Human rights: Food for adopting an undeniable thought ‘Macro causes are the constraint’
Human Rights Reader 490
Macro and micro causes of malnutrition
1. Here I attempt to look at how we can identify the major causes of hunger and malnutrition, review the principal characteristics of these determinants, and explore how we can convince others (peers, claim holders and duty bearers) of the implications for action that the profound understanding of these causes has, especially in terms of our attitude towards them as committed professionals active in different disciplines and contexts.
2. The Reader examines malnutrition (undernutrition) as the biological translation of a social disease with historical roots –the latter having determined the social and economic conditions that have lead to the malnutrition we find (not by chance) in a sector of the population. The analysis here presented will lead to the macro determinants of the violation of the right to nutrition. The more immediate causes responsible for malnutrition will here be called micro determinants.
3. Most macro determinants of hunger and malnutrition are conditioned by the overall policies that govern national economics (both internally and in foreign relations and trade). Macro determinants are only seemingly indirectly related to malnutrition. They are always related to international, national, and village level constraints. Macro causes explain most malnutrition in societies with capitalist modes of production. Malnutrition or nutritional vulnerability is a manifestation of a society’s inability to protect the livelihood of all its citizen –not because of overpopulation, or because agricultural productivity is not sufficiently high, but because ‘underdeveloped societies too often struggle for the livelihood of their own people by producing the livelihood of other societies’.
4. Macro causes usually relate to the major dialectical contradictions in a given society, especially in the agricultural, the food and the health sectors. Macro causes imply objective constraints to meaningful changes.
5. If one were to characterize macro determinants negatively, one would say that they correspond to those causes of malnutrition that are not removed or even touched by traditional nutrition intervention programs. In the long run, the fight against hunger and malnutrition, and against the violation of the right to nutrition thus becomes an eminently political struggle and not a technical one. Technology cannot achieve the fundamental structural changes needed to end hunger and malnutrition.
6. Removal of a few (or even one) of the main macro causes is more likely to alleviate malnutrition than acting on many micro determinants simultaneously. Nowadays, macro determinants are very frequently mentioned and identified by planners analyzing specific situations, but the plans they devise seldom tackle these determinants frontally.
7. Micro determinants are purportedly more directly related to the physiological condition of malnutrition. They include health, environment, and educational determinants, which are those most frequently identified and selected for direct intervention by Northern development planning approaches. In the past (and present), emphasis on this technical approach to nutrition planning has also justified the need for Northern-trained experts who often come with ready-made analyses …and solutions. Every expert brings her/his own view of development, and the suggestion for development programs will reflect their ideology.
8. Taken together, any attack on micro determinants only leads to a package of solutions or interventions that pretend to be apolitical and free of ideological connotations or influence. However, despite the fact that the spectrum of choices is a continuum, in the final analysis, one either bows to the system or objects to it, totally or partially. Any of these are political stances.
9. Nutrition workers keep inventing new ‘more comprehensive’ or ‘multisectoral’ approaches to old problems –as if these would change the major contradictions and the distribution of power within the system that is causing the problems to begin with.
Diagnosing the causes of the violation of the right to nutrition
10. It should be clear that we cannot agree on the content of nutrition planning if we do not share the same understanding of why people have been rendered poor and malnourished. Different socioeconomic contexts call for different nutrition planning approaches. 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 a mix of macro and micro determinants.
11. The challenge for the planners is to determine, in each national (or regional) context, how much and what kind of macro changes are necessary for the micro changes to have some prospect for success. The connections between macro and micro causes must be made explicit so as to justify the needed macro changes. This unequivocally means that any plan or program geared to ameliorating malnutrition as a public health and social problem will have to be participative and will have to include a mix of interventions designed to affect change in both macro and micro determinants. For example, technical measures in themselves are not tools for income redistribution (or disparity reduction!), but they may have a partial redistribution impact as a side-effect, assuming that they reach the lowest income groups.
12. In this context, the role of the nutrition planner (activist?) is beyond doubt a delicate one. Sensitization, empowering and accountability skills are perhaps more important than technical know-how. The type of strategy or plan that should follow a comprehensive participative situation analysis should be geared, first, to defining a set of specific activities directed to address and remove or minimize the effect of micro determinants, a classical approach, indispensably followed by a critical estimation of the potential of such a ‘package’ of interventions to solve or address the major problems of hunger and malnutrition. It is here where the inputs of claim holders is absolutely crucial.
