Sunday, 24 July 2011

MALNUTRITION: biological manifestation of a social disease

July 12th, 2011 by Claudio Schuftan
All lower-income countries need new generations of leaders in public health and in nutrition, with a new vision and energy. What about the even younger generation, of students who are already committed, perhaps passionately, to what they believe public health nutrition stands for, and who are planning a career – maybe a lifetime – in our profession? This column is addressed to them, in the form of a letter to a student. So:

Dear candidate,
So you want to join our guild of public health nutritionists. Good! I hope you will now allow me to give you a few words of advice, some of warning, some of encouragement.
I start with an issue that has worried public health nutrition workers for many years now, namely how we have been doing professionally in the international arena. Over the years, many of us have shared this concern. Before you embark on your professional journey, you need to see this and other issues. What we have experienced can help you better to judge what you are most probably going to get involved with, in your future career. That is why I am writing you this letter.
I am one of those who do not share the feeling that international public health nutrition is much healthier today than it was ten years ago. The academic training we are giving our new graduates in public health nutrition still often is of limited relevance. This is perhaps more so for students from the South, especially when trained in universities in the North, where they have to go through core curricula that include courses of no relevance to them.
In judging the most important advances in nutrition in the last ten years, many of our colleagues think these have been greatest in preventing and treating micronutrient deficiencies. This comes as no surprise. Most nutritionists still like ‘silver bullet’ fixes. These are ‘technical’, and the technical realm is the one in which they feel more at home, and more in command.

The main issues are structural
But malnutrition is really a political problem. It is the biological manifestation of a social disease. Some other colleagues think that advances in our field in the last ten years have included greater community involvement in nutrition programmes, and increased attention to care practices addressing women and children. This is so, up to a point. But I feel most colleagues do not really have a better, action-oriented understanding of the causes of malnutrition now, than they had in the 1990s. This was the decade in which we agreed that the correct conceptual framework of the causality of malnutrition is one that considers malnutrition as an outcome of different levels of causality. These are basic and underlying as well as immediate, and social, economic and environmental as well as behavioural and biological. All these levels and dimensions need to be addressed at the same time.
For the same period, colleagues have said that we have not come up with comprehensive designs for a better management of nutrition interventions. For them, this explains why we have not been effective in addressing protein-energy malnutrition. But design and management are not the main shortcomings of the last decade, or even the last thirty years. The main problem is the top-down, often curative and palliative thrust of the interventions. Also, it still amazes me that some colleagues even think that failures can be attributed to insufficient attention having been paid to the importance of nutrition counselling. This just shows their ethnocentric bias. ‘Counselling’ does not begin to address the basic problems of impoverishment and inequity that are at the root of malnutrition the world over.
The same bias can be found when colleagues think that reduced funding for nutrition projects is the major problem or constraint to achieving better results in the battle against hunger and malnutrition. Let us face it: If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!
I further disagree with colleagues who think the issue of lack of coordination among United Nations and other aid and development agencies providing nutrition services is central to our non-success in our work. The causes of this confusion or even conflict are ultimately related to issues of control, egos, and ‘old boy networks’, although there are also a number of genuine points of contention among agencies, some clearly ideological in nature. Yes, the non-coordination exists, and it is a disappointment. But it is not the main obstacle to faster progress.
Lack of commitment by governments to meaningful nutrition interventions is another excuse that is made too often, as a blanket statement, almost as a slogan. This said, I do accept that bureaucratic obstacles are a great burden. I know this after working for six years in ministries of health in Kenya and Vietnam, the latter a country where the politics are right, but where it takes a long time to get anything done.
But taken together, I cannot agree with the reasons given above as to why public health nutrition is ineffective. The major negative factors are structural, and are to do with the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment of those whose right to nutrition is being violated, every day of their lives.

