What follows is not a flight of
fancy. Scroll back up, please.
This column is headed by a
singular because plural portrait
of the original eminence
rouge, Cardinal and Duke
Richelieu, above all the creator
of the pre-revolutionary French
nation-state, the first prime
minister, who was adept at
looking at both sides and ahead
all at the same time. Why him,
this month? Wikipedia says he
‘sought to consolidate royal
power, and to crush domestic
factions’. No, no, that’s not
the reason.
This portrait suggests – I think
correctly – that there is never
one right way to characterise
phenomena, and that even within
the same culture or society
there are different points of
view on what counts as evidence
(1) in every aspect of life,
including public health
nutrition. The same information
can be used to support different
conclusions, what are the
relevant sets of facts is a
matter of opinion, and there is
no such thing as a totality of
evidence. This is why there is
always a need for courts of law.
We all know this, don’t we? The
most we can do, is to make
judgements that are (as far as
we can see) the best fit with
what we can study, observe or
deduce, to encourage or to take
actions derived from such
choices, to see what then
happens, and to remain
open-minded.
We cannot even always be sure of
what is what. Take the drawing
below. In a world like ours but
without rabbits, we would all
identify it as that of a duck.
In a world without ducks, we
would immediately see a rabbit.
But in our world as it is, which
is it? Out of context there is
no way to say (2). In the
context of a pond, say, or a
grassy field, we would not be in
doubt. When children are shown
this famous ‘puzzle-picture’ at
Easter time, they usually ‘see’
a rabbit. What the drawing
suggests is another
uncomfortable observation:
what’s right, including what we
say is ‘true’, depends on
circumstances.
Truth, in any final or absolute
sense, is a mathematical or
religious notion – truth by
definition or by revelation.
Probably all of us brought up in
the rationalist, empirical
convention tend to talk and
think in terms of ‘the facts’
accumulating to ‘the
conclusion’, which we take, not
necessarily using the term, to
be ‘the truth’.
In science, ‘the truth’ is
an illusion
But this approach is muddled and
mistaken. A fair analogy is
architecture. Facts are rather
like bricks. The idea that an
accumulation of bricks, however
carefully selected, leads to a
house, is obviously absurd.
Bricks are one essential
building material, but until
they are used to give shape to a
design they are just heaps. The
same applies in science. Facts
have meaning inasmuch as they
are driven by ideas, and by
their nature all ideas can be
challenged – some more readily
than others. To take the analogy
further, we do not normally
think of buildings as ‘true’.
Buildings may be practical,
beautiful or durable, but it
would be rather fanciful to call
a building ‘truthful’. A more
appropriate term is ‘sound’.
So it is with any structure of
knowledge. Appropriate questions
for any judgement include not
‘is it the truth?’ but ‘does it
follow from agreed principles?’,
‘does it explain most if not all
information agreed to be
relevant evidence?’, and ‘does
it work well?’ Judgements are
good and sound rather than true
– except in a loose sense of
‘true’ which really means ‘good
and sound’. After that,
questions to ask include ‘can
the principles be developed?’
and ‘can the judgement be
refined?’ and ‘is there a
different way is seeing things
and therefore a superior
judgement?’
This is challenging, certainly.
In his day, Richelieu very
likely was perceived as a puzzle
rather like the picture above:
people who had to deal with him,
up to the king of France and the
Pope in Rome, might well have
never been sure where he was
coming from. And as for the man
himself, Duke Richelieu may have
been more comfortable seeing
things from different points of
view than Cardinal Richelieu,
but there again, in those days
princes of the Church were less
bothered with certainties than
most scientists are today. In
the beginning is the idea, ideas
are what make humans special,
and this sentence is an example
of a good idea.
Footnotes
- Feyerabend P. Notes on
relativism. [Chapter 1]. In:
Farewell to Reason.
