Claudio Schuftan
En route to Kinshasa. Consulting work is catching up with me once again. This time I will spend a week in Kinshasa (Democratic Republic of Congo) as part of an evaluation I am doing of a local NGO, Etoile du Sud, that is implementing a three-years grassroots human right to health initiative. From what I have read so far, they have done a terrific job at mobilising communities to claim for their rights. I am excited, because I will be able to interact with the popular base of the NGO to assess how they have identified and prioritised the barriers to health they face. Logically, this will allow me to further know what they have done to remove or ease them, especially how they have mobilised the community for that. Key for me will be to find out what capacities have been strengthened for this work and to assess whether these new skills have contributed to sustainability. Few right to health projects have already been implemented for three years and little of what they are achieving has been reported. I will be able to share more next month.
Fittingly to this assignment I am about to embark in, I dedicate this month’s column to the unforgettable late Dr Cicely Williams whom I had the pleasure of meeting in person several times and even had her home for dinner a couple times in the late 1970s. To me, she epitomizes a colleague who can be rightly called perhaps the first public health nutritionist. What I admired most in her in my early career days was that, although she was deeply involved in clinical care, she never stopped having very clear what the ‘big picture’ that explained scandalous levels of morbidity and mortality was. And that is what I am devoting this months column to. But first, a short biography.
Cicely Williams was born in 1893 in Jamaica where she attended school. During World War I in 1914 she started to take First Aid and nursing classes and thought seriously about studying medicine. In 1916, after her father‘s death she decided to go to Oxford. She was one of the women admitted because there were so few male students during the war. After graduation in 1923, Cicely decided to specialize in paediatrics and soon applied to the British Colonial Office for an overseas posting. She was sent to the Gold Coast (now Ghana) in 1929 and spent 7 years there, learning to speak Twi and working to improve health conditions. She established clinics and hospitals and improved record keeping. She also worked with African herbal doctors to learn their treatments for diseases for which European medicine had no cures. Dr. Williams’ most important work in Africa was her diagnosis of the common and often fatal condition kwashiorkor. She learned that “kwashiorkor” meant the sickness the older child gets when the next baby is born. This seemed to indicate that, when they were no longer breast-fed, children were not receiving enough to eat. She quickly published her diagnosis of kwashiorkor as a protein deficiency disease, which attracted the attention of the medical world. In the late 1930s she was transferred to Malaysia. After suffering from terrible conditions and bad treatment during World War II in Japanese prisoner of war camps, which brought her near to death, she returned to Malaysia and was the first woman placed in charge of the maternity and child welfare services. She campaigned vigorously against the promotion by the milk companies of dried and canned milk as a substitute for breast-feeding in Third World countries. From the late 1940s to the mid-1960s she worked first with the World Health Organization, then as a university lecturer in Jamaica, England and Lebanon. She died in England in 1992. She is one of many outstanding Jamaican women who have received recognition for their contributions to the world’s peoples.
This brings me to share with you briefly what will be in the back of my mind as I embark on this consultation.
Factors such as foreign debt, international and national income mal-distribution, the exploitation and the commoditization of agriculture steered towards the production of cash crops, overt or hidden un- or underemployment and an array of other factors are some of the basic causes at the root of these two social diseases. Unfortunately, many of us do not even consider these factors in our work.
You and I have seen how many a development project has actually worsened the health and nutritional status of mothers and children. Examples are projects that favour cash cropping, introduce water-borne diseases through irrigation projects, or increase industrial pollution. In short, the social costs of development are unevenly distributed in most societies. Health benefits are mal-distributed following the skewedness of income distribution. By forgetting this, we keep dreaming we can revert the situation leading to ill health and malnutrition –if only we do our technical work better and more efficiently…
This does not mean that underlying and immediate determinants do need correction as they are more intimately related to inadequate food intake and preventable diseases. Actually, this is the area where most of us operate on a daily basis –implementing ‘solutions’– and where we feel more comfortable depending on our more specific backgrounds.
For example, many of us get involved in schemes providing incentives for staple and horticultural food production or in technical assistance to food producers (less so for women), in promoting food storage and preservation, in reorganising food marketing chains, in influencing food choices and food preparation, or in health and nutrition education activities. The problem is that through this route we often end up providing pat solutions that do not make any lasting dent on the global problem of malnutrition.
The actors: institutions, social groups and individuals
We need to re-examine where and at what level, each of us is mostly active-in in our attempts to combat malnutrition. Are we doing enough or anything at all at the underlying and basic levels or are we acting upon the consequences at the more immediate causal level? If the latter is the case, why do we continue to do so? Do we perceive the limitations of such actions when carried out in the absence of more profound structural changes? Have we chosen accommodation over confrontation? I have asked this often in my columns.
Institutions:
Judging from our perspective as public health nutritionists: Is not a good chunk of official aid from abroad doomed to at least partial oblivion from its very conception? How much foreign aid in rural development is actually only patching up the ‘holes’ of a process of an internal exploitation of the agricultural sector? International organisations often push development aid coming from their own preferences. These models are too often adopted by recipient countries, basically because they do not erode the power base of the ruling class still giving them an aura of commitment.
