2011 April blog

Claudio Schuftan

Here above is my hero Rudolf Virchow. He was a social visionary who in the late 1840s, articulated the social – and the economic and political – determinants of ill-health, malnutrition and misery. He did this with, I dare say, even more bite and relevance than has the WHO's Commission on the Social Determinants of Health, over a century and a half later.

Rudolf Virchow was a clinician and also a founder of epidemiology in the service of public health. Aged 27 and living in Breslau, in Germany, he was asked by the rulers of Prussia to identify the reasons for an outbreak of typhus in Upper Silesia. His report stated that the cause was poverty and in particular the outrageous living conditions of impoverished communities. He said: 'The proletariat is the result, principally, of the introduction and improvement of machinery…shall the triumph of human genius lead to nothing more than to make the human race miserable?' In the same year, 1848, the first proletarian uprisings shook many European governments, and Virchow helped to build barricades in Berlin.



The spirit of Rudolf Virchow permeates this column. Many of us older members of the Association recall that what we were saying and writing in the 1970s and early 80s was considered radical and extreme. Well, a good bit of it is now mainstream – even if more in lip service than in action. The mood I want to set here is captured in the heading above, which paraphrases Rudolf Virchow's most celebrated quote, substituting 'public health nutrition' for 'medicine'

What I am getting at here, in reminding us of Virchow and the many other trenchant observers and activists that came after him, including in our lifetimes, is that we seem to keep on and on diagnosing the obvious. Thus, why do we go on emphasising sectoral solutions that address what we think are 'new breakthroughs' in nutrition, without addressing what is fundamental? So much is important. But what is fundamental? Don't you feel we are sucked into fashions in nutrition work? Yes, important is the help given to some needy groups. But yes, fundamental, is the promotion of permanent structural changes.

The World Social Forum

It was with such thoughts in mind that I participated in the annual World Social Forum held this year in Dakar, Senegal. This initiative born in Porto Alegre, Brazil in January 2001, has become the biggest civil society network of grassroots activists in history. It has become stalwart in the fight for more democracy and a fairer world, and is a permanent space and process to build alternatives to neoliberalism. You can consider it an alternative to its great capitalist rival, the World Economic Forum held every year in Davos.

Although plagued by numerous logistic and organisational problems, some 25,000 activists from all over the world converged on Dakar to express their dissatisfaction with the prevailing state of affairs in our troubled planet.

Dakar was good to me. It helped me clarify old ideas. I heard President Evo Morales of Bolivia give a scathing speech denouncing neoliberalism in front of a crowd of thousands. But then I heard the President of Senegal declaring himself an open backer of neoliberalism. Almost half of the meetings were held in a myriad of tents put up in the university campus site. Colourful civil society organisation booths and a rainbow of crafts were there for us all to enjoy. Also interesting to me was to see so many activists with grey hair and bald heads coming from the world over: these, like me, are diehards from the 60s and 70s who have never given up. Bravo. The two and a half hour march through downtown Dakar was monumental, picturesque and combative. There was a festive ambiance with meetings well into the night.

No, there was no revolution in Dakar. But a real booster to the disposition of participants came from the same-time breaking news of the uprising in Egypt. Gatherings like this actually make me reflect on what I --and you-- are really contributing to our troubled world. And so:



Ultimate causes

We keep projecting trends and tendencies of the bad stuff we want to be stopped. But tendency is not destiny. The destiny is in our hands. When dealing with food and nutrition problems, it is important to act on the ultimate causes, as well as on their effects. It is little use to take care of the malnourished while the basic causes of hunger and malnutrition remain. We can propose steps to block such causes, or we can help solve their consequences. The greatest waste in the latter task is time, wasted on diagnoses for checking easily verifiable tendencies, wasted on excessive methodology. Decisions are thus delayed by a system without any synchrony with the velocity of what is happening. We simply often fail to strike the right balance between theory and practice, between academicism and activism.

Politicians and policy-makers often base their opinions on what they hear from those who do not know anything about the subject, and are viewing it from the outside. Or else, they make policy on the basis of what they hear from those who do know a great deal about the subject, and are viewing it from the inside, but from a biased point of view – which is to say, more often than what we'd like one of us.

All the elements needed to study malnutrition in its wider economic and political context are there. These include inequity between the various sectors of society, and the role of state and private interests and the conflicts between them. But in spite of this, our colleagues often continue to discuss matters within a narrow and constricting frame of habits, behaviours and knowledge – or ignorance. The implicit social model, of our colleagues, part of which for them often is an unacknowledged ideology, somehow does not allow them to appropriately react to the complexity of the social and economic phenomena they witness. An approach that assumes classlessness focuses its analysis on those who are seen as 'just happening to be poor', and not on the economic system that produces and reproduces poverty. As a result, most strategies to eradicate poverty have been directed at poor people themselves. Problems are thus 'solved' in an isolated and technical way, because there is still a lack of understanding of what determinants are really important and how they need to be addressed and resolved. In our system, colleagues who point out valid discrepancies between ideology and reality are marginalised or punished, rather than being respected and rewarded.

Projects dreamed up in a social vacuum must play themselves out in the real world of injustice and conflict. Projects we get involved with, often turn out differently from what we expect or intend them to. Am I not right? We need nutrition experts who are strong and flexible enough to ask the right questions rather than sell the wrong answers. Intervention strategies need to call for radical changes in the environment and the social system. It is only such strategies that have long-term potential.



