Halfdan Mahler, pictured above, is a cherished friend, and a member of the People's Health Movement. He was the Director-General of the World Health Organization for 15 years, from 1973 to 1988. He is now 87 years old. During his period of office, WHO co-sponsored the 1978 Alma Ata conference, where the bold goal of 'Health for All by the Year 2000' was proclaimed. How sad, that some 30-plus years later, this expansive vision of health, founded on the principles of primary health care and social change, has been replaced by the miserly and narrow-minded Millennium Development Goals (1).

In May 2008, Dr. Mahler addressed the WHO sixty-first World Health Assembly. He called again for an integrated approach to health, and what he said was greeted with a standing ovation from the delegates of all member states present. Two statements he made were for me outstanding. The first was:

So now, as a tribute to Dr Mahler, and in recognition of the truth of what he says and stands for, and of his vision for a more equitable world, I present some thoughts and ideas about the role of health and nutrition in the context of development.

Solving the problems of malnutrition was for many years considered primarily a health activity and prerogative. Unfortunately in many circles it still is. But there is much more to malnutrition than that.

After having witnessed the failure of many attempts to solve malnutrition through health and other specialist sectoral interventions alone, it is time that we all approached malnutrition as a human rights issue. As soon as we do this, we are directed towards looking at what are the basic causes of malnutrition and their resolution.

The food and nutrition chain is usually seen as a series of linked processes that food follows from its production (or import) to its consumption and utilisation. The links in the food chain are the following:

	storage
Production	---------->	transport,	marketing,	consumption,	utilisation:
	processing				digestion absorption metabolism

At each link in the chain there are weaknesses that directly or indirectly contribute to malnutrition. One of the tasks of the human rights-minded nutritionist is to identify these weaknesses, together with the claim holders, so as to strengthen as many of them as possible. In such an analysis:

• Political, economic, infrastructural, manpower, agricultural, educational, environmental, health and other constraints all need to be considered.
• Solutions often far removed from strict nutrition interventions are indispensable to succeed in the battle against malnutrition.
• Primary health care, agricultural, and rural development activities, all require a human rights focus, as demanded by organised claim holder groups.

Rural/urban imbalance

One of the weak links in the food chain is migration from rural to urban areas. Cities will continue to deteriorate if the countryside does not prosper. Every urban-migrating young adult is two less arms to produce food, and one more mouth to feed in the city. Those who stay behind increasingly are older women, children and elderly men. Given the current and projected massive urbanisation trends, increases in food supplies are liable to be only moderate in the future.

The traditional agricultural sector will, for years to come, continue to be the first driving force in many countries. Overall, it produces more than three-quarters of all food consumed. Availability of productive employment, revenue and food – in particular, staples – is often seasonal in rural areas. This compounds problems of health and nutrition during the hungry season.

In most lower-income countries, a sizeable proportion of the population – those of low income or subsistence status – get less than the recommended average daily calorie intake specified by the Food and Agriculture Organization of the UN (FAO). Urban averages are often higher than the FAO recommendations, but income disparities are widest in cities. It is safe to assume that 30 or more per cent of urban dwellers are also short of calories. Further, a minimum cost diet for an average family of five or six people is often above the minimum wage of unskilled urban workers. In most countries the overall purchasing power of the more impoverished proportion of the population will improve only very slowly, if at all - hence, malnutrition.

How to alleviate hunger and malnutrition.

The list of determinants of malnutrition is extensive, intricate, and interrelated. Here follows a list of policies and interventions that are necessary to move towards the eradication of malnutrition.

The capacity of any system to alleviate hunger and malnutrition depends on the concerted efforts government officers and political leaders at all levels make to address the basic, underlying and immediate causes of malnutrition. This is in turn related to whether those responsible are really actively and continually pushed towards their obligations in this field by active groups of claim holders demanding greater equity and social justice.

