37. Malnutrition and technical fixes

This month I remember the colleagues who coined the term ‘commerciogenic malnutrition’: Derrick Jelliffe and his wife Patrice (left and centre in the picture above). Derrick Jelliffe (born 20 January 1921 in Rochester, UK, died 18 March 1992 in Los Angeles) and his wife Patrice (1920-2007) were known to all of us who knew and worked with them as Dick and Pat. Dick’s charismatic leadership and Pat’s charm earned them many friends and admirers wherever they went, creating an international network of like-minded professionals and scientists.
The couple lived and worked in England, Sudan, Nigeria, Jamaica, Uganda and India. They were pioneers in tropical paediatrics and in infant nutrition. Already in 1962, Dick had published his Child Health in the Tropics. They are best-known for their jointly authored books Human Milk in the Modern World (1989), and for editing the multi-volume Advances in International Maternal and Child Health (1986). They ended their career in the US where Dick was a professor and chair at the University of California at Los Angeles (UCLA) where I had my closest encounter with him.
I had seen an advertisement for an associate professor in his department and went for an interview. I had met Dick earlier; informally, but he knew who I was. The interview turned out to be rather peculiar. He kept telling me I should reconsider my application because salaries in the Californian university system were uncompetitive. ‘You would come here, and we would love to have you, but it would be more for the prestige than for a decent livelihood’. I might have considered it, but it was a no-no for my wife Aviva.
The Jelliffes’ field observations triggered the so-called Baby Killers scandal and the Nestlé boycott They coined the phrase ‘commerciogenic malnutrition’ to refer to infant starvation caused by inappropriate promotion and use of infant formula and/or bottlefeeding in areas with poor resources and water supplies. Husband and wife became veritable champions of the protection, support and promotion of breastfeeding. Dick Jelliffe was the first effectively to identify the baby formula industry advertising and marketing as a major cause of the decline in breastfeeding.

In all this, Dick and Pat Jelliffe are as important in the history of public health nutrition as are Cicely Williams and Michael Latham. They studied the changing composition and properties of human milk, the contraceptive effects of breastfeeding, and the use of breastfeeding for rehydration. Charlotte Neumann of the UCLA school of public health has said that Dick Jelliffe ‘was the hero of all in international nutrition and health – he played a pivotal role in bringing paediatrics to Africa’.

Dick and Pat Jelliffe developed what amounted to a new science. Paediatric nutrition for the first time incorporated within it, aspects of social medicine and cultural anthropology. Dick was ahead of his time. Already in the 1960s he pointed out that hospital based high-tech medicine could not grasp the root causes of health problems in less-resourced countries. He was the founder-editor of the Journal of Tropical Pediatrics, and demonstrated that a quality journal can survive economically on the strength of its scientific content without having to depend upon advertising revenue.

At Makerere medical school in Uganda, beginning in 1959, Dick had his most productive period. In no time the paediatric department at Makerere was being counted among the top 15 in the world. He can be credited with giving paediatrics and nutrition a prominent place in the curriculum of medical schools. He personally educated and trained a cohort of paediatricians from almost every East African country, most of whom returned to their countries to become leaders.

Although born in England, Dick later became a US citizen. From 1972 to 1985, he wrote a weekly column, ‘Science, Food and Health’ for the Los Angeles Times. His wit shows up in some of his titles, such as ‘The humanization of bottle feeding – a non-starting concept’. I now continue this month’s column in what I hope is the spirit of Dick Jelliffe, one of my mentors.

Food aid is essential in all cases of acute emergency, as medicine is needed
to treat disease. But only structural approaches will lift people out of poverty

The main approaches to tackle malnutrition remain ‘technical fixes’. This despite the universally accepted concept that the causes of malnutrition have three distinct levels, underlying and basic as well as immediate, and that acting on each level is necessary, but is not sufficient. Technical fixes for the most part involve or combine making available money, equipment or medical-type interventions. These may be vertical, top-down ‘silver bullet’ approaches, typically emphasising one nutrient or health action, and not perceiving the bigger picture. When carefully and expertly administered, technical fixes often work – in the short term. But this is not necessarily for the reasons proposed. For instance, foods may be administered that are high in a certain ‘silver bullet’ natural or added micronutrient, which naturally contain many other nutrients.

