The need for a more critical and visionary attitude
Endnote
Postscript
References
Letter to the Editor in Public Hlth. Nutr., Vol.2, No.2, 1999.
CLAUDIO SCHUFTAN
schuftan@gmail.com
At the closing of the century, the central question I think we (international health and nutrition professionals) are not often enough asking ourselves is:
If we are trying to insert health and nutrition interventions in the Third World more in the realm of sustainable development, why is so much that has been said, written and spent on this having so little effect on the problems that our actions are actually seeking to address?
The answer to this question lies in various fronts; among them, more often than not:
– following Northern-led approaches, our praxis has become professionalized and, in the process, we have devaluated and demoted the role of popular knowledge in our fields of expertise;
– our prevailing values and attitudes as researchers and practitioners in this field have prevented us from acting as equals with our Third World national counterparts;
– we still control knowledge as part of the elite, and thus fail to get a deeper understanding that will guide more appropriate actions; the latter can only come from a process of genuine popular participation.
The root of the problem is that sustainable development is about processes of popular enrichment, empowerment and participation which our technocratic project-oriented view has simply failed to accommodate.
Also contributing to the irrelevance of many past and current approaches is the fact that overall development education has continued its traditional conservative role of transmitting society’s values mostly as they are perceived in the North. The time has come to demand profound changes that accommodate more multi-centric new approaches.
Those who teach (or taught) us, inevitably teach us part of themselves and the frame of values that is part of their background. The context any teacher comes from has its own frame of assumptions about what is real, what is unshakeable and what is safe. The problem is that sometimes these contexts become cages, especially in the type of international work we do in health and nutrition. The time has also come for new frameworks to break the old thinking patterns and make health and nutrition work more genuinely participative.
Unfortunately, difficult problems have the power of leading us to focus on their more manageable components thus totally avoiding the more complex, underlying and basic, structural questions. This is known as ‘the exclusion fallacy’ in which what we choose not to discuss is assumed to have no bearing on the issue. (Mc Dermott, W.B., 1989)
We cannot, therefore, continue supporting an outlook on the future that is partly based on presumptions and forecasts rooted in desires from outsiders (no matter how well intended); we need facts about the whole picture, not only about health and nutrition.
But an uncritical, repetitive reliance on the same old shallow facts in the interpretation of unresolved issues -i.e. not considering ill-health and malnutrition as outcomes of complex social and political processes- has equally foreseeable conservative consequences. Outlooks stemming from such a vantage point particularly suffer from an inexcusable narrow understanding of the nature of control processes in society (both in the North and in the South).
The predominantly functionalist theories of development we mostly still fall back on, see society largely as an organic whole that is normally in equilibrium; dialectical theories view society as a complex of forces in tension and conflict by reason of the divergence of interests behind them. The functionalist theories, which I criticize, assume that conflicts are resolvable within the existing social system. In dialectics, conflicts are supposed to lead to systemic change, to a more fundamental break with the existing order. (Langley, W.E., 1989)
Among the most prominent newer components of functionalist theories are all sorts of ‘multidisciplinary approaches’ to solve the problems of, in our case, ill-health and malnutrition. There is nothing terribly wrong with this concept, only that it gratuitously assumes that looking at the problems at hand from a ‘wider’, ‘pluri-disciplinary’ perspective is going to automatically lead us to the better, more rational and equitable solutions… Just by putting together disciplines and putting together brains ‘sown’ differently -without considering where these individuals are coming from ethically, ideologically and politically- has not, is not and will not, by itself, make a significant difference in the outcome and in the options chosen. (For sure so if, additionally, we do not actively incorporate beneficiaries in the decision-making process).
The need for a more critical and visionary attitude
Our failure to reach Health For All and succeeding in halving the global 1990 PEM rate by the year 2000 has been more than a wretched fact in history. As far as I am concerned, it has been an ice-age in our thinking on how ill-health and malnutrition are deeply linked to an overall unsustainable development model. Now, we need to think what ought to follow during the current thaw. [To use a cliché: If we know what we are looking for, we are more likely to get there and to know when we do].
In this endeavor, opposing the old ways is not enough; we have to set out a counter-concept. The present moment is still full of promise, because the old conceptual clarities are breaking down; an era is expiring. Openings are being followed by partial closures.