London: Verso, 1987. As you
see, this started as a
reference, because I believe
it’s right to indicate
sources of opinions as well
as of information. But the
idea that everything is
relative and that the
absolute is an illusion,
goes back 2,500 years to the
Greek philosopher Heraclitus
and his idea of flow. This
does not imply that
‘anything goes’. Some
conclusions have proved to
be sound over a long period
of time, and can in a loose
ordinary language sense be
said to be ‘true’, which is
very different from saying
that they are ‘the truth’.
Many others though,
including some with mounds
of data that apparently
support them, at best are
provisional transitional,
and quite often crumble or
collapse when pressed or
pushed. This is notoriously
the case with nutrition
science.
- Wittgenstein L.
Philosophical Investigations
II, ix. Oxford: Basil
Blackwell, 1953. Except that
Wittgenstein’s name
‘duck-rabbit’ evades the
issue. In no sense is the
picture that of a hyphenated
‘mythical beast’, a
combination of one creature
with another, such as a
centaur or a mermaid. It is
that of a duck, or a rabbit,
depending on context – your
point of view.
Food and drink classification.
Alcoholic drinks.
Degree of proof
Readers of this column can be
assured that I am not a
fruitarian, nor am I in my
everyday life a follower of all
dietary guidelines (any more
than you are). For instance,
since my youth I have been
enjoying wine, and began to buy
Chianti in straw-wrapped bottles
in London’s Soho to import to
secret school parties over half
a century ago.
But prompted by syrupy taste,
early-onset fuzzy brain-waves,
and examination of the small
print on the labels, how come
wine now seems usually to come
at 13 proof, even ascending to a
previously unknown
Port-approaching 14.5, whereas
not so long ago it was more or
less 12? This change has, in
effect, produced different
products.
Is there some trade-off being
discussed behind closed doors,
analogous to the ‘low-tar’
cigarette deals between
governments and Big Tobacco? Is
the plan that in due course,
labels will carry some mild
advice not to get drunk too
often (as they do in Brazil), in
return for the manufacturers
boosting the ethanol content of
any type of alcoholic drink?
Investigative journalist
readers, get to it!
Stunting. Wasting
What's wrong with being small?
What follows is a view that
contradicts the current
consensus, is highly
contentious, and I think is
correct. Here is another
puzzle-picture, though I need to
explain why it’s similar to the
drawing of a duck that may be a
rabbit, or a rabbit that may be
a duck. On the one hand, it’s
the bust of another great
Frenchman, François-Marie Arouet,
universally known as Voltaire, a
founding father of modern
thought, who died in full
possession of his faculties at
the age of 83, and is emtombed
in the Pantheon in Paris.
The introductory reason to
introduce Voltaire here is that
he is best known as a champion
of free-thinking and of
tolerance. He is supposed to
have said ‘I detest your
opinions, but I will defend to
the death your right to express
them’. In this spirit, a large
part of the purpose of the
original contributions to this
website, and also to the
Association’s journal
World Nutrition, is
to encourage discussion and
debate and, sometimes, to
express minority views which may
turn out to have more cogency
than is generally supposed. The
only way to find out, it seems
to me, is to air the views and
to ask for responses. So here
goes.
People great – and small
My main reason to show Voltaire
here, is that he was small, even
for his time (1). At around 155
centimetres, or 5 foot 1 inches,
he was shorter than the current
Queen Elizabeth of the UK now is
in old age. (If you saw pictures
of the reception by the Queen
and Philip of President and
Michele Obama, both practically
a head taller than their
counterparts, you may have had
the sense that these were almost
different species). If
epidemiology had existed as a
science in his time, and if an
epidemiologist from the foreign
land of les ros-bifs
(England) had checked out
British average stature, taken
this to be ‘the norm’ and done
some statistical abracadabra,
Voltaire would have been
classified as ‘stunted’. So on
the other hand, it’s the bust of
a stunted man.
Many other remarkable people,
some from long ago, some who
lived more recently, were small
and by current definitions were
‘stunted’. For example Benito
Juarez, the first native
president of Mexico, featured on
the current Mexican 20 centavo
banknote – here he is – was
around 4 foot 6 inches, or less
than 140 centimetres.
