Hero for this month is Patti Rundall, policy director of Baby Milk Action. High time too, and the month is right, because the first week of August is World Breastfeeding Week, and this year celebrates its 20th anniversary and also the 10th anniversary of the UN Global Strategy on Infant and Young Child Feeding. Patti always emphasises that she is just one of a global network of people and organisations dedicated to the cause of breastfeeding. This is true.

The structure of the column this month is as follows. First there is a think-piece about public health nutrition: its nature, purpose and aims. Sorry to say, these reflections are gloomy, but how could this be otherwise? We are living at a time of the supremacy of greed, dominated by transnational corporations and their allied and supportive organisations including most powerful national governments, in which most public institutions in most parts of the world – not all! – have been undermined and impoverished. In such a world most – not all! – nutrition professionals working in the public interest in the field, are like army surgeons patching up the wounded on the battlefields of futile wars, or if researchers, are like scribes annotating texts to be placed in libraries for other scribes to read and annotate.

But not all! Hence the second item this month, which gives some idea of why the networks upholding breastfeeding of which Patti Rundall is one conspicuous member, are effective and set an example that need to be followed by other organisations working in the public interest. Then I return to one of my themes: small is sustainable. Next month sketches the first acts of a drama centred on breastfeeding in which I played a speaking part, which outlines the circumstances in which public health nutrition action can succeed.

The profession of public health nutrition

Actors or observers?

Here's a question implicit in so much that is spoken and published on our topic. How do we get from where we are now, to where we want to be? It's a question worth asking every year or so. It leads to other questions. Who are 'we', where are we, when is now, why do we want to be somewhere else, and what for? Plus, what's stopping us? Only then can we get a grip on 'how'.

Here I assume that 'we' is not existential – humanity as a whole – but refers to us who are in some sense public health nutrition professionals. Also I assume we agree that where we are right now, is in a situation of crisis, confronted by pandemic uncontrolled obesity, diabetes, and other serious chronic diseases of which a major cause is bad nutrition.

We have reason to feel uneasy, and may be reminded of this as a result of experiencing backchat from friends and acquaintances outside the profession. It's unwise to mention at parties that you are a nutritionist, because of the risk of being asked for – or even being offered – a dieting regime. It is also problematic to identify yourself as a public health nutritionist, because after explaining what this means, you may be asked something like 'so how come the world is getting fat?' or else 'so why are there as many children starving now as ever there were?'. (Or, this month 'so why haven't you done something about Coca-Cola, McDonald's and the Olympics?'). Politicians also tend to ask questions like this. What do you say in response? Something like 'well, it's all very complicated…' does not hit the spot.

It is complicated, though. Also worrisome, is the nagging knowledge that ever since the emergence of nutrition science as a way to improve the human lot, a solution to one problem may create another and maybe bigger problem. One of last month's issues of The Lancet gives an example (1). To quote: 'In Chile, supplementary feeding programmes reduced undernutrition but had a much stronger effect on weight-for-length (or weight-for height) than on length-for-age… resulting in increased prevalence of overweight' (2). And also: 'In the USA, the Special Supplemental Program for Women, Infants and Children took decades to adjust to changing nutritional circumstances and revise the food package in an effort to prevent further increases in maternal and childhood obesity' (3).

The order of our house

This mild breastbeating may be annoying you. After all, who now claims that economists, or bankers – or politicians – are doing such a great job? But we should attend to the state of our own house.

It is perhaps self-evident that where we want to be, is in a world where diseases of which bad diets are a cause are at least under control. Who would disagree? But already some of us – including myself – would not express the goal in this way, and instead would refer to corrupted food systems and supplies, seeing the issue as more one of production than of consumption. In the same way, some of us tend to see the obstacle largely as one of unwise personal choices; whereas others of us – again including myself – see the current crisis, most of all in the global South, as caused largely by the dominance of transnational corporations unleashed in the last 30 years by what still remains the dominant laissez-faire political and economic ideology, put into practice (4).

