Claudio Schuftan
cschuftan@phmovement.org
How can we identify and act upon the major causes of hunger and malnutrition? Here I will review the principal characteristics of these determinants, and explore how we can convince others (peers, beneficiaries, and decision-makers) 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 contexts.
This examination looks at malnutrition (undernutrition) as the biological translation of a social disease with historical roots; therefore, all basic determinants of the social and economic conditions that lead to the malnutrition of certain sectors of the population will, for easier understanding, here be considered macro determinants. The more immediate and underlying causes responsible for malnutrition will here be called micro determinants.
Macro and micro causes of malnutrition
Macro determinants of hunger and malnutrition are conditioned by the overall policies that govern national economics (both internally and in foreign relations and trade). In a way, macro determinants are more ‘indirectly’ related to malnutrition; they are always related to international, national, and village level constraints. Together with many others, I contend that macro causes explain most malnutrition in societies with capitalist modes of production. Malnutrition, or actually nutritional vulnerability, is a manifestation of a society's inability to allow its poor populations to earn their livelihoods adequately and is neither a manifestation of modern medicine leading to overpopulated societies nor the result of agricultural production being insufficient. (One can actually ask oneself whether underdeveloped countries struggling for their own livelihood, oddly, produce to better the livelihood of other countries...). (1)
Macro causes usually relate to the major social contradictions in a given society, especially in rural areas. Macro causes are responsible for a myriad of constraints to meaningful changes.
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 the vast majority of traditional nutrition intervention programs. (A good example is nutrition surveillance). Since technology cannot achieve the fundamental structural changes needed to end hunger and malnutrition, in the long run, the fight against hunger and malnutrition thus has to become more of an eminently political struggle and not a technical one.
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 then devise seldom attack these determinants frontally.
Micro determinants more directly impinge on the physiological condition of malnutrition. Among other, they include health, environmental, and educational determinants; these are the ones most frequently identified and selected for direct intervention by Northern planning approaches. They largely emphasize technical approaches and have justified the need for Northern-trained experts who often come with ready-made analyses…and ‘packages’. The recent Lancet series can be said to, in good part, fall under this characterisation, I would say.
Every expert brings his own view and values of development, and their suggestions for nutrition programs will reflect that ideology.
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.
As nutritionists, we keep inventing new ‘more comprehensive’ or ‘multisectoral or ‘evidence-based’ 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 of malnutrition to begin with.
Diagnosing the causes of hunger and malnutrition
It should be clear that we cannot agree on the content of needed nutrition interventions if we do not share the same understanding of why people are poor and malnourished. Different socioeconomic contexts call for different nutrition plans. 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 and action upon a mix of macro and micro determinants.
The challenge for us 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 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, but they may have a partial redistribution impact as a side-effect --assuming that they reach the lowest income and marginalized groups, which is a big if.
In this context, our role is beyond doubt a delicate one. Sensitization and advocacy skills are perhaps more important than technical know-how. The type of strategy or plan that should follow a comprehensive diagnosis using the conceptual framework 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, followed by an estimation of the potential of such a package of interventions to solve or address the major basic causes of hunger and malnutrition…or vice-versa?
A list of the key macro causes should be 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 with beneficiaries’ de-facto participation. Engaging then in social mobilization, the list will aim at removing some of the structural bottlenecks or constraints that are ultimately determining a state of chronic hunger in defined sectors of the population. (The human rights-based approach reviewed in my column last month works on details to this end).
The similarities between poor countries being many, the following are some examples of national-level manifestations of macro causes:
• low percentage of national income received by the 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 food basket and not following food price inflation;
• low farm-gate prices for food crops as opposed to their urban retail prices;
• marketing boards' exploitative practices towards small farmers;
• imbalance between cash and food crops (as relates to land allocation and incentives);
• low percentage of foreign export earnings reinvested in agriculture;
• food import policies contradictory to national efforts to increase local food production;
• the share of agriculture in the national GDP slipping in favor of other sectors of the economy;
• credit bias towards the modern agricultural sector as opposed to the traditional, small farmers agricultural sector;
• lack of agricultural input subsidization for small farmers, especially for food crops;
• foreign aid not reaching the neediest;
• women left outside development programmes with little incentive to incorporate them in the money economy;
• little emphasis on the scanty budgets for genuine community development and 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
Malnutrition as a social disease cannot be cured through medical interventions (not even in a wide and comprehensive health package) nor can it be cured through the latter plus a package of agricultural interventions.
