[A reaction to Dr James Levinson’s 10th Annual Martin Forman Memorial Lecture, (SCN News No.15, Dec.1997) presented, as the original lecture, in the form of a letter to the student Erica who is planning to specialize in international nutrition, (published in SCN News No.16, July 1998)]
Dear Erica,
You probably did not expect that a concerned question of yours to professor Jim Levinson would propel you to some notoriety. Your question allowed Dr Levinson to go into some depth on what has worried nutrition workers for many years, namely how we are doing in international nutrition. Over the years, many of us have shared this concern. Reading his response to you I could find much that I identify with. But I also found things in which I have a slightly different view. (As you recall, Dr Levinson sent out a survey to many of us around the world working in operations/programs/policy/research/teaching/and or training). I thought that the things in which I disagree with him would help you even better to judge what you are planning to get involved in in your future career. That is why I am writing you this follow-up letter.
What I read from the results of the quick survey Dr Levinson carried out world-wide is sometimes different.
I was one of those (20%) who did not share the feeling that international nutrition was much healthier today than it was 10 years ago. I also was of the opinion that the academic training we are giving our new graduates in international nutrition was of limited relevance, perhaps more so for students from the developing countries, especially if trained in universities in the North (where they have to go through core curricula that include courses of no relevance to them).
Judging the most important advances in nutrition in the last 10 years, the survey respondents chose advances in reverting micronutrient deficiencies. This came as no surprise. Most nutritionists still like ‘silver bullet’ fixes, primarily because they move within the technical realm -a realm in which they feel more at home and more ‘in command’. But, at its roots, PEM is more of a political problem: it is the biological translation of a social disease. Of the four next choices for important advances that were chosen, I can agree with two: greater community involvement in programs, and increased attention to care practices addressing women and children. But for the other two, I have slightly different interpretations: It is not that we now have a ‘better’ understanding of the causes of malnutrition; we have rather reached a point in which we have convinced more people about the ‘correct’ conceptual framework of the causality of malnutrition, one that considers malnutrition an outcome of those different levels of causality.
Further, I disagree with the argument that we have achieved better designs and management of nutrition interventions in the last ten years. It is argued that this has led us to significantly better resolve the problems of PEM. To me, design and management are not the main constraints our nutrition interventions have had in the last 10 years. The main top-to-bottom, often palliative, thrust of them has been (and still is) the main constraint. I was definitely surprised, Erica, to read the next major advance chosen by respondents: ‘greater sensitivity to the importance of nutrition counselling’; this just shows the ethnocentric bias of the respondents…..as if ‘counseling’ would solve the problems of poverty and inequity…
The same bias can be found when respondents chose ‘reduced funding’ as the major problem or constraint to achieving better results in the battle against PEM. If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!
I am sorry, Erica, to disagree not only with the respondents, but also with Dr Levinson on the centrality of the issue of ‘interagency infighting’ in our work in international nutrition. It exists, and it is a disappointment, granted. But it is not the main obstacle to a faster progress (see below). The issue of a ‘lack of commitment by governments to meaningful nutrition interventions’ was chosen as another major obstacle. But this argument has been made too often, always keeping it as a blanket statement, almost as a slogan. It is time we analyse this in more depth; only then will we learn how to tackle it better. (1)
Further, I do agree that ‘bureaucratic problems in getting things done’ are a great burden. In this, I am a rather new full convert after having just worked 3 years in Vietnam, a country where the politics are right, but the bureaucracy is simply slow.
Jim Levinson concludes from these responses above something that I cannot agree with. He says that this shows that ‘the major negative factors faced in international nutrition are not…structural… constraints, but rather problems that the nutrition community…. can…control’. I could not disagree more. The major negative factors I think are indeed structural and related to the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to revert malnutrition on the scale that is needed. (2)
It s the grassroots ‘pull’ that is missing; and we are not pushing it decidedly enough.
As an example of the factors that we as members of the nutrition community can control, Jim Levinson comes back to the issue of infighting. On this, I contend with others that none of the agencies that are the protagonists of this infighting are in the path of real empowering and sustainable changes that have a chance to win the battle over malnutrition! The fight is indeed related to issues of control, egos and ‘old boys networks’, but there are also a number of genuine, ‘honest, above-board’ points of contention amongst them, some of them clearly ideological, and on issues of real empowerment beyond lip service. The question is whether this infighting is really having an irrefutable negative impact on how sustainable what actually gets done in the field is. I do not think so. There just are no real good role model official agencies out there. Your generation, Erica, will have to give them new, bolder directions. Development agencies -UN or other, donors or not- are simply not immune to the political discourse, and some, in my opinion, just plainly deserve to be undermined (as long as they keep those conservative, outdated positions). We cannot ‘expect better’ from agencies for the mere fact that they are involved in nutrition…
Your professor, Erica, then goes on to make the confession that he himself thinks he has been dogmatic and inflexible in the past. There is a flaw in this statement. Political stands one takes based on adopting an ideology. (3) This puts one in contradictions with proponents of a different ideology. We do not adhere to our positions as the ‘only’ position, but as (what we dearly hold as being) the right position; that is what we stand for. (4) There is nothing wrong with thinking that you are right each time you enter into a dialectical discussion, even if your position shows to have been wrong later on -as long as there is an ideological consistency in your having taken that position. Dialectics is about change, and this includes recognising and amending your own mistakes.
