From Claudio Schuftan, Ho Chi Minh City, Vietnam

The recent Lancet series on Maternal and Child Nutrition has been criticised, in these columns (1) and elsewhere (2,3). My concern here is with the fourth paper in the series, on ‘The politics of reducing malnutrition’ (4). This includes a series of ‘key messages’, which need responses, as follows.

Key message. ‘Emerging country experiences show that rates of undernutrition reduction can be accelerated with deliberate action’.

Response. But the actions highlighted in the paper and the whole series, are mostly technical interventions. These do not address the underlying and basic causes of any type of malnutrition.

Key message. ‘Politicians and policy makers who want to promote broad-based growth and prevent human suffering should prioritise investment in scale-up of nutrition-specific interventions, and should maximise the nutrition sensitivity of national development processes’.

Response. But most politicians and policy-makers in powerful countries are not interested in addressing the fundamental, structural causes of malnutrition –as the authors of the paper surely know. And what is ‘maximise the nutrition sensitivity of national development processes’ supposed to mean?

Key message. ‘Findings from studies of nutrition governance and policy processes broadly concur on three factors that shape enabling environments: knowledge and evidence, politics and governance, and capacity and resources’.

Response. Politics and governance come first though. By themselves, knowledge and evidence get nowhere.

Key message. ‘Framing of undernutrition reduction as a political issue is short sighted and self-defeating. Political calculations are at the basis of effective coordination between sectors, national and subnational levels, private sector engagement, resource mobilisation, and state accountability to its citizens’.

Response. Of course sustained prevention and reduction of undernutrition, including hunger and starvation, is a political issue in the sense of requiring appropriate policies. Nothing short sighted and self-defeating here. Beware that ‘political’ is often a code-word used by some colleagues for ‘ideology with which we disagree’. Well, undernutrition and its fundamental causes is certainly an issue for the ideology with which they disagree. On the other hand, if the politics of policy-makers for ideological reasons includes partnerships with Big Food, those sectors of industry whose profits depend on products that damage public health, little or nothing will be achieved – more likely, bad will get worse.

Key message. ‘Political commitment can be developed in a short time, but commitment must not be squandered – conversion to results needs a different set of strategies and skills’.

Response. To the first sentence – oh, really? One example please, of real quick commitment, not mere lip-service. True, commitment to implement batteries of technical treatments imposed without consultation of the bearers of the right to nutrition can be done quickly, as shown by the Scaling Up Nutrition initiative. But will we agree on the set of strategies and skills needed?

Key message. ‘Leadership for nutrition, at all levels, and from various perspectives, is fundamentally important for creating and sustaining momentum and for conversion of that momentum into results on the ground’.

Response. Yes, indeed. But let’s think about what ‘leadership’ means. It’s not just shown by it being top-down emanating from a politician, as so many seem to think. True leadership is a lot of work. It involves risk and pain, comes from and through the people most affected, and works for structural change.

Key message. ‘Acceleration and sustaining of progress in nutrition will not be possible without national and global support to a long-term process of strengthening systemic and organisational capacities’.

Response. True, depending though on what ‘systemic and organisational capacities’ the authors mean.

Key message. ‘The private sector has substantial potential to contribute to improvements in nutrition, but efforts to realise this have to date been hindered by a scarcity of credible evidence and trust. Both these issues need substantial attention if the positive potential is to be realised’.

Response. The problem with the woolly term ‘private sector’ used here, is that in practice it refers mainly to Big Food – the transnationals whose profits depend on unhealthy ultra-processed products like sugared drinks and burgers. Here there is a great deal of credible evidence that such corporations cannot be trusted to be part of improving public health. Why should they and how could they – this is not their business, which is to make more profits and thus serve their shareholders and financiers. Let’s get real.

Key message. ‘Operational research of delivery, implementation, and scale-up of interventions, and contextual analyses about how to shape and sustain enabling environments, is essential as the focus shifts toward action’.

Response. Impossible to be sure what this means. Yes, the people engaged need to check what they are doing and if that really works. Mind you, the latter means that long and sustained impetus must come from empowerment of the people most affected.

This Lancet paper, like others in the series, and most other reports and papers on the prevention and control of malnutrition of all types, assumes that the answer is more and more transfer of financial, material, medical and human resources from on high. But surely we all know by now that this type of approach by its nature can be no more than palliative, and worse, tends to perpetuate dependency, inequity and immiseration.

We should be very suspicious of glossy prospectuses and reports produced by ‘aid’ agencies, charitable foundations and the micronutrient business, showing smiling children and grateful parents in ‘the developing world’ and what are now known as ‘emerging countries’ or ‘LICs’ (‘lower-income countries’). Malnutrition of any type cannot be conquered by training more health personnel. Malnutrition in all its forms is a social disease. It is the duty and responsibility of all of us engaged in public health nutrition to know this and to act on that knowledge.

Claudio Schuftan
Ho Chi Minh City, Vietnam
Email: cschuftan@phmovement.org

References
1. Gupta A, Rundall P, Jonsson U. Conflicts of interest. Maternal and child nutrition. Big Food and Big Science. [Feedback]. World Nutrition August-September 2013 4, 7, 570-577.

2. Nandan T. Malnutrition: public concerns, private solutions. Lancet’s pitch for engagement of private players to fight malnutrition divides top policymakers in India. Governance Now. 1-15 August 2013. Access pdf here

3. Sachdev HPS, Gupta A, Kapil U, Choudhury P, Dubey F, Shiva M, Bansal C. Statement. Policy implications of Lancet series on nutrition, 2013. Guard against commercial exploitation of malnutrition. Open letter. June 2013. Access pdf here.

4. Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N, and the Maternal and Child Nutrition Study Group. The politics of reducing malnutrition: building commitment and accelerating progress. The Lancet 2013; published online 6 June. http://dx.doi.org/ 10.1016/S0140-6736(13)60842-9

Schuftan C. Maternal and child undernutrition. Technical fixation [Feedback]. World Nutrition October-November 2013, 4, 8, xxx-xxx