So already we are in difficulties, because there is no general agreement within the profession. This is not to suggest that there are diametrically opposing views. But there is certainly impatience and friction. This in part centres around whether or not colleagues see the state of population nutrition as a political issue.

Besides which, others of us continue to maintain that the main crisis is not chronic non-communicable diseases, which at least for those of us who are relatively educated and privileged are to some extent self-inflicted. Rather, our main concern should remain infant and young child malnutrition in the classic sense, involving nutritional deficiencies exacerbated by constant infection and infestation, typically in communities with limited ability to help themselves. This may well be the view of most older nutrition professionals who are or have been based in impoverished countries in Africa and also Asia. And of these colleagues, a substantial number believe in good faith, in common with UK Prime Minister David Cameron, that transnational corporations are not part of the problem, but are the actors who are best able to provide the solution.

The position of industry

The view that the activities of industry increase the burden of disease is, after all, relatively new. When inadequate food was the main issue in industrialised countries, which it was until almost the middle of the last century, the food industry, including big corporations, were usually seen as benefactors. Further, a growing number of colleagues, while preferring public to private initiatives, feel that it is futile to go on opposing the privatisation of public institutions. They feel that the only hope lies in civilising the colossally powerful billionaires and corporate chief executives who obviously are now the masters of our universe. After all, the argument continues, Michael Bloomberg has got the point. Why not others?

This is not all. In common with colleagues in other disciplines, many nutrition scientists, including a large number who are dedicated to the protection and improvement of public health, believe that their profession is the study and not the application of nutrition. Some go further and state that their work would be confused and even contaminated if they became involved with public policy, which they believe, in the phrase of Peter Medawar, is the responsibility of 'our political masters' (2).

Nor is this all. A substantial proportion of nutrition professionals work for transnational corporations and allied and associated organisations, and almost by definition are concerned with public health. Also, many nutrition research centres, non-government organisations, and professional conferences, depend on industry funding, as do many senior research scientists and their teams. None of this necessarily alters the view of fellow professionals involved with industry on what the problems are, but their views on the solutions are likely to differ from those of colleagues who make a point of avoiding significant engagement with industry.

Further, the majority of colleagues, senior as well as young in their careers, simply get on with ordinary science, without getting involved what they may regard as inappropriate political posturing.

So now back to where these thoughts began. What they show, it seems to me, is that 'we' is an illusion. Or else, that one sufficient block on effective action is us. Within the profession of public health nutrition there is no doubt general agreement on matters of broad principle, but there is certainly a very wide range of views on what are the main problems and the best solutions. There again though, perhaps this is true of any profession.

References and notes

1. Gordon-Larsen P, Jones-Smith J. Challenges in ameliorating hunger while preventing obesity. The Lancet 5 July 2012. http://dx.doi.org/10.1016/ 50140-6736/12/60909-x.
2. Uauy R, Kain J. The epidemiological transition: need to incorporate obesity prevention into nutrition programmes. Public Health Nutrition 2002, 5, 223-229.
3. Oliveira V, Frazao E. The WIC Program: Background, Trends, Economic Issues. Washington DC: USADA/ERS, 2009.
4. Monteiro C, Cannon G. The impact of transnational 'Big Food' companies on the South: A view from Brazil. PLoS Medicine July 2012, 9, 7. Obtainable at: http://www.plosmedicine.org/article/info%3 Adoi% 2F10.1371%2F journal.pmed.1001252
5. Peter Medawar used this phrase towards the end of his valedictory book The Limits of Science (Oxford University Press, 1984). Was he being ironic? After a passage on the vast power of science he says 'This places on scientists a moral obligation which, considered as a profession, they are only just now beginning to grapple with. From our political masters it calls for a degree of wisdom, scientific understanding, political effectiveness, world sense and goodwill that no administration in any country has yet been able to muster'. Ironic or not,with the steadily increasing privatisation and commercialisation of public affairs in the last thirty years, this is surely even more true now.

