions we carry with us.
This paper will focus on three main areas: First, a brief discussion of the situation of ill health and malnutrition in the world with its macro- and microdeterminants, followed by a critical look at the individual and institutional actors in the battle against ill health and malnutrition, and finally, a critical review of the methods and solutions presently being applied in an attempt to solve these problems.
The situation: The macro and micro levels.
Ill health and malnutrition amongst the poor are the biological translation of a social disease.
Both internally and externally determined macro causes are definitely at the base of ill health and malnutrition of vast sectors of the poor populations of the world.. It’s no coincidence that the poor are the ones who suffer from these deprivations. Factors such as the foreign debt, international and national income maldistribution, the exploitation of the primary (agricultural) sector, the commoditization of agriculture, overt or hidden un- or underemployment and an array of other factors are some of the macro causes at the root of this social disease. Poverty rather than any microbe, parasite or worn is the key vector of disease and malnutrition.
A number of the development schemes implemented in the third world to improve the well-being of the lot have actually often worsened the health and nutritional status of the workers be it by favoring cash cropping, introducing water-borne diseases through large (or small) dams or irrigation projects, increasing industrial accident rates and pollution due to substandard security measures or through many other mechanisms. In short, the social costs of production are unevenly distributed in most societies. Health benefits are maldistributed following the skewedness of income distribution. At a minimum, health services just lend to assure the reproduction of the labor force. By forgetting these macro restraints, we keep dreaming we can revert this situation leading to ill health and malnutrition – if only we do our technical work better and more efficiently…
The above does not mean that there are no micro elements in the causal chain which need correction as they are more intimately related to inadequate food intake and disease. Actually, this is the area where most of us operate on a daily basis – implementing solutions – and where we feel more comfortable depending on our more specific backgrounds.
Classically, we get involved in: schemes providing incentives for food production or technical assistance to food producers (sometimes even for women), promoting food storage and preservation, reorganizing food marketing chains, influencing food choices and food preparation, implementing all or some of the GOBI FF components of primary health care, or in health and nutrition education activities, or so many other. The problem is that through this route we end up, more often than not, providing pat solutions that, at least in the last 12 years, since the Rome Conference, have not made any dent on the global problem of malnutrition. (One often wonders if things would have been any worse without all these interventions…). It has been argued that what we have been witnessing is rather a process of modernization of poverty in which a number of new variables have been introduced that have mostly only confounded the problem.
This review of the current situation is brief to the point of caricature. However, what should emerge is that each element in this analysis is at the same time a consequence and a cause to an underlying or more superficial level of causality. This will become clearer in the following framework presented in Figure 1 which highlights the different causes of malnutrition in a more graphic way.
Figure 1. THE CAUSES OF MALNUTRITION (Adapted from U. Jonsson)(1) AVAILABLE FROM THE AUTHOR
The actors : institutions, social groups and individuals
Figure 1 is particularly helpful to reexamine where, at what level, we are mostly active in our attempts to combat malnutrition. Are we doing enough or anything at all at the underlying and basic levels or are we acting upon the consequences at the more immediate causal level? If the latter is the case, why do we continue to do so? Do we perceive the futility of such actions when carried out in the absence of more profound structural changes? Have we gone from confrontation to accommodation? It is here where our ethics and ideology play a decisive role; their heavy influence permeates not only our behavior as individuals, but also of our institutions and the social groups we belong to (2).
Institutions:
All bilateral and multilateral development institutions channel their aid through governments. The state, in third world capitalist-dependent countries where most aid flows to, is, more often than not, sustained by the local dominant class that has shown little genuine interest in altering the status-quo beyond keeping the overall situation in the country politically under control. Thus, for example, the urban-biased and capital-intensive policies we see in so many of these countries come as no real surprise.
Under such circumstances, isn’t most official aid from abroad doomed to at least partial oblivion from its very conception? How much foreign aid in rural development is actually only patching up the “holes” of a process of internal exploitation of the primary sector (3)? Moreover, all along, international organizations have been and are pushing development in the third world coring from their own (western) biases often acquired in previous development work on other continents and under totally different circumstances. These models are too often enthusiastically adopted by the ruling elites of these new recipient countries, basically because they do not erode their power base and still give them an aura of commitment. If this aid would somehow dent their power base, governments would flatly reject them, even if grants would have to be foregone. International organizations, nevertheless, actually do exert some kind of pressure on third world governments -in the name of the “world’s public opinion”- that the latter can hardly refuse nowadays i.e. the adoption of primary health care and its components.