Redistribution of resources and the consequent increase in purchasing power of the marginalized majority is a necessary, though not sufficient, solution to the problem of hunger. Poverty wears many other masks (e.g., cultural and educational deprivation, poor health, inadequate sanitation and housing), and each mask has its own features. We should not be tempted, through a lack of perspective, to try to improve only the features of the masks, without doing anything about the real face of poverty, which is socioeconomic deprivation and gross power imbalances in society.
I feel that many among us 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. (In the logical framework of projects, recommendations are often worded or hidden as risks, i.e. saying we assume the government will do such and such for our project to really succeed; those are very often macro issues).
The outspokenness with which we state the need for corrective measures directed to the macro determinants will depend on the political environment in which each of us works. Political and professional risks are usually high (2), and many colleagues feel that their positions in academe, government, or international or private organizations might be jeopardized if they demand radical solutions. They take a ‘survivor's attitude’ --and this is disturbing.
We simply 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 and DO impinge on nutrition.
Macro determinants can be exposed in a number of ways, not all of which are dramatic or sensationalistic. 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 Immediate and Underlying Causes of Malnutrition Will Have a Better Chance of Having an Impact." (3) This should be followed by a subjective estimate of the realistic potential of each macro intervention to ameliorate malnutrition –including, and based-on, the de-facto demands that mobilized groups of beneficiaries will place in front of authorities. (The human rights-based approach reviewed in my column last month works on details to this end as well). The idea is to contrast the potential of the latter with the potential a package of micro interventions to achieve the same or similar goals has. 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.
Political and ideological constraints, as well as the attitude and commitment of decision-makers towards eradicating hunger will determine how far the planning team can go in this.
The major problem with this approach is that it will look ‘too politically radical’ to the powers that be. If this is the case, then the particular governments are most probably not genuinely interested in solving the problems at hand --and I think we too often underestimate this. But this may be difficult to determine, given the frequency with which governments pay just lip service to their commitments.
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 --surely including things that politicians and decision makers have probably known all along...
We sometimes wrongly assume that decisions makers are rational, righteous, and pious and will accept hard scientific evidence or react to outrageous injustice.
Colleagues who participate 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.
The role of ideology (4)(5)
Nutrition seems to be as good an entry point as any other (education, energy, natural resources, climate, the environment, etc.) for getting involved in questions of equity in our societies.
Nutrition can lead to global considerations if it is not seen as an isolated issue.
Malnutrition should not be attacked on grounds of utility, but because such an attack is morally necessary. What we need to fight for is equity, not utility. Poverty should not be seen as an inevitable evil, but as a basic injustice to be corrected. In that sense, poverty is to be considered more as a relative rather than an absolute condition.
The ideology and outlook on world affairs of the individual searching for the determinants of hunger and malnutrition (largely determined by social class extraction) play a vital role in the selection of the contents of the final in-depth analysis used (one seems to see only what one wants to see). Once a certain level of consciousness is attained, an action-oriented attitude usually follows. At this point, there is a convergence of ideology and action that makes the difference between taking an observer's as opposed to a protagonist's role. Knowing about injustice does not move many of us: becoming conscious about it generates a creative anger that calls for involvement in corrective actions. The latter can only happen within the framework of an ideology consciously acquired. In the context of nutrition, then, ideology carries the additional connotation of commitment, both emotional and intellectual, as well as being action-oriented.
Ideology is not simply a body of ideas determining goals; it also includes the instruments, strategies, and tactics to be used in planning for economic and social change. (6)
Objectivity in the analytical stages of the planning process is nothing but a myth, and since the solutions proposed will heavily depend on the final diagnosis of the causes identified, there is no assurance that by following the procedures described above for the identification of macro and micro determinants, one will end up with a better, more comprehensive plan to ameliorate hunger and malnutrition in any specific situation. The implications of this, center at least around two issues:
i. Will the outlook for eliminating hunger and malnutrition in the world be any better without a concomitant process of political maturation of the people involved in nutrition work?
ii. Would more efforts towards demonstrating the futility of ongoing food and nutrition programmes mark the beginning of a new, more aggressive approach?
The possible answers to these two questions are again ideologically charged.