Public interest organisations. Breastfeeding

Getting organised

As you have seen, my hero this month is Patti Rundall. But in an important way though, I am wrong to single Patti out. My reason to do so is that she has guided, inspired, charmed, coaxed and bullied me for nearly 20 years now, especially throughout the 1990s when I chaired the UK National Food Alliance (now Sustain, at http://www.sustainweb.org/). More than anybody else she has made me understand the real purpose of public interest civil society organisations. So she is a friend and comrade, and yes, a hero.

This said though, talk to anybody in the breastfeeding movement, however charismatic and famous she or he may personally be, and you will be told the same thing. This is that the movement gains its strength and influence from its solidarity – its common vision, purpose, and goals. These are expressed formally in stated aims and objectives that are openly and respectively discussed, and that are then put into action by networks of networks organised geographically and around themes, partnerships and projects. Flexibility is also essential: the ability to respond efficiently to events as they arise, including emergencies. One critical aspect here is that many hundreds – thousands – of good honest caring people, many of whom are parents, from village to international government level, are informed, involved, and engaged.

Violations of the Code of Marketing of Breast Milk Substitutes: advertisements promoting infant formula feeds in Russia, 2001 (left) and Taiwan, 2002 (right).

The pictures above give a glimpse of what those who advocate breastfeeding are up against. These are of advertisements in 2001 and 2002 for baby formula in Russia and Taiwan that break the UN Code of Marketing of Breast Milk Substitutes, twenty years after it was adopted by the WHO World Health Assembly in 1981 (1). How on earth can civil society organisations largely made up of volunteers, monitor and check such practices, given the colossal scale and power of leading baby formula and feed manufacturers of which one – Nestlé – is the biggest transnational food and drink manufacturer in the world?

With difficulty, is one answer. Because their cause is clearly righteous, is another – except it needs to be remembered that not so long ago, artificial baby formulas were commonly seen as equal to or even superior to breastmilk. What is now the universally accepted perception that 'breast is best' did not occur by chance.

Another answer, is that the leading breastfeeding civil society organisations operate in much the same way as Greenpeace: they are global while devolved nationally and locally, and they combine penetrating research, formidable intelligence (2), incremental information, and direct action (3)

Now for the organisation diagram that helps to explain why the breastfeeding movement is so effective, and why (sorry) other organisations wanting to make a difference in nutrition-related public health fail and will continue to fail. This diagram shows how the World Alliance on Breastfeeding Action works – which it does. It is a transparent and accountable indication of a transnational civil society organisation – with its sister organisations, as far as I know, unique in our field in being effective.

Here above: the organisation diagram of the World Alliance for Breastfeeding Action (WABA). Its very close resemblance to a web or a net is significant

Within this yes, there are leaders, like Patti Rundall. But she is the first to tell me how anything learned from her has to be referred to and agreed by her Indian colleagues, who have very good reason to be a lot tougher than she is. Besides, as Patti warned me in 2000 (and more of this next month), in effect – not her exact words – if you think I take no prisoners, just you wait for Annelies Allain! Later I learned – and this is for next month's column.

Annelies Allain, a founder of IBFAN, schmoozing with two WHO directors-general: Halfdan Mahler (1973-1988) and Gro Harlem Brundtland (1998-2003)

But I return to a theme of this column. With great pleasure I notice that around two-thirds of the people now joining the Association are women, and that most of these are relatively young. One reason this is promising, is that women are usually – not always – so much better than men at working together. Now please see the picture below, which records the acceptance by the global breastfeeding movement of the Right Livelihood Award, also known as the alternative Nobel Prizes.

Righteous recognition. Demonstration of maybe the one and so far the only effective public health nutrition organisation, which is devolved worldwide

For the first time a network and not an individual was selected. Representing IBFAN are (from left to right) Britta Hejdenberg (Sweden), Elisabeth Sterken (Canada), Ruth de Arango (Guatemala) and Ira Pushpadewi (Indonesia) holding the award, Alison Linnecar (Switzerland/UK), Pauline Kisanga (Tanzania) (also holding the award), Hisayo Kikodoro (Japan) – and Patti Rundall (UK). We may see this picture as iconic.