Of very many other examples of
great ‘stunted’ people, Genghis
Khan and the former Chinese
premier Deng Xiao-ping were more
or less 5 foot, or around 152
centimetres Immanuel Kant, David
Ben-Gurion, Milton Friedman, and
Isambard Kingdom Brunel, may
have been a couple of
centimetres taller. The picture
below is of the civil engineer
Brunel, recently voted the
second greatest English person
ever,
chomping a stogie.
Like ‘lift’
shoes, big hats give an
impression of height only if you
are the only person wearing one.
In her younger life Queen
Victoria, who presided over the
British Empire for over 60 years
and who had nine children, was 5
foot,
shrinking in old age to 4 foot 8
or 142 centimetres. William
Wilberforce and Ho Chi Minh were
maybe a couple of inches taller
than Voltaire. James Madison,
Josef Stalin, Mohandas Gandhi
and Pablo Picasso were around 5
foot 4, or 162 centimetres, and
Nicholas Sarkozy of France and
Vladimir Putin of Russia are
probably both around 5 foot 5
(165 centimetres), though their
use of ‘lifts’ makes this a
guess.
But famous people don’t get
classified as ‘stunted’. The
term refers to all people who
are two standard deviations
below the height deemed to be
desirable, which, being
interpreted a different way,
means people below the 5th
percentile of height of people
measured and recorded at a
specific time in the USA. It is
applied generally to anonymous
percentages of populations and
in particular children under the
age of 5 in ‘the developing
world’, irrespective of the
reasons why they are short. Thus
in the map below, 31-50 per cent
of under 5s in the countries
coloured red, and over half in
the countries coloured brown,
are classified as ‘stunted’.
Likewise ‘wasted’ refers to all
people who are two standard
deviations lighter than the
weight deemed to be desirable,
determined by the same criteria.
The general idea is that we, who
are OK, have the responsibility
to feed them, who because of
being liable to be two standards
of height or weight or more
below what we define as being
OK, are therefore not OK, in
order that they approximate to
our height and weight, and
thereby ‘fulfil their human
potential’, and – or so it is
claimed – gain higher marks in
class, get better paid jobs, and
generally make more contribution
to society.
Benefits of being small
In my opinion this is a bad use
of science, horrible public
health, and in its effects
already an obvious contributor
to the collapse of public health
and the destruction of the
world. This said, I will sketch
some of the stages of argument.
An immediate response to the
mention of Benito Juarez, Deng
Xiao-Ping, Nicholas Sarkozy etc,
is to say that these and other
remarkable short people are
exceptions that prove nothing,
and that almost all remarkable
people are tall. Well, I wonder
if this is true. Obviously it
will become true in societies
like our own now, that promote
people simply because they are
tall.
But in general is this true,
throughout history? In the
absence of systematic records I
beg leave to doubt this. It
surely would have depended on
circumstances. In pastoral
societies without money where
wealth was embodied, as
sometimes in Africa, enormous
tall men would tend to be the
chiefs, and the husbands of fat
women. In societies whose
success and survival depended on
vast migrations and invasions on
horseback, as in mediaeval
Mongolia, the model of manhood
was like that of a jockey, small
and light.
And in
modern times? Here is a
photograph taken during the
invasion of Vietnam by the USA,
by the great Magnum photographer
Philip Jones Griffiths, a dear
friend of mine who died
recently. What you see is a US
grunt looking at an old lady who
is comforting an injured baby,
perhaps her grandchild. Philip
confirmed to me that the GIs
were generally around 6 foot or
more (say, 185 centimetres) and,
being fit, maybe around 185
pounds (say, 85 kilos), whereas
the average male Vietnamese
peasant was around 5 foot 3 (160
centimetres) and perhaps 132
pounds (say, 60 kilos). Women
were correspondingly smaller and
lighter; old ladies, more so.
The same is true of rural people
in pre-industrial societies all
over India and China and
elsewhere in East Asia.