The interagency struggles we are here talking about are often disguised as technical, but are actually political and ideological and often address issues of paradigmatic changes…are we sure there are that many common goals to pursue together by these agencies? I repeat, we have to look at it as a dialectical struggle.
By now, Erica, you have guessed that the politics of it all is at the very centre of international nutrition. With this fait accompli, it should be clear that you cannot escape the responsibility of taking a political stands on nutrition yourself. This will help you to question your own current education, as well as all that you see out there in the job market that is waiting for you shortly.
As relates to the question whether international nutrition has become ‘too narrow in its focus’ (less concerned with the socio-economic determinants of malnutrition) I agree with the majority that thought that this was the case. The question though is whether it has become/or it has most of the time been too narrowly focused beyond lip service; I’d vote for the latter. The mixed response received on this question, Jim Levinson suggests is due to ‘some genuine ambivalence on the subject’. I beg to disagree: it is not ambivalence; it reflects the ideological split of respondents. What this points at dramatically is at the (tabu) question that the survey omitted: “How would you classify yourself politically?’’ Why was this not asked in he first place? If it had, it would have led to the really most interesting cross-tabulations in the study. (5)
It is said, Erica, that on micronutrients and breastfeeding ‘concrete achievements are possible’. This is precisely the silver-bullet-type option many of our colleagues chose. What tells us that ‘addressing tougher intersectoral (underlying) issues’ is less likely to lead us to concrete achievements if we put all our hearts to it? You see how easily we can get biased? We need to avoid nutritionists in your generation running away from the more difficult choices and challenges in the battle against (the real) malnutrition.
As relates to incorporating nutrition into larger development perspectives, I see the issue not as being one of ‘nutrition keeping or not keeping its own identity’; I see it as nutrition being (for us) the powerful point of entry to the bigger picture where it rightfully belongs according to the conceptual framework of the causes of malnutrition. (6) Nutrition will indeed keep its identity in such an approach! To be taken seriously, I contend, nutrition has to become a strategic ally in the big picture of development; if it stays territorial, it will miss the boat. (7)
Further on, the respondents were asked to rank international agencies in terms of how they had served the field of international nutrition. UNICEF came out on top and FAO at the bottom. Low rankings received by agencies we thought major nutrition actors, do not necessarily mean they lost their funding or now have a lesser commitment to work in international nutrition; it rather reflects that they probably are perceived as having embraced the wrong approaches to solve malnutrition in the last 10 years (perhaps those that were too sectoral?). Lower current funding, in my view, reflects nothing more than one more swing of the pendulum that has affected international nutrition funding following the fashion swings in the thinking of the international community. (Or is it that we have little to show for for the increased funding we enjoyed in the last few years…?).
Dr Levinson is right, Erica, when he tells you that the current state of affairs in international nutrition ‘will pose increasing frustrations and challenges’ for you and your generation. My doubts though come from looking at how politically unintersted your generation (particularly of students in North America and Western Europe) has become. If you are one of them, don’t worry, you will not face increasing frustrations and malnutrition will continue to plague this world in the years to come.
Those who ‘argue that international nutrition has had its days, that it is no longer in fashion’ may be right, after all. But this is because it may have been irrelevant in global terms in reverting trends of (again) rising malnutrition rates. It is just tough trying to beat the gigantic odds of globalization, structural adjustment and expanding market economies that have no room for the poor. As for having been a passing fashion, this actually serves us well: international nutrition cannot be a passing fashion, Erica! We invite you to join in. Dr Levinson argues that ‘the world turns its back on problems like these at peril of its very humanity’. But then, who said that globalization, structural adjustment and the market are humane…?
In closing, Erica, Jim Levinson conveys to you his confidence and optimism that our work has the ability to make a difference. The question is which difference. Pat solutions will do no more. (8) It is not a matter of an increasing number of activities in international nutrition starting to take place again in developing countries; it is the matter of what kind or type of activities. Issues of inequity are at the base of the problems at hand. And if nutrition is used as a port of entry to revert such inequity, I would share his optimism. But we need your upcoming generation, Erica, to get the job done. This is what expects you if you decide to join us. I see your role as a potential ‘instrument of change’ in slightly different terms than Dr Levinson sees it in his closing lines. You will, by now, understand that what motivates us (and you) depends on what we (you) stand for. The range is from the ethical to the political, from romantic approaches such as those of charity and the desire to help the needy, to the political approaches that attempt to fight inequities and injustice by empowering people to fight for their own rights. (9) But many of our commitments wane as we get older, Erica; so do the bold as you are young. The sky is the limit.
Dr Claudio Schuftan, schuftan@gmail.com
Saigon, Vietnam
[References available upon request]