There are some institutions that are working towards a more equity-oriented development. True. Most of them are non-governmental organisations, both national and international. The more the latter are connected with work at the grassroots, the more they tend to be such an exception. That is why I am looking forward to my assignment in Kinshasa. Other NGOs, you and I know, do nothing but execute traditional western bilateral agencies projects.
Social groups:
A number of grass root organizations have begun springing up and taking fate and future into their own bands It is to this phenomenon and its potentialities that we should definitively be paying more attention at. (Hence my trip to Kinshasa). A new alternative is emerging. I am exploring it. Perhaps you may want to join similar efforts.
Individuals:
You know the mantra here: We legitimize processes with the wrong focus. Would leaving our ivory towers to participate in what is happening in the real world help?. The question here is: Who are we cheating? Ourselves? The people we pretend to work for? Both? So far, we have hit our heads against the wall often enough. We now need to come up with concrete and sensible recommendations and with a renewed commitment to see them through.
The methods and solutions:
Examples of interventions such as nutrition surveillance, long-term food aid, nutrition education, nutrition rehabilitation, community and family gardens, complementary foods and nutrient supplementation, among others are still high in the agenda of ‘packaged development programmes’. Many of these approaches have serious shortcomings, a few have been more successful.
- Nutrition surveillance has served more as an instrument to keep a log about or ‘chronicling’ the evolution of nutritional status (often deteriorating) and has seldom succeeded to put in motion commensurate solutions to reverse recorded negative trends.
- Non-disaster food aid has well-known disincentivating effects on local agricultural systems and entails logistical costs that need to be borne by the recipient countries.
- Nutrition education too often ends up teaching people to eat what they cannot afford.
- Nutrition rehabilitation, on the curative side of acute malnutrition, is probably a necessary stopgap measure. But, even after successful rehabilitation of severe cases, a number of the children die not too long after –a constant reminder of the unchecked underlying and basic determinants.
- Family gardens are a sensible alternative since they attempt to tackle the direct underlying cause of food shortages. Unfortunately they are not too often successful in the long run.
- Complementary food programs also have worthwhile elements in them, provided local foods are available and utilized for preparing the mixes in the household. Dr Cicely Williams, my hero of this month, played a key role in he area of breastfeeding and complementary feeding. Using imported or centrally produced products has had precarious results. (I do not have to remind you about the ongoing controversy here about ready to use supplementary foods –RUFS).
- Nutrient supplementation programs, i.e. iron and iodine, have a greater potential for impact. Nevertheless, they are at a totally different level when compared with the enormously more complex problem of tackling the problems and consequences of protein-energy malnutrition. (I do not have to remind you about the ongoing controversy here as pertains to supplementary Vitamin A distribution).
Even if we become conscious about the need for some structural interventions, it is difficult to find the appropriate channels to reach decision-makers and, much less, to influence prompt actions in that direction. We can share with them what needs to be done, but there is little chance of implementation. Perhaps the best way for us is to interact directly with community organizations to help them articulate their grievances and demand change.
Moreover, the kinds of interventions that are eminently equity-oriented, e.g., land reform, small farmer credit, price incentives to food producers, subsidization of agricultural inputs linked to labour intensive agriculture with high priority for food crops, equitable food distribution schemes, participatory decision-making are still distant from the radar of many public health nutritionists despite the fact that they are at the heart of what really could make a difference.
Epilogue:
We are left with the hard question of what to do?
Should we begin looking for global and local alternatives with the participation of those sectors for whom the present system has failed to provide sustainable solutions? If more work at the grassroots level is what is needed, what ought our role be in this task? How much effort do we need to devote to changing ourselves and our peers to assume such a role?
A discontent already exists among many public health nutritionists. How can we cultivate it positively for genuine changes to get underway? We can become change agents. We have science on our side; let’s not make the latter a liability. Let us redouble our efforts at communicating. To more decisively work with and for the people in dire need, on the ethical issues, we will agree. But can we get one step closer on the political economy of ill-health and malnutrition?
As public health nutritionists, we have come a long way. We have gone from emphasizing basic research to applied research; from there to multidisciplinary research (even accepting the social sciences into our work). Every step has undoubtedly widened our horizon and brought us closer to a more political view and understanding of the problems of ill-health and malnutrition. But we have not reached the point where we really get politically creative in our search for solutions. It is like the old philosophical riddle of the turtle trying to finish the race: At every instance, it hat first to go half the remaining distance to the end line before being able to actually get there. Therefore, it never arrives.
Nothing short of the equivalent to a second adolescent crisis will allow us to take that step. Are we living up to it?
Acknowledgment and request
You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.
Please cite as: Schuftan C. The political economy of ill-health and malnutrition. [Column]. March 2012. Obtainable at www.wphna.org
The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.
This column is reviewed by Geoffrey Cannon.
cschuftan@phmovement.org
www.phmovement.org
www.humaninfo.org/aviva
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