Since the 1950s a high
proportion of these populations
have been defined by United
Nations agencies, official and
unofficial aid and development
organisations, the governments
of their own countries, and
almost all scientists who make
normative recommendations, as
‘malnourished’ – meaning
undernourished – simply because
they are small.
When I present on this topic, as
I sometimes do, and show this
picture, I explain that it tells
a dark story. Half an hour
later, the GIs, and Philip, had
taken off and were above the
village in helicopter
fire-ships, and everybody in the
village had been bombed, shot or
incinerated, except perhaps some
who fled into deeper tunnels in
time. The caption to the
picture, in the spirit of the
captions Goya wrote for his
‘Disasters of War’ series, is:
‘Who won the war?’
John Waterlow, one of the few
living nutrition scientists
surely seen as one of the
all-time greats, has been
brooding on the issues of height
and weight for many years. In
the 1985 UN report Energy and
Protein Requirements, which
he chaired, and much of which he
drafted, and in other writing,
he points out that physically
active light, small people such
as Nepalese porters, Indian
miners and even African pygmies,
may be stronger and have more
stamina than bigger, taller
people (2,3). He concludes,
cautiously: ‘I am inclined to
think that except when there is
a demand for heavy and
continuous physical work, it is
no great physical handicap to be
small’ He then makes a more
profound point. ‘If everyone was
to achieve the height now common
in industrialised countries,
this height explosion would be
almost as disastrous as the
population explosion, carrying
with it the need not only for
more food, but for more
clothing, more space, more
natural resources of all kinds’
(3).
Markers are not causes
Now, I propose what is the
correct approach to human
height. First and foremost,
there is nothing wrong as
such in being short. The
issue is the causes of
shortness. Some causes of
shortness are benign. Among
these, I suggest, are relatively
frugal while adequate (5) and
nourishing diets consumed by
mothers before and during
pregnancy, followed by extended
breastfeeding and similarly
frugal while adequate and
nourishing diets during weaning
and then childhood. Within
populations the general result
will be small, light children
and adults. These populations
can be, and often have been,
active and healthy (5).
Shortness, even when it can be
defined as ‘stunting’, is not
the public health issue. The
issue is factors which make
children short, and which also
make them in some sense
physically or mentally backward
or even retarded. These include
repeated infections and
infestations, diets that are
inadequate sources of energy
even for small people, and also
are poor or deficient in various
micronutrients and other
bioactive substances. They also
include broader determinants of
ill-health such as unsafe water
supplies, inadequate primary
health care, poor schooling, and
all the other manifestations of
poverty and misery.
In practice, many and even
probably most children who by
the standards of people in
materially rich countries are
decidedly short, do suffer the
results of poverty and misery.
Consequently, shortness defined
as ‘stunting’ is a rough and
ready, fairly reliable marker
for malnutrition – and also for
other manifestations of
deprivation. To put this another
way, children in Asia, Africa
and elsewhere who are by the
standards of visiting health
professionals very short, are
probably suffering the effects
of infection, infestation, and
other deprivations of their
rights and entitlements. But
this does not mean that
shortness is itself a cause of
their suffering. It is not.
This point is extremely
important, because it indicates
the right, and the wrong, public
health approaches to
impoverished populations. The
wrong approach is to feed
infants and small children with
lots of energy-dense foods, in
order to make them bigger than
they otherwise would be. To
repeat, size in itself is not
the issue. Plus as we all know
now, with the Chile experiment
as an outstanding example, the
result of overfeeding small
infants, is rocketing rates of
fat children and obese adults,
with all that implies (6).
The right approach is the
classic primary health care
combination. This includes
ensuring that the food supplies
and therefore diets of women of
child-bearing age are adequate
and nourishing; that mothers
breastfeed their children
exclusively until six months and
beyond; that water supplies are
clean; and that children are
free from infections and
infestations. Broader approaches
are also essential. These, like
the cessation of invasion,
dislocation and civil wars, are
often beyond the capacity of
health professionals except
inasmuch as they can be
effective citizens.