In my experience, and that of many and perhaps most fellow colleagues who live and work in the global South, or who have extensive field experience, any type of technical fix does not and cannot work over a longer period of time. This is above all, for two surely very obvious reasons. One is that the root cause of malnutrition at population level is poverty. When people remain impoverished they are most likely to remain malnourished. Two is that another basic cause of malnutrition is the lack of the type of information and awareness that will eventually enable impoverished and malnourished communities become organised so that they take action to protect themselves.
It is only when impoverished and exploited people see why their communities are suffering from malnutrition, that they can become empowered to struggle for their rights. Of course, all is not as simple as this may sound. In countries, regions and localities that are severely impoverished and marginalised (and this includes inner city and other areas in the global North as well), governments have a duty to intervene, with aid agencies also having a role to play. But my experience and judgement is that such actions will only continue to work well if they enable and empower the people most affected to lift themselves out of immiseration.
Ever since the discovery that microbes are an immediate cause of some diseases, and then the development of antimicrobial drugs, government officials and other policy-makers have searched for and sometimes thought they have found technical ‘silver bullets’ to ‘win the war on world hunger’. This paradigm still strongly influences what remains the dominant global North-led aid and development philosophy and practice. One such silver – or golden – bullet is throwing money at public health problems. This, more often than not, does not reach the people who need it most, especially when what they most need is sustained income generation support. Another silver bullet is food. But more often than not, it takes the form of surplus production in the donor country which, when donated in large quantities, messes up the local staple foods price structure with dire and even devastating consequences for local farmers and growers.
Just as medicines are needed to treat serious diseases, of course food aid is essential in situations of famine and acute severe deprivation. But unless food or other material aid is just one part of broader programmes, the underlying and basic causes of malnutrition will continue to prevail, and the people most affected will become dependent on external supplies that are not sustainable. What they need is solutions that help them fend for themselves with appropriate people-centred support from their local and national governments.

Any form of ‘silver bullet’ and other technical approach addresses immediate and sometimes underlying causes of malnutrition; but not basic, structural causes. These include poverty, and indeed the causes of poverty, which include bad governance, gross inequities, abandonment of public services, land misallocation, cities with inadequate infrastructure, insecurity ranging from delinquency to incessant wars, and ignorant or corrupt politicians and officials. Policy-makers and donors often brush such issues aside or see them as immoveable. But in such circumstances food and other aid can make bad worse.
Political abracadabra
Donors especially in the global North, often act as if conclusions derived from the collection and manipulation of statistical data will lead to effective planning and action, irrespective of the actual local and national circumstances. In this way, public policies and actions are determined by methodologies devised by experts far away from and ignorant of the populations they are supposed to serve. Derrick Jelliffe himself observed that (like money, or science in general) statistics is a good servant, but can be a bad master. He liked to point out that statistics was originally termed ‘political arithmetick’ by founding fellow of the Royal Society William Petty. Another term might be political abracadabra.
Use of sophisticated quantitative techniques, including in the field of nutrition, results in gross oversimplification of reality and in abstract analyses. Coding of information for scientific purposes involves reducing human nature to a few basic characteristics. Beware! This reductionism leads to biased conclusions that are typically neither rational nor sensible. Use of such superficially impressive data leads proponents of the ‘efficiency-above-all’ school to ignore the consequences of the actions they propose and help to implement. The results are more often than not disastrous. Technocrats often complain that the fault lies with ‘political impediments’ that prevent them from implementing the collection of policies and actions that they advocate for. In fact, these ‘impediments’ usually are the actual circumstances that, away from the computers in which numbers are crunched, we all live with.
The dominant ideology now is one of ever higher ‘techno-expectations’. Super-technology, controlled by ‘masters of the universe’ in Big Government, Big Business and Big Science, is positioned as the way to greater freedom and equity – not to mention fame and wealth. We all know now that this approach has not worked. It never could have worked. In the case of malnutrition, the ingrained poverty of populations that are the subjects of intervention rarely crosses the minds of privileged and wealthy people, who include the elites in impoverished countries. These groups have vested interests in the spread of technology, including that which now controls food and agriculture systems. Follow the profits.
I go further. Endorsed by the establishment that pushes technical fixes, the governments of the countries that receive aid do so in order to reduce pressure for political and economic changes that would make for more open and democratic societies. It was ever thus, except now the bread come by truck and the circuses are on television. By pushing for external food and other aid, politicians and officials in the recipient governments merely prop up their political survival and evade making serious, sustained attempts to reduce inequality and injustice.
To say yet again, the basis of population ill-health and malnutrition is the disempowerment of the people. This fundamental issue is ignored and, instead, endless new ‘band-aid’ programmes are used. As long as governments have ‘something to show’ in the form of new buildings, new equipment, and optimistic reports with pictures of smiling grateful faces originated and endorsed by the aid agencies, foreign support continues to flow.