I think we urgently need to share, give and receive advice on strategies and tactics to face international organizations and governments in the third world to avoid the continuation of this perpetuation of maldevelopment. The strategies to face transnational corporations need to be explored in this same context as well. Are stringent conditionalities in the macroeconomic area fostering explicit income redistribution measures, the way to go, both at the national and international level? (of course, even this can be misapplied and the end result may be even worse…). The ideological barrier, once again, stands in the way of an assured success of such actions.
There are some exceptions of institutions that are working towards a more equity-oriented development. Perhaps two or three of them are independent UN agencies, but most of them are non-governmental or private volunteer/organizations (NGOs, PVOs), both national and international. The more the latter are connected with work at the grass roots, the more they tend to be such an exception. Other PVOs, on the other hand, are nothing but appendices or the executing arms of traditional western bilateral agencies.
Social groups:
Short of an overt class struggle, a number of grass root organizations (sometimes called people’s development organizations, PDOs) have begun springing up and taking fate and future into their own bands; some more successfully so than others. Cooperatives, labor unions, consumer unions, popular organizations, women’s organizations of many types and purposes have started to look into food, nutrition and health issues. It is to this phenomenon and its potentialities that we should definitively be paying more. The efforts to bring together, melt and distill these individual experiences to face common challenges is to become a higher priority for all of us. A new alternative is emerging. We need to explore it. Perhaps you may want to join in the effort. Reading a copy of the Manifesto of the World Food Assembly is perhaps a first step (4).
Individuals:
If not directly involved with one of the above social groups, I think that we are often being used in one way or another and are thus, knowingly or not, at the service or status- quo. We get involved in pat solutions, often dreamed up in a vacuum. We often even begin to believe in these solutions coming from our own ideological biases which are not too different from those of western donor agencies. In so doing, we legitimize this process. Ideological barriers act as a stained glass through which all of us look at one reality drawing different conclusions. Worse even, many of us never leave our ivory towers to look outside and see what is happening in the real world. As nutritionists, for instance, we have not succeeded. Malnutrition has not decreased. We have even failed to show a more decisive support and to speak up for the more successful experiments in countries trying to tackle infectious diseases and malnutrition with efforts at the macro level. Some of them are even right now in jeopardy through external aggression and would need our full support. So, what have we been achieving all these years? Have we been using the appropriate too l s, strategies and tactics in the battle against hunger, ill health and malnutrition?
We need to revise our role as advocates and genuine change agents; how our own personal ideological inclinations, may be hampering us to become such agents. As health workers, we can ill afford having split allegiances when we are out there trying to solve the problems of disease; hunger and malnutrition. We cannot afford to say – this is what science has taught me to do, I do it and anything beyond is not up to me and thus, none of my business. Who are we cheating? Ourselves? The people we pretend to work for? Both? Much of the present day chaos results from the tendency of the average good person to “let George do it”. As a start, the question is: Are we ready to listen to each other as peers? On substance, on substantial issues, as equals facing common challenges and opponents (all, those who have a stake in the status-quo). By now, we know what and who these opponents are; we have hit oar heads against the wall often enough. Next, we have to make sure that we keep our discussion action-oriented and not academic – the latter a deviation we tend to fall into too often. We should, not primarily aim at developing a political economic approach to the study of ill health and malnutrition. We need to come up with a concrete and sensible recommendations and with a renewed commitment to see them through.
The mass media could also be considered as actors of sorts in this battle against ill health and malnutrition, even if it is by default. The media too often distort development issues In the third world due in great measure to their own western (northern) ideological bias. Or, they simply do not report on some crucial issues about health and malnutrition, short of whatever can be exploited with sensationalism. Unfortunately, we have little leverage to redirect this biased outlook the media are bringing to our radios, television screens and newspapers on a daily basis. The media should become one of our targets for lobbying and advocacy in the immediate future. UNESCO’s experience in this field and the US’s response to it should not deter us.
The methods and solutions:
Solutions can be directed at the macro causes (basic and some underlying causes in figure 1) the micro causes or at both. For example, most of what nutritionists have done falls in the context of the micro interventions.