13. A list of the macro causes should be jointly identified and a brief analysis made of why and how each one of them contributes to the persistence of malnutrition, so that anybody can understand these links. A list of possible interventions should be prepared that aims at removing some of the structural bottlenecks or constraints that are ultimately determining a state of chronic hunger in defined sectors of the population. To repeat, all this cannot be done on a top-down fashion! Both claim holders and duty bearers need to be involved.
14. The similarities between poor countries being many, the following are just some examples of national-level manifestations of macro causes:
• low percentage of national income received by lowest 20 percent of the population (income maldistribution);
• land maldistribution;
• high percentage of landless agricultural laborers;
• rural unemployment;
• urban migration and urban unemployment;
• low minimum wage policies in all sectors of the economy, not in tune with the cost of a minimum diet and not following food prices inflation;
• low farm-gate prices for food crops as opposed to their urban retail prices and/or produce marketing boards’ exploitative practices towards small farmers;
• imbalance between cash and food crops (land allocation and incentives);
• low percentage of foreign export earnings reinvested in agriculture;
• food import policies contradicting national efforts to increase local food production;
• neglect of the primary sector with the share of agriculture in the national GDP slipping in favor of the secondary and tertiary sectors of the economy;
• credit bias towards the modern agricultural sector as opposed to the traditional agricultural sector;
• lack of agricultural input subsidization for small farmers, especially for food crops;
• foreign aid not reaching the neediest;
• women left outside development programs with little incentive to incorporate them in the money economy;
• little emphasis on the scanty budgets for genuine community development and for rural cooperatives;
• low primary school enrolment rates especially for girls;
• feeble efforts to increase adult literacy, especially for women; and
• scanty budgets for preventive health services.
Proposing solutions
15.Malnutrition as a social disease cannot be cured through medical interventions (not even in a wide comprehensive package) nor can it be cured through the latter plus a package of agricultural interventions.
16. Redistribution of resources and the consequent increase in purchasing power of the lowest income group is a necessary, though not sufficient, solution to the problem of hunger. Moreover, poverty wears many other masks (social determinants), e.g., cultural and educational deprivation, poor health, inadequate sanitation –and each mask has its own features. We should not be tempted, through lack of perspective, to try to improve only the features of the masks, without doing anything about the real face of poverty, which primarily is socioeconomic deprivation.
17. Many planners have divided the remedial actions they finally propose into two groups: recommendations and interventions. The former, which often concern macro determinants and the need to change or remove them, are worded in very vague, general terms and have no specific implementation budget set aside; the latter, which often concern micro determinants, are prepared in more detail, have a fixed implementation deadline, and are usually budgeted-for.
18. The frankness with which planners state the need for corrective measures directed at the macro determinants will depend on the political environment in which they are working. Political and professional risks are usually high, and many planners feel that their positions in academe, government, or international or private organizations may be jeopardized if they demand radical solutions. They take a ‘survivor’s’ attitude –and this is disturbing. We actually 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.
19. Macro determinants can be exposed in a number of ways, not all of which are dramatic or sensational. For example, the possible interventions that flow from the analysis of the macro determinants could be listed under a title that could read something like. “Conditions under which Interventions Addressing the More Immediate Causes of Malnutrition Will Have a Better Chance of Having an Impact.” This should be followed by a subjective estimate of the potential of each macro intervention to ameliorate malnutrition. The idea is to compare and contrast the potentials of the latter with the potentialities of the package of micro interventions to achieve the same or similar goals. In other words, what this kind of a presentation tries to emphasize is that if macro determinants are removed (or minimized) interventions that follow such removal and that are geared towards removing micro determinants stand a much better chance of having a real and lasting impact.
20. The above is the gentlest way of making this point clear. There are many other, more direct ways, of highlighting the need for structural changes to eliminate the violations of human rights. This Reader has hammered some of these over the years. Political and ideological constraints, as well as the attitude and commitment of decision makers towards eradicating all human rights violations, will determine how far development planning teams can go to address what is here brought up.
21. The major problem with this approach is that it may look too politically radical to some governments. If this is the case, then the particular governments are most probably not genuinely interested in solving the problems at hand. But this may be difficult to determine, given the frequency with which governments pay lip service to their commitments.
22. At the very least, a presentation such as the one proposed here has an educational value, especially if it is documented with some hard evidence (things that politicians and decision makers have probably known all along, but ignored). We sometimes wrongly assume that decisions makers are rational, righteous, and pious and will accept hard scientific evidence or react to outrageous injustice…
23. Technicians who have participated in the planning process may gain a new consciousness as a consequence of using this approach, a fact that is of value per se and that makes the effort worthwhile.
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
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