Even if willing and capable, I contend that governments, and other institutions in duty bearer roles will fail to do anything significant about malnutrition, unless a significant number of the following actions are planned and carried out in any national development programme:

• Strong encouragement of organisation of claim holders to secure their participation in development activities at all levels.
• Measures to slow down urban migration, such as increasing rural employment opportunities, making food crops more profitable to producers, and providing a minimum of infrastructural services in rural communities. These entail a change in investment priorities towards overall rural development.
• Measures to curb urban unemployment.
• Explicit incorporation of women into the development process, for example by making them eligible for agricultural extension, bank loans, and credit.
• Fair market prices for producers of cash crops.
• Agricultural banks to strike a fairer balance between cash-crop and food-crop credit allocation, favouring the latter.
• Minimum wages to be based on the results of balanced food-basket cost studies.
• Higher import duties to be levied on luxury items, especially luxury foods and drinks.
• Subsidies for selected durable inputs for small farmers, such as tools and small machines.
• Subsidy of fertilisers and pesticides. A fair balance to be struck between the proportion of these inputs going to food production as distinct from cash-crop production.
• Adequate logistical support for agricultural extension workers and community development workers.
• Priority given to home and school gardening programmes and small dry-season irrigation projects.
• Measures to improve farm-level food storage practices, in order to decrease food losses.
• Primary school enrolment to be increased especially for girls, and more teaching of work-related skills within school curricula.
• Adult literacy campaigns, with emphasis on women, to be intensified.
• Organisation and financing of a network of day-care centres in the country.

This list is by no means complete. It probably includes most of the more rights- and equity-oriented actions duty-bearers should embark on. It is essential that all such actions are monitored by claim holders.

The bottom line is as follows: Improving the nutritional status of vulnerable groups in the population remains closely related to the alleviation of poverty. It also requires specific interventions in several sectors. Only some of the determinants of malnutrition can by partially or totally corrected by explicit health interventions.

Halfdan Mahler gave his address to the 2008 World Health Assembly sitting next to the current WHO director-general Margaret Chan, as you can see below. Above is the second statement made by Dr Mahler on that occasion that I especially cherish.

Inspired by Dr Mahler and what he stands for, it is fitting for us nutrition workers to explore the special role of primary health care in the battle against malnutrition.

The vision of universal primary health care

Primary health care is the most viable, logical and best possible approach to progressively reach the goal of health for all. Whenever it has gained a real commitment beyond lip service in the allocation of resources in a country, it has improved the health and nutrition of its people, especially through the active community involvement it calls for. By doing so, it addresses the host of local health and nutrition problems as felt by the users of health and nutrition services.

Primary health care goes beyond conventional health care as it organises claim holders around activities aimed at addressing the immediate, underlying and also basic causes of ill-health, malnutrition and poverty. In the spirit of Alma Ata, it actually can mobilise claim holders to change some of the determinants of their neglected condition. Happily, 2010 has seen a revival of the call for primary health care, and also for universal health coverage, from WHO and also from civil society organisations (2).

A real emphasis on primary health care involves the shifting of priorities away from urban-biased, hospital-centred and physician-centred approaches. Interventions that indicate primary health care goals are being seriously pursued include:

• Construction, staffing, equipping and opening to use of more primary health care centres.
• Training of relevant paramedical personnel, village health workers and traditional birth attendants.
• A higher percentage of the national health budget shifted to preventive services, including nutrition.
• Ensuring the required national vaccination coverage is attained and maintained.
• Expansion and extension of the coverage of overall maternal-child health services, including nutrition and child-spacing (family planning).
• Ensuring preventive and curative approaches to malaria, tuberculosis and HIV and AIDS, not forgetting respiratory infections, intestinal parasites and diarrhoeal diseases.
• Increasing the number of deliveries properly attended by trained personnel.
• Expansion of the pre- and post-natal suprervision of mothers, to include monitoring maternal nutrition during pregnancy and lactation, and provision of iron and folia acid supplements, plus tetanus vaccination and malaria prevention during pregnancy.
• Promotion and expansion of latrine construction programmes through self-help.
• The number of households with access to safe and sufficient drinking water to be increased through community-managed projects.
• Introduction and use of growth monitoring and nutrition counselling in all communities, to include the training of personnel and of community members.
• Retraining of field health personnel with emphasis on nutrition and preventive health activities.
• Development of nutrition protocols for the treatment of malnourished children, to standardise the therapeutic approach at the national level.
• Mechanisms put in place to record and periodically report birth weight data.
• Review and improvement of the nutrition curriculum in all university health related courses.
• Introduction of health and nutrition education through the radio.
• Introduction of health and nutrition modules in the science curricula of primary, secondary and technical schools.
• Marketing controls of baby formula and of baby weaning foods. Banning of promotion of these products through the media and directly to mothers.