In trying to solve the problem of malnutrition, intra-professional responsibility should not be neglected. This responsibility has to be taken up starting with a process that critically analyzes our professional affairs and goals with their inherent contradictions. Basically, nutritionists should be searching for a new ethos, a professional, political ethos. The sense of responsibility found in many scientists does not seem to be sufficient to see necessary changes occur; it leads nowhere. It may solve the conscience problems of the person who devotes time and effort to doing ‘something’ to solve, malnutrition. However, it seems to have little effect on the real problems of poor people and the malnourished.
An isolated emotional commitment is loose and romantic; ideological commitment is militant. The concept of being socially responsible is nothing but a euphemism for what really should be called political responsibility. Political commitment is important precisely because governments function as political entities. (7)
Political forces are fought with political actions, not with morals, or with technological fixes.
It is precisely a misunderstanding of reality (or a partial understanding of it) that often reinforces the amoral position of some colleagues --or some of them may not really want to understand; they have, all too often and for all the wrong reasons, already made up their minds about one reality, thus often searching for the statistical ‘whats’ instead of analyzing the ‘whys’. (8)
Used as a technical tool, nutrition science offers no real solution, no matter how much new coordination between different sectors (e.g., health, agriculture, education) it succeeds in setting up at any or at all levels. To continue pushing such technical tools is to perpetuate the problems. In the vast majority of cases, it will mean a waste of scarce resources and of precious time.
Critically speaking, nutrition science will continue to offer us no more than a good diagnostic tool, a not-so-good framework to consider alternative intervention strategies…and a basis to validate ideologically charged policy decisions.
Working with the community
If little can be expected from nutrition programmes pushed from the central level, then community-level (grassroots) organization around food and nutrition issues may be the more viable answer in the long run.
Popular participation and mobilization is absolutely key to success in nutrition work but, as nutritionists, we have persistently disregarded this central issue --or have only tinkered with participatory approaches. What is needed is more dedication to working directly with those who happen to be poor and/or discriminated so they can tackle the causes of their poverty and malnutrition themselves. This calls for us to go, as much as possible, back to field work and out of our offices or laboratories. Only there can the strengths needed for a change in direction and perspective be found.
Nutritionists need to learn from the people and from their perceptions of the problems, establish links with local mass movements and participate in their consciousness raising.
The participation of the affected population begins with creating awareness that they have a problem --and that their right to nutrition is being violated. This, to be followed by ample discussion about what can be done about it. Here, the outsider's role is to ask the right questions and not to point at what s/he thinks is wrong.
It is only through praxis that political consciousness can be strengthened, and it is only when people are convinced that change is in fact beginning to take place that they will listen and learn the more abstract concepts we use; the same must fit into their experience. (9) In our work with the community, we have to pass from a mutually shared analysis and understanding of the local micro determinants of malnutrition, which should be more easily identifiable and perceived by the community at the beginning, to the analysis and understanding of the local and then national and global macro determinants of that (their) condition.
For the latter to be possible, the community will probably have to go through a slow process of political maturation before effectively gaining consciousness of the role of the social and economic constraints that determine malnutrition in their milieu. People have to become aware of their problems in a specific context first and then in an ideological one. The exposure to them of the basic macro constraints should, in the first instance, lead to generating social commitment to effecting the needed structural changes.
It is important to demonstrate to the community that it is in their power to change not only the physical reality that surrounds them but the social reality as well. (10)
There are three levels of possible involvement in fieldwork. (11) At the first level, one solicits the participation of the community in a given project. (Participation has turned out to be harmless for the vested interests and is, therefore, a regular appendage of every government project these days). A second level calls for outright consciousness raising among the population. At the third level, an effort is made towards the mobilization of the masses and the effective empowering of the poor.
Because village problems are often not a priority for governments, local felt needs have to be converted into concrete issues so that a course of action to address them can be mapped out. This may involve developing functional knowledge about people's rights, or challenging public agencies, landlords or other powerful people or institutions by filing specific demands or claims. A new type of community-oriented nutritionist is needed for this Herculean task: one that plans with people to get organized to work together in solving the problems.
We need to move in the direction of training nutritionists as trainers of others so that their own community-oriented experiences can be reproduced at many levels in each country. The shortcomings of this approach are many, not the least of which is the fact that it is a very slow process, based on mutual trust in each community and that its replicability is also very slow even in the best of cases. The dangers, of course, are also significant, especially when the government is hostile to community mobilization.