Interventions such as nutrition surveillance, long-term food aid, nutrition education, nutrition rehabilitation, community end family gardens, weaning foods and nutrient supplementation, among others, still high in the agenda of packaged development programs. Many of these approaches have serious shortcomings, a few have been more successful.
Even risking being a bit simplistic, what actually distills from these micro interventions is the following:
Food and nutrition surveillance has served more as an instrument to keep a log about (mostly) deteriorating conditions and has seldom been used as a base to put in motion commensurate solutions to reverse the recorded trends when these have been negative. Data collected and recorded in the periphery seldom reach the more central levels to be aggregated and used for planning purposes and virtually never get fed back to field workers to reassure them of the importance of their extra effort in recording all this information.
Non-disaster food aid and distribution has well-known effects in acting as a disincentive to local agricultural systems, have been largely unsuccessful and entail huge logistical problems and costs that need to be borne by the recipient countries.
Food and nutrition education, in the presence of widespread food shortages, end up teaching people to eat what they cannot afford or do not have and thus has only limited potential. It reflects an attitude such as: “Keep them poor, but teach them”.
Nutrition rehabilitation, on the curative side, is probably a necessary stopgap measure. But when food is scarce, again, the need for this activity increases and there is little these centers can offer in the long run even if they do have some food available for the initial phases of the rehabilitation. An additional sobering caveat is that even after successful impatient rehabilitation of severe cases of protein-calorie malnutrition (+ or – 60% in the best hands), no less than 30% of the children die not too long after leaving the recuperation facility, thus serving as a constant reminder of the unchecked underlying macro determinants.
Community and family gardens are a sensible alternative to pursue since they attempt to tackle the direct underlying cause of food shortages. Unfortunately, very few of these attempts have been successful on an ongoing basis.
Weaning food programs also have some worthwhile elements in them, provided local foods are available and utilized for preparing the mixtures in the household. Whenever imported ingredients or mixes (or centrally produced products) have been utilized results have been precarious. Educational activities in relation to weaning practices are among the few more successful of those activities especially in the prevention of Kwashiorkor.
Nutrient supplementation programs, i.e. vitamin A, iron and iodine, have a great potential for impact and are cheaper to implement. Nevertheless, they are at a totally different level when compared with the enormously more complex problem of tackling the problems and consequences of protein-calorie malnutrition and chronic hunger; socioeconomic determinants interfere less.
Our role as consultants when hired to work on the above micro interventions in the third world (40,000 expatriate experts in Africa alone) is indeed a delicate one. We run the risk of legitimizing them in the absence of any other more structural interventions that will more directly break the vicious circle of hunger, malnutrition and poverty. Even if we become aware of the need for some macro interventions, it is difficult to find the appropriate channels to reach decision-makers, and much less to influence prompt actions in that direction. We can share with them what needs to be done but there is little chance of implementation. Perhaps the best way for us would be to interact directly with community organizations to help them articulate their grievances.
Micro interventions do have infinitely better chances of succeeding if macro policies are implemented concomitantly or in advance. These are the kind of interventions that tackle some of the root causes of ill health and malnutrition (for example, think about China, Cuba and more recently Nicaragua). Equity-oriented development policies (i.e. land reform, small farmer credit, price incentives to food producers, subsidization of agricultural inputs) linked to labor intensive agriculture with high priority for food crops, equitable food distribution schemes, participatory decision-making and many others along the same line are at the heart of what really could make a difference.
Primary health care (PHC) as an approach has a special role to play in this context. Its philosophy, as set in Alma Ata, carries the seeds of equity and participation. It calls for decentralization and democratization of the health services.
However, in its application and beyond lip service, PHC has been too often downgraded to the status of a mere rural health branch within the ministries of health with none of the equity parameters being followed.
Two words of caution are called for at this point on the issue of what I call “quasi or pseudo” macro intervention techniques or approaches that many of us have advocated for at one time or another. These attempts at acting in the macro context depart from a flawed analysis of reality and have consequently mostly failed (and are doomed to continue to fall). Among the most prominent of these that I am aware of in our field are two: Nutrition Planning and “Multidisciplinary Approaches to Solve Hunger and Malnutrition”. There is nothing terribly wrong with these two concepts but they gratuitously assume that looking at the problem of hunger and malnutrition from a wider perspective is going to automatically lead us to the better, more rational and egalitarian solutions.