If we in public health nutrition really and truly do want to make a difference, changing what is wrong and protecting what is right, I suggest that we here have our inspiration and guide: the global breastfeeding movement. In my experience and judgement, in our field these networks are so far alone in making any real difference for the better to public health nutrition.

Notes

1. The pictures and other material in this item are taken from Annelies Allain's report Fighting an Old Battle in a New World. How IBFAN Monitors the Baby Food Market (Uppsala: Dag Hammarskjöld Foundation, 2005). It is not suggested that Mead Johnson or Nestlé are the only formula manufacturers who flout the UN Code.
2. Intelligence in the sense as used in the Central Intelligence Agency. The most effective operators within the breastfeeding movement seem to know everybody who counts and, even more formidable, seem to be respected and even liked by their most aggressive adversaries.
3. Direct action is an essential and invariable part of all effective civil society organisations. This is a lesson taught in different ways by Mohandas (Mahatma) Gandhi and by Nelson Mandala, as well as more historically by the fights for universal suffrage. Direct action does not have to involve breaking current law, but it certainly does involve seeming at the time to be unreasonable. Now I suggest a rule, which is: all organisations that want to make any sort of difference, and which remain reasonable, will contribute to the problems they seek to solve.

Human size

What pictures may tell

Here is Queen Elizabeth (left) at the 60th anniversary of her accession; and here (right) is Michael Bloomberg stepping out with partner Diana Taylor

Lately a point made by the great nutrition scientist and activist John Boyd Orr, to his patient colleague David Lubbock, has been coming to mind. In his inimitable Ayrshire accent, he said words to the effect of: 'Laddie, if you want people to understand what you're saying, you have to say it again and again, a hundred times, a thousand times'.

Sizing up the UK royal family

Hold the thought, and have a good look at the pictures above. The one on the right shows the very self-confident Michael Bloomberg, mayor of New York City, who is around 1.71 (5 foot 7.5), with his partner Diana Taylor. This makes him a bit taller than Lionel Messi, currently the world's number one footballer, and a lot taller than Sachin Tendulkar, the cricketer who many would rate as the world's number one batsman.

The picture on the left was taken and published this summer on the occasion of the 60th anniversary of the accession of Queen Elizabeth to the UK throne. A future viewer might make a number of remarks, such as on the curious custom of English upper-class women in our era to wear cakes on their heads.

Another remark surely would be on the astounding difference between the height of the Queen, whose height is at a guess now about 1.57.5 metres (5 foot 2) and that of her grandson William and his wife Kate Middleton, now the Duke and Duchess of Cambridge (2), who are both a head taller than she, as you can see. Indeed, people in times to come who didn't know what the occasion was or who the people were, might well assume that the old lady and the young couple were not related. There again, this picture might appear with others of grandparents and grandchildren from say the 'BRIC emerging market economies' of Brazil, Russia, India and China, in a textbook celebrating the nutritional and other public health aspects of 'the realisation of human growth potential' in the 20th century.

'Stunting': no simple solutions

Well, it's been said already in World Nutrition (2) and elsewhere (3-5), and it's going to be said again here, briefly, with a bow to Boyd Orr. The consensus among specialist nutrition and other relevant scientists is that it is best to be tall. It still seems to me that the case for this position is not solid, and certainly in one respect is wrong. Much depends on what is meant by 'best'. Best for what?

Take 'stunting'. This term is mostly used to refer to children especially in low-income and impoverished countries and settings, whose height for age is below specified levels. It is important to know that this includes children who are short but who show no sign of any kind of disease or impairment. Judged in this way, 'stunting' is certainly a reliable marker for gut infections that cause diarrhoeal diseases, for parasitic infestations, and also for grossly inadequate diets of the mother in pregnancy as well as of the child, all of which have interactive effects. It is also true that when resources dictate mass treatment, de-worming, use of essential antimicrobial drugs, and diets that are adequate in quantity and quality, perhaps in that order, are necessary.