Debates about past historical rights and wrongs are to guide us to come up with more cohesive propositions for tomorrow. If there is no cohesion in our vision, the campaigners will weary and the campaign will perish; we thus need a vision firmly embedded in a practice. To walk away from these debates is a luxury we cannot afford. We need to wedge open a space for the larger discussion of what ought to follow, a discussion that looks at all levels of causality of ill-health and malnutrition in poor countries -from immediate to basic causes. Yes, this will mean changing the terms of the discussion, because a vision is not much good if it simply stays in the air as something devoutly to be desired; a vision of that sort is a mirage: it recedes as you approach it. To be of use, the vision has to suggest a route, and this requires that it take into account a lot of unpleasant realities.
A vision is of no use unless it serves as a guide for effective action. These actions will, once and for all, have to be biased towards the oppressed, because it is their rights that are being trampled-upon. We ought to express and manifest solidarity towards the oppressed, because only then will our (joint) vision gain weight and credibility in its commitment to equity and justice. We can no longer abandon the have-nots to the dollar-dispensing Northern bilateral or multilateral agencies. The moment cries for us to press for more. Windows of opportunity have a way of slamming shut. (Gitlin, T.,1988)
I am aware it is still very difficult for some of us to maintain our political agility in a hostile environment. But the role of an avant-garde is to cause fermentation. We cannot fall in the trap of believing someone else is going to take care of these things for us; we have to get active. A strategic overhaul of our actions requires nothing less than a crisis in our thinking and if by now there is no such a crisis in the horizon, we have to perhaps create one.
The future of our work in health and nutrition cannot be a simple extension of the past. If we try to pursue a path of business-as-usual we will find some altogether unusual consequences. However much we may engage in fine-tuning the engine, this will not suffice unless we redesign certain sizable parts of the motor itself. (Myers, N., 1987)
The future will have to inevitably differ. It is of un-postponable critical importance to deliberately concentrate on neutralizing the known social forces that are propelling us professionals in the rather hopeless direction we are moving, both at the national and at the international level. Changes as fundamental as the ones at stake here can only be promoted by people who have no vested interest in the survival of the non-sustainable development system as it operates now to the detriment of the dependent countries and their poor. (Harman, W.,1989; Bracho, F.,1990)
The brick wall of political will (the lack thereof) is best tackled through practical actions that take into account who will win and who will lose.
A new professionalism will emerge only if we are explorers and ask, again and again, who will benefit and who will lose from our choices and actions in our work in health and nutrition. New professionals ‘who put the last first’ already exist; we still are a minority. The hard question is how we can multiply and, most importantly, how we can interact, coalesce and organize dynamic networks among ourselves and between us and grassroots organizations.
In sum, I reiterate that a mere extension of what most of us have already been doing in public health and nutrition is not powerful enough to really get the goal of inserting health and nutrition more in a sustainable development path achieved. Not only do we need to come up with conceptual breakthroughs, but also to provide blueprints for the needed institutional changes that will support the new arrangements.
We need to act as what Antonio Gramsci called “organic intellectuals” -intellectuals whose work is directly connected with the popular struggle. “Orthopraxis” (right acting) is ultimately more important than “orthodoxy” (right doctrine)…even if it means temporarily retreating for tactical reasons: One who stands at the edge of the cliff is wise to define progress as a step backwards…
Endnote:
Making prescriptive recommendations on what each of us needs to do to contribute our individual grain of salt to making health and nutrition interventions more effective and sustainable would be presumptuous on my part (although I have attempted it elsewhere) (Schuftan, C.,1982,1985,1988). This article has no such intention. It just is a wake-up call for some and an always timely reminder for others. It is about being more critical about what we do and see. This, as a basis for each of us to develop our own (new) vision for the future: a vision that fits our own specific situation, one that we commit ourselves to share, and one that we are willing to implement working with others.
Postscript:
After submitting this piece to the Editor, he suggested that it “could be (made) more powerful and helpful (to the readers) if I were prepared to set out a model of how it could (all) work”. He agreed that being prescriptive had its dangers. He also suggested I should cite if and where there are examples “where such an approach has begun to work”.
So -feeling more than a bit uneasy about it- here are some elements of such a model (not the full cohesive counter-concept I talked about).
At the risk of sounding panfletary, I think these elements could begin making our work yield more potentially sustainable and equitable outcomes. I can think of no other format than presenting the major (mostly normative) points in the form of bullets (here in no real particular order).
We need to de-professionalize our work.
This will mean seeking, re-valuing and incorporating popular knowledge and know-how into planned actions.
In the process, our Third World counterparts -and local civil society organizations- have to take a more visible lead (even at the cost of some possible mistakes).
All relevant knowledge has to be shared with the beneficiaries openly and upfront for them to fully participate in the decision-making process from the very start.