Nutrition planning was introduced more or less 15 years ago and rapidly gained momentum. It applied systems analysis techniques to widen our understanding of the Food and Nutrition System with its intricate interrelationships. We were to stop thinking about malnutrition as a health problem (actually only the tall of it) and look at the Food Chain – from food production to its consumption and ultimate metabolization. Therein lies the key to success. Nutrition planning revolutionized our field and was “sold” almost as a new panacea (5).
As a tool of analysis nutrition planning definitely widened our horizons. But it made us believe for a while that analysis could be made objective. It overlooked the ideological barrier that makes that but an illusion: we see things we want to see, the way we want to see them, or the way we were taught to look at them. Moreover, when it comes to the synthesis process and we have to identify the major bottlenecks or constraints that stand in the way of a smooth flow of food in the food chain in order to come up with the soundest and most cost-effective solutions, food and nutrition planning techniques cannot even pretend escaping subjectivity. Again due to our ideological straight jacket. We tend to have more eyes for and opt for the micro or if we see the macro we somehow still mostly opt for the micro because we think it is the “doable” part of it all.
The call for multidisciplinarity, for sharing paradigms amongst different scientific disciplines and scientists to solve the problems of malnutrition, falls under the same optic of my criticism. Just by putting together brains “seeded” differently, without considering where they are coming from ideologically, is not going to, all of a sudden, make a significant difference in the outcome and the options chosen. They may well stay in the micro domain, now everybody involved assuring a small piece of the cake for his/her discipline in the package solution proposed.
Traditional multidisciplinary approaches – as opposed to a dialectical approach – also take the social and political institutions and power relations as given, thus ending up being conservative in their recommendations.
Epilogue:
Given the nature of the situation described, the objective and subjective limitations of the actors involved in trying to do something about it and of the methods and solutions being applied, we are left with the hard question of WHAT TO DO?
Should we start by denouncing the state of affairs brought up by what has just been said and begin looking for global and local alternatives with the participation of those sectors for which the present system has failed to provide even minimum benefits? Works at the grassroots level would then be an attractive avenue (4).
What is our role in this task? How much effort do we need to devote to changing ourselves and our peers to assume such a role?
Health and nutrition can and should be ports of entry for structural changes. The hows of this is what we should explore in more depth. The discontent already exists among us. How can we cultivate it positively to reach the state of creative anger I think is needed for genuine changes to get underway? We can become change agents. We have science on our side. Let’s not make the latter a liability. Sharing paradigms and cosmogonies is difficult, not impossible. Let’s not fail at communicating. We have to cut down on existential reflections and speak and work with and for the people in dire need. On the ethical issues, we will agree. But can we get one step closer ideologically and thus politically?
As health scientists, we have come a long way. We have gone from emphasizing basic research to applied research; from there to multidisciplinary research – even accepting the social sciences as “scientific enough” for us. Every step has undoubtedly widened our horizon and brought us closer to a more political view and understanding of the problems of ill health and malnutrition. But we have not reached the point where we really get politically innovative in our search for solutions. It’s like the old philosophical riddle of the turtle trying to finish the race: At every instance, it hat first to go half the remaining distance to the endline before being able to actually get there. Therefore, it never arrives.
We get as far as a locked gate. The conservative elements of our ideology prevent us from trespassing or unlocking the gate.
Nothing short of the equivalent to a second adolescent crisis will allow us to take that step. The problem is a political one, not a technical one and we are not living up to it.
References
1. Jonsson, U.: A Conceptual Approach to the Understanding and Explanation of Hunger and Malnutrition in Society. Presented at the workshop on “Hunger and Society” in Soliwayo, Tanzania, December 1983.
2. Schuftan, C.: Ethics, Ideology and Nutrition. Food Policy, 7(2), May 1982.
3. Schuftan C.: Foreign Aid and Its Role in Maintaining the Exploitation of the Agricultural Sector: Evidence from a Case Study in Africa. Intl. J. of Health Services 13(1), 1983.
4. World Food Assembly. Manifesto: That All May Eat – Action for Change and Justice, 1984 (WFA: 5 Harrowby Court, Harrowby St., London WIH 5FA, England).
5. Schuftan, C.: Nutrition Planning – What Relevance to Hunger? Food Policy 3(1), February 1978.
Claudio Schuftan
Ho Chi Minh City, Vietnam.
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