‘Silver bullet’ top-down interventions using money, food or nutrients should be effective short-term but do not address the basic causes of malnutrition
As opposed to what many donor agencies want us to believe, general improvements in nutrition in the last 30 years mean that the era of technological breakthroughs in impoverished countries, especially in the global South, has almost or completely ended. Programmes that still use technical fixes packaged with slogans such as ‘The Child Survival Revolution’, ‘Adjustment with a Human Face’, or ‘The Social Dimension of Structural Adjustment’, are almost or entirely useless.
Reduction of the development process merely to the injection of more capital is equally futile. The global North aid and development superstructure that offers health, nutrition and other development aid, conditioned on the cooperation of the elites in the global South, displaces more radical options with a real chance of sustained success. A reason for this is that such options would involve lessening of inequities as a result of which the current elites would lose some of their economic and political power. The dominant foreign assistance policies and programmes are driven by the ideology of economic globalisation intrinsic to which is greater reach and power for transnational corporations. Under this guise, food and other systems become increasingly centralised in ways that make less-resourced countries increasingly vulnerable and impoverished.
Under the influence of the global North-led development paradigm, much of the global South has largely lost its own creative self-assurance, because of thinking and still continuing to think that the global North knows better. This depressive view is now changing in many countries, notably in Asia and Latin America. Many of us believe that the People’s Health Movement, to which I belong, is making a difference, as are the networks dedicated to protect breastfeeding throughout the world, in which the Jelliffes remains an inspiration.

The benefits of breastfeeding are now being promoted all over the world, including in New York City (left) and also in sub-Saharan Africa (right)
May all this change as the time of the Millennium Development Goals comes to an and in 2015, as part of the new global development agenda now being drafted? Is there a realistic alternative to the global North-led development paradigm, with its focus on technical fixes? I think there is, but one answer is that there is no single alternative. True, there are principles that we professionals need to live and work by. Putting these into practice depends on encouraging the people most affected to become actively involved; and for that they need to be empowered, to take the lead, and to demand new conditions that will, once and for all, enlighten their ways of life and being. In development work nothing is black or white. In many of the ‘grey areas’ there are health professionals and community leaders fighting for meaningful local and higher-level changes.
Much remains to be done before equity-oriented, community-centred, genuinely sustainable development systems are given real top priority and are given due recognition at international and national levels. But this is the way forward, most of all in the global South. Let’s now finally turn away from technical ‘silver bullet’ approaches. It cannot be said too often, that by their very nature these have never been, never are, and never will be sustainable. One sufficient reason is that they do not and cannot engage and energise the people who most need support.
What is needed now is an effective networking of like-minded organisations, movements, professionals and citizens, the world over. This is imperative to overcome false hope forms of development. It is also essential in order to counter globalisation in its present form, which is making inequalities worse, increasing deprivation and poverty, and draining resources from the global South.
In our work we need to learn lessons from good and socially conscious practice, and from inspiring examples such as those of Dick and Pat Jelliffe, Cicely Williams, and Michael Latham. These heroes have passed on now, but their influence continues to grow, thanks to their legacies in the form of the World Alliance for Breastfeeding Action and the International Baby Food Action Network. These are global activist networks that empower communities and mothers in the global South such as in Africa (right, above) and that have encouraged legislators in many parts of the world, including in New York City (left, above) to pass laws that fight obesity and make breastfeeding the social and cultural norm once more.
Let’s keep thinking, writing and acting together and making good use of electronic communications to build a better world.