The question that still remains at the end of this discussion is whether this approach is realistic or not. If it is not, let us keep in mind that not being realistic is a judgment that history can change: what might sound unrealistic today can very well become true tomorrow, if we work for it with decision.
cschuftan@phmovement.org
How can we identify and act upon the major causes of hunger and malnutrition? Here I will review the principal characteristics of these determinants, and explore how we can convince others (peers, beneficiaries, and decision-makers) 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 contexts.
This examination looks at malnutrition (undernutrition) as the biological translation of a social disease with historical roots; therefore, all basic determinants of the social and economic conditions that lead to the malnutrition of certain sectors of the population will, for easier understanding, here be considered macro determinants. The more immediate and underlying causes responsible for malnutrition will here be called micro determinants.
Macro and micro causes of malnutrition
Macro determinants of hunger and malnutrition are conditioned by the overall policies that govern national economics (both internally and in foreign relations and trade). In a way, macro determinants are more ‘indirectly’ related to malnutrition; they are always related to international, national, and village level constraints. Together with many others, I contend that macro causes explain most malnutrition in societies with capitalist modes of production. Malnutrition, or actually nutritional vulnerability, is a manifestation of a society's inability to allow its poor populations to earn their livelihoods adequately and is neither a manifestation of modern medicine leading to overpopulated societies nor the result of agricultural production being insufficient. (One can actually ask oneself whether underdeveloped countries struggling for their own livelihood, oddly, produce to better the livelihood of other countries...). (1)
Macro causes usually relate to the major social contradictions in a given society, especially in rural areas. Macro causes are responsible for a myriad of constraints to meaningful changes.
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 the vast majority of traditional nutrition intervention programs. (A good example is nutrition surveillance). Since technology cannot achieve the fundamental structural changes needed to end hunger and malnutrition, in the long run, the fight against hunger and malnutrition thus has to become more of an eminently political struggle and not a technical one.
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 then devise seldom attack these determinants frontally.
Micro determinants more directly impinge on the physiological condition of malnutrition. Among other, they include health, environmental, and educational determinants; these are the ones most frequently identified and selected for direct intervention by Northern planning approaches. They largely emphasize technical approaches and have justified the need for Northern-trained experts who often come with ready-made analyses…and ‘packages’. The recent Lancet series can be said to, in good part, fall under this characterisation, I would say.
Every expert brings his own view and values of development, and their suggestions for nutrition programs will reflect that ideology.
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.
As nutritionists, we keep inventing new ‘more comprehensive’ or ‘multisectoral or ‘evidence-based’ 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 of malnutrition to begin with.
Diagnosing the causes of hunger and malnutrition
It should be clear that we cannot agree on the content of needed nutrition interventions if we do not share the same understanding of why people are poor and malnourished. Different socioeconomic contexts call for different nutrition plans. 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 and action upon a mix of macro and micro determinants.
The challenge for us 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 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, but they may have a partial redistribution impact as a side-effect --assuming that they reach the lowest income and marginalized groups, which is a big if.
In this context, our role is beyond doubt a delicate one. Sensitization and advocacy skills are perhaps more important than technical know-how. The type of strategy or plan that should follow a comprehensive diagnosis using the conceptual framework 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, followed by an estimation of the potential of such a package of interventions to solve or address the major basic causes of hunger and malnutrition…or vice-versa?
A list of the key macro causes should be 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 with beneficiaries’ de-facto participation. Engaging then in social mobilization, the list will aim at removing some of the structural bottlenecks or constraints that are ultimately determining a state of chronic hunger in defined sectors of the population. (The human rights-based approach reviewed in my column last month works on details to this end).
The similarities between poor countries being many, the following are some examples of national-level manifestations of macro causes:
• low percentage of national income received by the 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 food basket and not following food price inflation;
• low farm-gate prices for food crops as opposed to their urban retail prices;
• marketing boards' exploitative practices towards small farmers;
• imbalance between cash and food crops (as relates to land allocation and incentives);
• low percentage of foreign export earnings reinvested in agriculture;
• food import policies contradictory to national efforts to increase local food production;
• the share of agriculture in the national GDP slipping in favor of other sectors of the economy;
• credit bias towards the modern agricultural sector as opposed to the traditional, small farmers agricultural sector;
• lack of agricultural input subsidization for small farmers, especially for food crops;
• foreign aid not reaching the neediest;
• women left outside development programmes with little incentive to incorporate them in the money economy;
• little emphasis on the scanty budgets for genuine community development and 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
Malnutrition as a social disease cannot be cured through medical interventions (not even in a wide and comprehensive health package) nor can it be cured through the latter plus a package of agricultural interventions.