We need to move away from the project-oriented approach and move to processes of popular enrichment and empowerment (consciousness raising of Paulo Freire).
Needed expertise now has to be drawn not from academicians, not even from professional practitioners, but much more from the ‘everyday sufferers of the effects of the prevalent inequitable system’.
Beneficiaries are to define what changes we will be looking for and let these guide the drawing of action plans.
Action plans are thus to be negotiated and finalized in the field, not in our offices.
Development education has to be carried out from the beneficiaries’ perspective with their choice of contents and priorities.
All this means we have to shed many of our biased values and be more open to the beneficiaries’ values.
Our analyses need to incorporate more the underlying structural causes of ill-health and malnutrition so as to see them as part of the ‘big picture’ (including those changes brought about by globalization).
Such analyses will force us to tackle not only the multidisciplinary aspects, but the complex social and political issues preventing people from improving their own health and nutrition (mostly related to control processes in society).
We will have to confront face-on and expose the forces that oppose greater equity so as to neutralize them (from the local level to the international arena).
This means that we will have to adopt a dialectical approach as a more effective means to lead us to the needed systemic changes at the base of the major contradictions shaping the present situation.
A conceptual framework of the causes of ill-health and malnutrition seen as outcomes -like the one UNICEF uses- is a needed intermediary step to assess and analyze the causes at different levels and to come up with converging concomitant (necessary and sufficient) actions at the different causal levels.
We will have to intensify our efforts at using the internet to build networks of like-minded colleagues that can consolidate a strong worldwide solidarity movement.
We will have to become more active and vocal open critics of the type of (often tinkering) bilateral and multilateral aid that is perpetuating old non-empowering/non-equitable approaches.
We will have to actively help forcing institutional changes in bilateral and multilateral aid agencies (the UN system included) that make them more democratic and transparent.
We will have to embark in a significant overhaul of the curricula of health/nutrition and development professionals that will prepare a new generation of more sustainable development-oriented professionals.
All the above -being desperately incomplete and a bit caricaturesque- sounds quite grandiose (and even romantic) and is packed with heavy-sounding, politically-charged action verbs. These action verbs probably define the current ‘organic intellectuals’ of Gramsci, and what is here proposed should help move the process from orthodoxy to orthopraxis; otherwise, we might as well forget it.
But the processes that can lead to sustainability and equity can (and should) start with small direct actions that we can help bring about more easily. Actions at grassroots level can take many forms, but should always reach a point in the discussion where who is losing and who is winning (and why) is thoroughly analyzed. At higher levels, most of us have more experience on how to start discussions leading to change. We just have to commit ourselves in a more militant way to get and/or keep the process going and, above all, challenge the status-quo that gives the impression nobody cares.
Examples where some of these elements have worked exist. Some of them have become cliches (Kerala, Sri Lanka, Cuba, Iringa, Jamkhed and so many others). They all have in common bottom-centered, gender-sensitive, empowering approaches and a political choice to tackle the underlying deep roots of poverty, injustice and ignorance. Many organizations have championed causes such as the one proposed here (mentioning some would do injustice to the others), but evidently the effort has not been enough to the tenor needed to achieve global impact.
Note that the route suggested by this (clearly not) new vision requires we break with the old development paradigm; and this means stepping into many vested interests’ toes.
We are in for an exciting new era. We need all the courage we can muster. Wouldn’t you rather become a protagonist than a bystander?
References:
Bracho,F., 1990, The common cause for worldwide sustainable development: A Southern view, IFDA Dossier 75/76, Jan/April, pp.63-67.
Gitlin, T., 1988, After the thaw, Tikkun, 3:6, Nov/Dec, pp. 50-53.
Harman, W., 1989, Redefining global development, Development Forum, XVII: 2, March/April, p.21.
Langley, W.E., 1989, Liberation theology and the politics of transformation, Transnational Perspectives, 15:1, pp. 23-29.
Mc Dermott, W. B., 1989, The forbidden agenda, Transnational perspectives, 15:1, pp. 6-8.
Myers, N., 1987, New Economics, No. 1, March, p.8.
Schuftan, C., 1982, Viewpoint: Ethics, ideology and nutrition, Food Policy, 7:2, pp. 159-164.
Schuftan, C., 1985, Hunger and malnutrition: Outlook for changes in the Third World, J. of Trop. Pediatrics, 31:6, pp. 299-300.
Schuftan, C. 1988, Multidisciplinarity, paradigms and ideology in national development work, Scand. J. of Dvpt. Alternatives, VII: 2 + 3, pp. 241-290.
Claudio Schuftan
Saigon, Vietnam.