There is very much more to be
said here. As always, responses
are encouraged.
Footnotes and
references
-
Fogel R. The persistence of
misery in Europe and America
before 1900. [Chapter 1] In:
The Escape from Hunger
and Premature Death,
1700-2100. Cambridge:
Cambridge University Press,
2004. From various sources,
Robert Fogel reckons that
the averages height of men
in Britain towards the end
of the 18th century was
around 5 foot 6 (168
centimetres) and of
Frenchmen around 5 foot 4
(164 centimetres). No doubt
upper-class men were on
average relatively tall.
Robert Fogel comments:
‘During the eighteenth and
nineteenth centuries,
Europeans were severely
stunted by modern
standards’.
-
World Health Organization.
Energy and Protein
Requirements. Report of a
joint FAO/WHO/UNU expert
consultation. Technical
report series 724.
Geneva: WHO, 1985
-
Waterlow J. Needs for food.
Are we asking too much?
[Chapter 1]. In:
-
Waterlow J, Armstrong D,
Fowden L, Riley R (eds).
Feeding a World Population
of More Than Eight Billion
People. A Challenge to
Science. New York:
Oxford University Press,
1998.
-
Yes, I realise that
‘adequate’ begs a lot of
questions. And yes, I am
referring here to what has
been the furious controversy
epitomised as the ‘small but
healthy’ debate, associated
with the Indian nutrition
scientist PV Sukhatme and
his sympathisers.
-
Chilean experiment? Readers
of this column from Chile
will know what I
mean. Otherwise, google
‘Fernardo Mönckeberg’ and
follow where this leads. It
is a long, winding and dark
story. More in future
columns.
Hunger
Getting it wrong
You might imagine that
the points made in the previous
item above, while interesting
and even convincing, are not
especially important. If so you
would be wrong. Here I
illustrate why, using two
photographs taken in Brazil.
The first picture shows the
current Brazilian president
‘Lula’ on stage. Born into
poverty, and sometimes seen as
the Brazilian equivalent of
Abraham Lincoln, Lula knows
himself what it means when a
family is hungry much of the
time. This was his own
experience as a child. This fire
burning in him has ignited the
Brazilian Fome Zero (Zero
Hunger) programme, a flagship
initiative based in the
president’s own office. Lula
believes that any food that
satisfies hunger is good.
Meaning, for quick effects,
readily available, energy-dense,
fatty or sugary (and often also
salty) processed products, are
the goods.
So here is Lula with a couple of
his ministers (who look glum) on
a Nestlé platform in Brazil,
together with company
executives, in effect puffing
their products and their
propaganda. He believes, because
of his own experience, and also
because of what he has been
told, that any microbiologically
safe product that efficiently
delivers calories, contributes
to the protection of public
health and the welfare of
impoverished people. Plus he
evidently has no problem with
the incursion of any
transnational food and drink
company into Brazil. Alas.
And the result? The next
picture shows Nestlé delivering
its products to the poor people
of Brazil on a big river in Amazonia, with a
floating supermarket of its
branded products. Will this
imprint in the minds of
impoverished communities and
families, the idea that Nestlé
purveys health? Yes, it will.
Can these families and
communities readily afford
branded processed products,
including artificial formula and
weaning foods? No, they cannot.
Will these massively marketed
campaigns, with evident
presidential support, erode
commitment to sustainable,
appropriate food systems that
give employment to local
communities? Yes, they will.
Has Lula got it wrong? In
this case yes, big time.
Brazilian readers of this
column, prepare to enlighten the
next president, who takes office
next year, in 2011. And once he
is out of office, watch Lula’s
waistline.
Request and acknowledgement
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: Cannon G.
Blogs, columns, referencing and
review, and other items.
[Column] Website of the World
Public Health Nutrition
Association, July 2010.
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 Fabio
Gomes. My partner in the New
Nutrition Science project is
Claus Leitzmann. My thanks also
and always to Google, Wikipedia,
and the astonishing Guardian
On-Line.
geoffreycannon@aol.com
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