This list is also not exhaustive and, as said, includes some actions that are not strictly in the realm of primary health care. But all of them, and other more, are related to the problem of malnutrition and how to ameliorate it. Assessing national health plans to see if they incorporate these activities, and to what degree, will help to determine the capacity of the health sector to tackle the social determinants of malnutrition.

Implementation of all these interventions will be expensive and maybe beyond the capacity of poor countries in the short run. Nevertheless, progressive realisation strategies for health and nutrition, with measurable benchmarks for claim holders to monitor, have to be set. The alternative would be to relegate primary health care to a token programme within the national health strategy – a policy that should be fiercely opposed by claim holders.

Resources, dependency and power imbalances

To be effective, policies need to be rational and technically feasible. But this is not enough. There is also the question of human, financial and other material resources.

Can the rightful demands of claim holders be met with the existing primary care resources in a country? If no, then strengthening of primary health care capabilities needs to become a key national priority. Too often this has been overlooked, and otherwise well-conceived nutrition components of primary health care programmes have remained and remain on paper only. Inventories need to be made of existing available resources. This done, the missing resources, and the needs and areas for improvement, can be identified.

Foreign aid, such as World Bank loans, in part intended to alleviate hunger and malnutrition, has created dependency. The foreign debt this kind of aid generates is a constant reminder of the neo-colonial domination by countries of the North. Part of such borrowed money is used to maintain consumption levels, mostly for urban populations, while the prices of impoverished countries' export commodities generally fall. Little of such borrowed money has contributed to equitable economic growth and food self-sufficiency.

Yes, much more investment is needed in better health and nutrition programmes. But there is another issue here. Governments are likely to feel threatened by empowered and autonomous and driven claim holders, as much as this is exactly the purpose of universal primary health care. So here, maybe, is the greatest challenge faced by committed health and nutrition workers: to be aware that they are engaged in shifting the power imbalances between the governing and the governed.

We must not retreat into helpless passivity, watching the biological, ecological and social systems around us deteriorate. We can alter trends and avert catastrophes if we recognise and exercise our own power to make a difference. (6).

We ought to be advocates of the poor. Are we? Putting nutrition into primary health care programmes is of itself not enough. There are bigger issues, such as land mal-distribution, low farm gate prices, lack of investment in the peasant sector, and in health, in education, in water and in sanitation. More specifically, the control of food production and the value of food produced is still taken out of the hands of food producers. Further, peasants are pressed by their governments, which in turn are pressed externally, to favour technically advanced, large-scale agribusiness, which will never reverse the impoverished countries' food shortages.

Poverty – and to be more precisely the process of impoverishment – is the main issue here. Emphasis on more production of food fails to address the issues of why people in rural areas are poor, are in poor health, and are malnourished. These people are not fatalists or short-sighted or lazy and unimaginative. They are oppressed. Food and nutrition are political issues, and we professionals need to recognise this and act accordingly. One way forward is to insist on equity, on the human rights-based approach, and on universal primary health care, with what can then be an effective nutrition component. This is what Halfdan Mahler believes and stands for, and he is right. I sent him this column in draft. In his response he quoted a verse of Halfdan Rasmussen:

I fear
not execution,
not torture and not hate,
not death from rifle barrels or
the shadows on the gate,
I fear not restless nights
with shooting stars of streaking pain,
I fear but blindness from a world
indifferent and insane.

References

1. Editorial, Social Medicine, Vol. 3, No. 2, May (2008).
2. World Health Organization. Health Systems Financing: the Path to Universal Coverage. World Health Report. Geneva: WHO, 2010.

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. Unless we all become partisans... and other items. [Column]. Website of the World Public Health Nutrition Association, February 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.