Redistribution of resources and the consequent increase in purchasing power of the marginalized majority is a necessary, though not sufficient, solution to the problem of hunger. Poverty wears many other masks (e.g., cultural and educational deprivation, poor health, inadequate sanitation and housing), and each mask has its own features. We should not be tempted, through a lack of perspective, to try to improve only the features of the masks, without doing anything about the real face of poverty, which is socioeconomic deprivation and gross power imbalances in society.
I feel that many among us 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. (In the logical framework of projects, recommendations are often worded or hidden as risks, i.e. saying we assume the government will do such and such for our project to really succeed; those are very often macro issues).
The outspokenness with which we state the need for corrective measures directed to the macro determinants will depend on the political environment in which each of us works. Political and professional risks are usually high (2), and many colleagues feel that their positions in academe, government, or international or private organizations might be jeopardized if they demand radical solutions. They take a ‘survivor's attitude’ --and this is disturbing.
We simply 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 and DO impinge on nutrition.
Macro determinants can be exposed in a number of ways, not all of which are dramatic or sensationalistic. 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 Immediate and Underlying Causes of Malnutrition Will Have a Better Chance of Having an Impact." (3) This should be followed by a subjective estimate of the realistic potential of each macro intervention to ameliorate malnutrition –including, and based-on, the de-facto demands that mobilized groups of beneficiaries will place in front of authorities. (The human rights-based approach reviewed in my column last month works on details to this end as well). The idea is to contrast the potential of the latter with the potential a package of micro interventions to achieve the same or similar goals has. 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.
Political and ideological constraints, as well as the attitude and commitment of decision-makers towards eradicating hunger will determine how far the planning team can go in this.
The major problem with this approach is that it will look ‘too politically radical’ to the powers that be. If this is the case, then the particular governments are most probably not genuinely interested in solving the problems at hand --and I think we too often underestimate this. But this may be difficult to determine, given the frequency with which governments pay just lip service to their commitments.
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 --surely including things that politicians and decision makers have probably known all along...
We sometimes wrongly assume that decisions makers are rational, righteous, and pious and will accept hard scientific evidence or react to outrageous injustice.
Colleagues who participate 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.
The role of ideology (4)(5)
Nutrition seems to be as good an entry point as any other (education, energy, natural resources, climate, the environment, etc.) for getting involved in questions of equity in our societies.
Nutrition can lead to global considerations if it is not seen as an isolated issue.
Malnutrition should not be attacked on grounds of utility, but because such an attack is morally necessary. What we need to fight for is equity, not utility. Poverty should not be seen as an inevitable evil, but as a basic injustice to be corrected. In that sense, poverty is to be considered more as a relative rather than an absolute condition.
The ideology and outlook on world affairs of the individual searching for the determinants of hunger and malnutrition (largely determined by social class extraction) play a vital role in the selection of the contents of the final in-depth analysis used (one seems to see only what one wants to see). Once a certain level of consciousness is attained, an action-oriented attitude usually follows. At this point, there is a convergence of ideology and action that makes the difference between taking an observer's as opposed to a protagonist's role. Knowing about injustice does not move many of us: becoming conscious about it generates a creative anger that calls for involvement in corrective actions. The latter can only happen within the framework of an ideology consciously acquired. In the context of nutrition, then, ideology carries the additional connotation of commitment, both emotional and intellectual, as well as being action-oriented.
Ideology is not simply a body of ideas determining goals; it also includes the instruments, strategies, and tactics to be used in planning for economic and social change. (6)
Objectivity in the analytical stages of the planning process is nothing but a myth, and since the solutions proposed will heavily depend on the final diagnosis of the causes identified, there is no assurance that by following the procedures described above for the identification of macro and micro determinants, one will end up with a better, more comprehensive plan to ameliorate hunger and malnutrition in any specific situation. The implications of this, center at least around two issues:
i. Will the outlook for eliminating hunger and malnutrition in the world be any better without a concomitant process of political maturation of the people involved in nutrition work?
ii. Would more efforts towards demonstrating the futility of ongoing food and nutrition programmes mark the beginning of a new, more aggressive approach?
The possible answers to these two questions are again ideologically charged.