But it does not follow that short height in itself is a problem. This is not a mere academic point. Certainly, women of child-bearing age should be physically active and eat well. Certainly, very small babies need special care, which includes good nutrition and also nurture, in environments where water is safe and sanitation is adequate. But accelerating the growth of children, by very energy-dense therapeutic foods, or by diets largely composed of energy-dense ultra-processed products (now common or even seen as normal in the global South) accelerates rates of obesity. That is to say, treatments designed to specifically to push child growth by pushing calories into children, tend to make them fat. What is best to do in impoverished countries and settings, is now revived as a hot topic, after it was first raised over 60 years ago (6,7).

The environmental footprint

Small people often make better soldiers. In history, it was light cavalry
who were the conquerors. These days, wars tread very heavily on the earth

In one respect at least the 'tall is beautiful' thesis is mistaken. With a second bow to Boyd Orr, here again is reproduced the slide above. The point is simple. The bigger we are, the heavier our environmental footprint. The smaller people and populations are, in height and in weight, the fewer resources of all sorts they need. The point has been recently made in a paper published by BMC Public Health (8). The authors calculate that while the US population is 6 per cent of the world's population, its biomass amounts to 34 per cent of the global total. By contrast, while Asia's population is 61 per cent of the global total, its biomass amounts to a mere 13 per cent. The authors conclude that if all countries had the BMI of the US, this would amount to 58 million tonnes extra, or 473 million extra adults.

Public health nutrition is a branch of public health, and as such has social, economic and environmental as well as biological and behavioural dimensions. Very well. In that case, when considering human height, and the future of generations to come and that of the planet, it's a question of weighing up and balancing all relevant considerations. Let debate flourish.

Meanwhile let's not look down on Queen Elizabeth. At 85 she is in great shape.

Note and references

1. Queen Elizabeth is officially 5 foot 4 (1.62.5). This is not credible. She is likely to have shrunk a couple or so inches (say 5 centimetres) as part of the ageing process. Adjusting for her hat she must be at least a foot (25 centimetres) shorter than William.
2. Samaras T. Reasons to be small. [Commentary] World Nutrition, March 2011, 2, 3: 108-135. Obtainable at www.wphna.org
3. Anon. Small is ecological [Editorial] World Nutrition, March 2011, 2, 3: 101-107. Obtainable at www.wphna.org
4. Cannon G. Thinking about height. In: This great movement of ours? and other items. [Column] Website of the World Public Health Nutrition Association, July 2011. Obtainable at www.wphna.org
5. Cannon G. Let the light shine. In: The preservation of the world, and other items. [Column] Website of the World Public Health Nutrition Association, November 2011. Obtainable at www.wphna.org
6. Victora C, Barros F. Commentary: The catch-up dilemma – relevance of Leitch's 'low-high' pig to child growth in developing countries. International Journal of Epidemiology 2001; 30, 2, 217-220.
7. Leitch I. Growth and health. British Medical Journal 1951, 5, 142-151.
8. Walpole S, Prieto-Merino D, Edwards P et al. The weight of nations: an estimate of adult human biomass. BMC Public Health 2012, 12, 439. doi:10.1186/1471-2458-12-439

Halfdan Mahler

In praise of direct action

Usually these columns end with a quotation from the hero of the month. But Patti Rundall is more a doer than a writer, and in any case it feels right to quote from somebody who in turn is one of her heroes. This is Halfdan Mahler, director-general of the World Health Organization from 1973 to 1988, architect of the Alma Ata 'Health for All' statement championing universal primary health care. He is the UN chief official who first gave the breastfeeding movement the presence and influence within the UN system, national governments, health professional organisations – and the baby formula and feed industries – that it continues to battle for and hold onto.

Reference

1. Mahler H. Foreword to Allain A. Fighting an Old Battle in a New World. How IBFAN Monitors the Baby Food Market. Uppsala: Dag Hammarskjöld Foundation, 2005.