The Ecol. of Food and Nutr, Vol.38, No.6, 1999.
CLAUDIO SCHUFTAN
schuftan@gmail.com
The time has come for the nutrition community to more consciously take notice of how micronutrient interventions and Protein Energy Malnutrition (PEM) interventions have progressively drifted apart. They have de-facto become different tracks in nutrition work answering what seems different challenges. In short, they have grown into two, by now, well differentiated separate domains.
Recognizing this fact is important, because it links this discussion to the future of international nutrition and to the evolving debate on Public Nutrition and its future role.
More than before, in the last six to eight years, a significant number of nutrition workers have chosen to focus their efforts on the alleviation of micronutrient deficiencies. This is also true for many donor agencies working in nutrition. One can rightly wonder if this represents an attempt to avoid the more difficult choices and challenges in the battle against malnutrition and -in the name of nutrition- focusing more on its more achievable areas of impact thus choosing the relatively easier path to staying involved in nutrition work.
Often, this greater micronutrient focus represents swings from earlier work in PEM. Examples of these swings towards assigning greater priority to work in micronutrients can be seen: in USAID’s Office of Nutrition work; in quite a bit of the nutrition work of UNICEF and other bilateral donors, and certainly in the new Micronutrients Initiative (the latter not a real swing, but a fresh start riding this new wave of preference or new mood among many of our nutrition colleagues).
The difference between both areas of concentration in nutrition work is based on a matter of balance between an endeavor that is primarily technical with only few political overtones, and one that is the opposite: primarily political with some added important technical challenges. The micronutrients endeavor does have a potential for silver bullet solutions to work; PEM does not (and nutritionists seem to like to have silver bullets in their armamentarium indeed…).
What we are talking about here is not an academic nuance only. This, because the solutions to PEM are greatly outside the field of nutrition itself and those for micronutrients are importantly inside the realm of what we can do technically. As a consequence, both these endeavors or components of nutrition work have to adopt different strategies and require different skills, approaches and tactics.
Colleagues that get involved in micronutrients work get absorbed in resolving mostly immediate and only some underlying causes of malnutrition, but they rarely touch its basic causes. (UNICEF, 1990) They also address more top down than bottom up programmatic challenges (such as management, distribution logistics, food technology issues, and other). Not all this type of work is strictly nutrition engineering though. Work on food fortification, in Brazil for example, tries to push the issues into the socioeconomic and cultural arena and tries to involve consumers and to promote community participation.
But staff involved in micronutrient work traditionally lobby for policy changes which are less controversial, less political (than PEM), and tend to get easier support from national decision-makers. Examples of such policies are: adding a Vit A component to EPI plans, starting nutrient fortification schemes, or getting salt iodization legislation and regulations passed.
When applying IEC techniques in micronutrient work -especially to change the dietary habits of a population (in terms of diet diversification), or to change the behavior of pregnant/lactating mothers- our colleagues face many more problems in succeeding, precisely because all the socioeconomic issues come to the fore (the same issues encountered in the battle against PEM). They feel and are less well equipped (or less in control/less inclined) to handle those issues. Too often, therefore, nutritionists end up teaching mothers to feed themselves and their families what they cannot afford, or -using social marketing techniques- they seek to impose changes in behavior without seeking the people’s understanding of why these changes are needed and beneficial to them. Social marketing simply fails to put people more in control of their own lives. Examples of these rather mechanical, seldom sustainable, uses of social marketing and the media are many around the world and have been highlighted elsewhere. (Schuftan, 1998)
On the other hand, combating PEM is about poverty alleviation (and not about economic growth as many development programs push these days). It is about equity, popular participation and wealth redistribution, about access to health and to education; it is about the appropriate care women and children get. (UNICEF, 1998) All these variables are adversely affected by the many Structural Adjustment Programs imposed on developing countries worldwide. [The relationships between structural adjustment programs, poverty and PEM hardly needs to be insisted upon here yet again]. (Schuftan, 1998)
I do not contest the fact that micronutrient deficiencies can be (and eventually do get) reverted when tackling immediate causes of malnutrition only, especially if well funded and well targeted: “get that capsule/pill/fortified salt into the mouth of beneficiaries, and it is done”. And that is good; deaths and suffering related to those deficiencies are averted; no quarrel with that. But this concentration cannot be morally justified at the expense of postponing or foregoing actions to tackle PEM.