In trying to solve the problem of malnutrition, intra-professional responsibility should not be neglected. This responsibility has to be taken up starting with a process that critically analyzes our professional affairs and goals with their inherent contradictions. Basically, nutritionists should be searching for a new ethos, a professional, political ethos. The sense of responsibility found in many scientists does not seem to be sufficient to see necessary changes occur; it leads nowhere. It may solve the conscience problems of the person who devotes time and effort to doing ‘something’ to solve, malnutrition. However, it seems to have little effect on the real problems of poor people and the malnourished.
An isolated emotional commitment is loose and romantic; ideological commitment is militant. The concept of being socially responsible is nothing but a euphemism for what really should be called political responsibility. Political commitment is important precisely because governments function as political entities. (7)
Political forces are fought with political actions, not with morals, or with technological fixes.
It is precisely a misunderstanding of reality (or a partial understanding of it) that often reinforces the amoral position of some colleagues --or some of them may not really want to understand; they have, all too often and for all the wrong reasons, already made up their minds about one reality, thus often searching for the statistical ‘whats’ instead of analyzing the ‘whys’. (8)
Used as a technical tool, nutrition science offers no real solution, no matter how much new coordination between different sectors (e.g., health, agriculture, education) it succeeds in setting up at any or at all levels. To continue pushing such technical tools is to perpetuate the problems. In the vast majority of cases, it will mean a waste of scarce resources and of precious time.
Critically speaking, nutrition science will continue to offer us no more than a good diagnostic tool, a not-so-good framework to consider alternative intervention strategies…and a basis to validate ideologically charged policy decisions.
Working with the community
If little can be expected from nutrition programmes pushed from the central level, then community-level (grassroots) organization around food and nutrition issues may be the more viable answer in the long run.
Popular participation and mobilization is absolutely key to success in nutrition work but, as nutritionists, we have persistently disregarded this central issue --or have only tinkered with participatory approaches. What is needed is more dedication to working directly with those who happen to be poor and/or discriminated so they can tackle the causes of their poverty and malnutrition themselves. This calls for us to go, as much as possible, back to field work and out of our offices or laboratories. Only there can the strengths needed for a change in direction and perspective be found.
Nutritionists need to learn from the people and from their perceptions of the problems, establish links with local mass movements and participate in their consciousness raising.
The participation of the affected population begins with creating awareness that they have a problem --and that their right to nutrition is being violated. This, to be followed by ample discussion about what can be done about it. Here, the outsider's role is to ask the right questions and not to point at what s/he thinks is wrong.
It is only through praxis that political consciousness can be strengthened, and it is only when people are convinced that change is in fact beginning to take place that they will listen and learn the more abstract concepts we use; the same must fit into their experience. (9) In our work with the community, we have to pass from a mutually shared analysis and understanding of the local micro determinants of malnutrition, which should be more easily identifiable and perceived by the community at the beginning, to the analysis and understanding of the local and then national and global macro determinants of that (their) condition.
For the latter to be possible, the community will probably have to go through a slow process of political maturation before effectively gaining consciousness of the role of the social and economic constraints that determine malnutrition in their milieu. People have to become aware of their problems in a specific context first and then in an ideological one. The exposure to them of the basic macro constraints should, in the first instance, lead to generating social commitment to effecting the needed structural changes.
It is important to demonstrate to the community that it is in their power to change not only the physical reality that surrounds them but the social reality as well. (10)
There are three levels of possible involvement in fieldwork. (11) At the first level, one solicits the participation of the community in a given project. (Participation has turned out to be harmless for the vested interests and is, therefore, a regular appendage of every government project these days). A second level calls for outright consciousness raising among the population. At the third level, an effort is made towards the mobilization of the masses and the effective empowering of the poor.
Because village problems are often not a priority for governments, local felt needs have to be converted into concrete issues so that a course of action to address them can be mapped out. This may involve developing functional knowledge about people's rights, or challenging public agencies, landlords or other powerful people or institutions by filing specific demands or claims. A new type of community-oriented nutritionist is needed for this Herculean task: one that plans with people to get organized to work together in solving the problems.
We need to move in the direction of training nutritionists as trainers of others so that their own community-oriented experiences can be reproduced at many levels in each country. The shortcomings of this approach are many, not the least of which is the fact that it is a very slow process, based on mutual trust in each community and that its replicability is also very slow even in the best of cases. The dangers, of course, are also significant, especially when the government is hostile to community mobilization.
The question that still remains at the end of this discussion is whether this approach is realistic or not. If it is not, let us keep in mind that not being realistic is a judgment that history can change: what might sound unrealistic today can very well become true tomorrow, if we work for it with decision.
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