The rhyme above appeared in my column some months ago. It does not give me peace. Reading it again, I feel something is missing. What are we supposed to do differently or better? What is the overall problem in our work in nutrition? Is it that too often we are trying to find reducible solutions to irreducible problems? Is it that the wrong technologies have for too long been destroying genuine community life and have thus led to maldevelopment that has perpetuated malnutrition? Does technology 'dilute and dissolve' ideology? I think yes. I agree with those who say that a technocratic utopia is the most banal of all utopias.

What, then, is the appropriate role of the science of nutrition in people's development in situations where exploitation and oppression are ongoing, but room still exists for technological initiatives that marginally 'improve' the material wellbeing and nutrition of poor people --at least up to a certain point? Conversely, can affected communities be easily mobilised for political action, for structural changes, if the current system still so allows? Should progressive forces stand aloof from such space? Should they be part of the effort to distract mass attention from the need for fundamental social change? Or should a combination of economic and political mobilisation also be pursued? These questions are not easy. Public indignation is difficult to sustain; it can be dissipated by token, merely symbolic patch solutions.

Ideological or technical 'fixes'

We need to confront the fact that there are two kinds of problems: reducible and irreducible. The difference between them is simple. Reducible problems have clearly definable solutions, while irreducible ones do not. You know when you have got the answer to a reducible problem --it fits like the right piece in a puzzle. But, beware! Problems such as inequity and injustice appear irreducible, because their solutions are deemed 'not fixable'. But do not worry, we are told. Technological advances are the answer to reducible problems, so it is imagined that they can and will solve the irreducible problems as well. This is, of course, an illusion.

When the world is messy, the tendency is to fall back either on ideology or on technology. Good young people respond to the seduction of technology. 'It's more independent of experience and you don't have to know much'. But technology is not the origin of change; it merely is the means whereby society changes itself.

Technology has flattened differences around the world. Cultures that took centuries to build and sustain have been transformed by 'development' in a few decades. Political action is almost always successful in response to strongly felt needs --more liberty, a different racial division, or simply more bread. Technology invents needs and exports problems. (By the way, are you by any chance fixed up with an iPad? Or perhaps an iPhone?).

Political action always has motives --a why-- such as grievances, and the need for redress; it follows a long period of abuses and usurpations. Great technological changes, on the other hand, do not have a why. Technology, unlike politics, is irreversible. We may be able to develop a new strain of wheat and so contribute to stave-off starvation somewhere. But it may not be in our power to cure injustice anywhere, even in our own country, much less in distant places.

We need to change our system of thinking rather than trying to conquer hunger and malnutrition by the use of technology. Technology is basically improvisational. It treats the symptoms; it provides no lasting cures. Moreover, technology is part of the problem. New policies will thus require a patient and possibly painful re-education of us all.

Technical pragmatism, even by women and men of good will, comes up with strategies with no political sensitivity, that are 'implementable', or 'do-able', and are appealing to all 'reasonable' people. Technocrats paste together fragments of several alternatives, often resulting in a pastiche and not a real synthesis.

If this is the best that the best applied thinkers of the international nutrition establishment can produce, then indeed our thinking is no more than aimless wandering in a desert



The real challenge in our present world is not to maximise happiness (which in practice is interpreted by neo-liberalism as maximising economic growth, higher gross national product, consumerism, or acquisition of quantity of goods). The challenge is to organise our society to minimise suffering.

Ultimately, our civilisation will not be judged so much on its vast accumulation of scientific knowledge, as on its trusteeship of that knowledge and its efficient application to the betterment of living and the minimisation of suffering. We – you – cannot continue increasing our – your – affluence, while most have not even got their essentials. Will acting on this truism lead to conflict? Probably. Conflict is not necessarily violence. Conflict is common where there are competing interests. Conflict is a necessary means to attain true dialogue with people in authority. Therefore, avoiding it --as we often do-- is no solution. So where does this put us?

Raising our own consciousness

Our nutrition community needs a programme of consciousness-raising, so that empowered in this way, we ourselves can raise the consciousness of others and empower them. We need to generate an attitude of inquiry and of demand among the beneficiaries of our programmes, so that they can move from fatalism and apathy, to the realisation of their own power and rights to change reality in their favour.

Nutritionists should bring to their beneficiaries systematic knowledge of the wider social structure and its workings along the lines of their inalienable human rights --a knowledge that is critical in the choice of strategies for social change. Nutritionists should also bring knowledge of initiatives to change society that have been applied elsewhere, so that lessons can be learned from those experiences. The power of new ideas needs to be mobilised through the communications revolution we now live within. New forms of learning, education, awareness creation and 'conscientisation' need to be proactively pursued in this endeavour.

As nutrition professionals, we have a responsibility to be leaders in the abolition of absolute poverty wherever it exists. Relative poverty, which can be seen as dissatisfaction with one's relative position in the income pyramid, is important, but it is not morally important as a priority. A new ethos is required, involving discouragement of consumerism. This cannot be done without a substantial change in power relations.

People-who-happen-to-be-poor are not capable of engaging in conflict until they de-facto show that they are no longer servile and afraid. They need to move from a culture of silence to a position of dignity – and the adoption of the human rights-based framework is the better way forward. Where do you and I stand, when it comes to promoting this transition, and to provide rallying points for mobilisation in this direction?

Work in nutrition can lead to liberation. Any action that gives the people more control over their own affairs is an action for real development. This is true even if it does not offer them better health or more bread in the short run. But for this to happen, our work needs to be built from the bottom up. Otherwise we are part of the culture of Social Darwinism, in which the ones who make it are the richest, the most powerful, the 'whitest' and the 'malest'.

Acknowledgement 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. Fundamental public health nutrition: Nutrition is a social science and nutrition is nothing but politics on a grand scale, and other items. [Column] Website of the World Public Health Nutrition Association, April 2011. 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.


2011 April blog: Claudio Schuftan

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