The main issues are political
One of the real issues at stake is the genuine empowerment of claim holders, the people who are suffering from malnutrition. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to reduce malnutrition on the scale that is needed. It is the grass-roots pull that is missing and, as professionals, we are not pushing grass-roots mobilisation strongly, as we should. Will this be covered in your curricula? I am a skeptic.
On UN and other aid and development agencies, the big issue is that there are just no real good role models. Interagency competition and rivalry is often disguised as technical, but is actually political and ideological. My experience is that none of these agencies is really engaged in making empowering and sustainable changes with a potential to win the battle over malnutrition. Your generation, dear candidate, will have to give these agencies new, bolder directions. They are not immune to the political discourse. Some need to be challenged, even confronted, for as long as they keep to their conservative, outdated positions.
Very few of your future professors, dear candidate, are sold on the position I present to you here. They tend to be dogmatic and conservative, sticking to outdated or obsolete concepts, and a paradigm I think is fading. This is a challenge for you as well as for them. Take your stand. We take political stands based on adopting a consistent overall philosophy, which is to say, an ideology. This puts us in opposition to those with different ideologies. It is best not to adhere to our positions as the ‘only’ ones, but as those we stand for. It is good to believe you are right, when you enter into a discussion on the deep-rooted problems of hunger and malnutrition, even when you later come to see that you need to shift your position, just as long as your revised position remains consistent. Dialectics is about change. This includes recognising and amending your own mistakes.
By now, dear candidate, I hope you can sense that politics are at the very centre of international public health nutrition. This means that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current and future education, as well as all that you will see out there in the job market that is waiting for you shortly. What this points to dramatically is the almost taboo question, so rarely addressed, asked or answered: ‘How would you classify yourself politically?’ Why is this not asked in the first place?
It is said that, on micronutrients and breastfeeding, more concrete achievements are possible. This is precisely the silver-bullet type option many of our colleagues choose. Why should addressing tougher underlying and basic intersectoral issues be seen as impossibly difficult? These are what will ultimately lead to sustained improvements in public health –if we all put our hearts and minds to the task. Nutritionists in your generation need to face the more difficult choices and challenges in the battle against malnutrition and its real causes.
Properly understood, public health nutrition is part of the larger development perspective. I see it as being our point of entry to the big picture where it rightfully belongs, according to the integrated conceptual framework of the causes of malnutrition. Nutrition will keep its rightful identity in such an approach. To be taken seriously, our discipline has to be engaged with all aspects of development; if it stays territorial, it will remain only marginally relevant.
Are the impediments to public health nutrition too great?
Dear candidate, the current condition of international public health nutrition will continue to pose increasing frustrations and challenges for you. My acute concern is seeing how politically uninterested so many of your generation, particularly in North America and Western Europe, have become.
Those who say that international public health nutrition was just one fashion that now has had its day might be right, after all. If so, this is because our vocation may have turned out to be irreversibly irrelevant in global terms in addressing malnutrition, the rates of which are now rising again. It is just tough trying to beat the gigantic odds of inhumane and often outrageous economic globalisation, structural adjustment, and expanding ‘market economies’, that have no room for the problems of impoverished people.
But international public health nutrition must not and cannot be a passing fashion! We invite you to join in. If leaders and citizens turn their back on problems like these, they are part of a movement towards an inhumane, unjust and unsustainable world that will have gone wrong, for ever.

Yes, you can make a difference
In closing, dear candidate, I convey to you my confidence and optimism that our work has the ability to make a difference. The question is, what difference, and what for. Routine, pat solutions will not do. It is not a matter of an increasing number of activities in international public health nutrition starting to take place again in low-income countries. It is a matter of what kind or type of activities. Issues of inequality and of the right to nutrition are at the base of the problems at hand. And if nutrition is used as a way to revert such inequalities, I will be an optimist. But we need your upcoming generation, dear candidate, to get the job done. Perhaps you can start by questioning the curriculum you will be exposed to.
I have worked in many places on most continents, and this, in my experience, is what awaits you if you decide to join us. I see your role as a potential agent of change. I hope that, by now, you have a sense of what motivates us, the older workers who keep going as best we can, and of what we stand for. Principles include those that are ethical and social. Motivation can include romantic approaches such as those of charity and the desire to help the needy, but what’s most needed are political approaches that attempt to fight inequalities and injustice by empowering people to fight for their own rights.
Unfortunaytely, many of our commitments and energies wane as we get older, dear candidate. Do what is bold, now that you are young. Reach for the stars.

Claudio Schuftan
Ho Chi Minh City

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