PEM does not respond unless its immediate, underlying and basic causes are tackled simultaneously, i.e. interventions at each individual level are necessary, but not sufficient. (UNICEF, 1990)
As relates to sustainability, because micronutrient strategies so heavily depend on government (and donor)-based service delivery and logistic interventions and on capacity building at some levels only, they very often do create dependency on a given technology and on the continuation of centrally funded and controlled services. Ergo, sustainability remains elusive.
On the other hand, resolving PEM depends more on empowering people and communities to get involved in actions selected by themselves and, although not often achieved, this has the potential of creating less dependence and more self reliance and sustainability. (Schuftan, 1996) [Nutrition work done in Iringa, Tanzania, comes to mind as an example that stands out for its sustainability].
Micronutrient interventions will foreseeably reach coverages in the 90% range almost universally sometime in the early 21st century -mainly due to strong pushes by the donor community. And then, what? Will we see a switch back to PEM work (which by then will have become worse)?
PEM will not go away (or perhaps not even decrease) in the next generation. (ACC/SCN, 1997) The donor community involved in it pays more lip service to needed basic changes than putting their money and actions where their mouth is. And governments are not tackling these basic problems on their own either. Moreover, macroeconomic policies imposed by the Bretton Woods institutions are actually, more often than not, acting against the alleviation of PEM. (Schuftan, 1998)
I contend that nutritionists tend to choose tracks in their careers according to their preference plus the level of tolerance of frustration they can stand in their (nutrition) work. The question is: Do a political ideology and ethical commitments also play a role in their choices when faced with only snail pace progress? In other words, are ultimate goals of social transformation part of the equation in their choice? If the answer is ‘no’, I see a bleak future for the role our guild can play in the battle against malnutrition in the world. Changes will come about without and despite us; history will bypass us.
And I worry, because I see these future challenges that will have to be faced by our young and upcoming colleagues not being clearly spelled out in their curricula during their undergraduate and graduate training. Some say we are training less than engineers (Berg, 1995). I would say we need more than engineers: we need nutrition activist engineers.
Constructively looking forward, then, what challenges do what is here being said pose?
The above are the main scenarios and options that colleagues embarking in the battle against malnutrition have, by necessity, to face… today. It is a matter of choice to decide which option one wants to become more involved in. Any work in nutrition is not only engineering or activism; it involves both. But, if we are to overcome the great challenges ahead, the scale has to regain a greater balance away from a historic tilt towards mostly engineering. More decisive work on PEM -including more activism- is badly needed along with our efforts to conquer specific nutrient deficiencies. We need to recommit ourselves to it. We also need to train our new generations of nutritionists accordingly, not neglecting preparing them much better for their role as activists with a clearer understanding of and capacity to intervene in the political dimensions of malnutrition.
References:
ACC/SCN (1997), Third report on the world nutrition situation: A report compiled from information available to the ACC/SCN, Geneva, December, Chapter 1, Stunting and young child development, pp. 1-15.
Berg, A. (1995), Martin Forman Memorial Lecture.
Schuftan, C. (1996), The community development dilemma: When are service delivery, capacity building, advocacy and social mobilization really empowering?, Community Development Journal, 31:3, July, pp. 260-264.
Schuftan, C. (1998), book review of Werner, D., D. Sanders, with J. Weston, S, Babb and B. Rodriguez (1997), Questioning the solution: The politics of primary health care and child survival, a Healthwrights paperback, Health Wrights, Palo Alto, CA, in Health Policy and Planning, 13(1):1, March, pp. 103-104.
UNICEF (1990), Strategy for improved nutrition of children and women in developing countries, a UNICEF policy review, UNICEF, New York, NY, USA, Chapter IV, Strategy to achieve nutrition goals, pp. 17-22.
UNICEF (1998), The state of the world’s children, Oxford University Press, New York, Chapter I, Malnutrition causes, consequences and solutions, pp. 7-90.
Claudio Schuftan
Saigon, Vietnam.