Some more Food for Thought
--------------------------
HEALTH, NUTRITION AND SUSTAINABLE DEVELOPMENT
At the closing of the century, the central question I think we are not
often enough asking ourselves is: If we are trying to insert health and
nutrition interventions in the Third World more in the realm of sus-
tainable development, why is so much that has been said, written and
spent on this having so little effect on the problems that our actions
are actually seeking to address?
The answer to this question lies in various fronts; among them, more
often than not: - following Northern-led approaches, our praxis has be-
come professionalised and, in the process, we have devaluated and de-
moted the role of popular knowledge in our fields of expertise; - our
prevailing values and attitudes as researchers and practitioners in
this field have prevented us from acting as equals with our Third World
national counterparts; - we still control knowledge as part of the
elite, and thus fail to get a deeper understanding that will guide more
appropriate actions; the latter can only come from a process of genuine
popular participation.
The root of the problem is that sustainable development is about proc-
esses of popular enrichment, empowerment and participation which the
(our) technocratic project-oriented view has simply failed to accommo-
date.
Also contributing to the irrelevance of many past and current ap-
proaches is the fact that overall development education has continued
its traditional conservative role of transmitting society's values
mostly as they are perceived in the North. The time has come to demand
profound changes that accommodate more multi-centric new approaches.
Those who teach us, inevitably teach us part of themselves and the
frame of values that is part of their background. Each context they
come from has its own frame of assumptions about what is real, what is
unshakable and what is safe. The problem is that sometimes these con-
texts become cages, especially in our type of work in health and nutri-
tion. The time has also come for new frameworks to break the old think-
ing patterns and make health and nutrition work more genuinely partici-
pative.
Unfortunately, difficult problems have the power of leading us to focus
on their more manageable components thus totally avoiding the more com-
plex, underlying and basic, structural question. This is known as 'the
exclusion fallacy' in which what we choose not to discuss is assumed to
have no bearing on the issue. (Mc Dermott)
We cannot, therefore, continue supporting an outlook on the future that
is partly based on presumptions and forecasts rooted in desires from
outsiders (no matter how well intended); we need facts about the whole
picture, not only about health and nutrition. But an uncritical, re-
petitive reliance on the same old shallow facts in the interpretation
of unresolved issues --i.e. not considering ill-health and malnutrition
as outcomes of complex social and political processes -- has equally
foreseeable conservative consequences. Outlooks stemming from such van-
tage points particularly suffer from an inexcusable narrow understand-
ing of the nature of control processes in society (both in the North
and in the South).
The predominantly functionalist theories of development we mostly still
fall back on, see society largely as an organic whole that is normally
in equilibrium; dialectical theories view society as a complex of
forces in tension and conflict by reason of the divergence of their in-
terests. The functionalist theories, which I criticize, assume that
conflicts are resolvable within the existing social system. In dialec-
tics, conflicts are supposed to lead to systemic change, to a more fun-
damental break with the existing order. (Langley)
Among the most prominent newer components of functionalist theories are
all sorts of 'multidisciplinary approaches' to solve the problems of,
in our case, ill-health and malnutrition. There is nothing terribly
wrong with this concept, only that it gratuitously assumes that looking
at the problems at hand from a 'wider', 'pluri-disciplinary' perspec-
tive is going to automatically lead us to the better, more rational and
equitable solutions... Just by putting together disciplines and putting
together brains 'sown' differently - without considering where they are
coming from ethically, ideologically and politically - has not, is not
and will not, by itself, make a significant difference in the outcome
and in the options chosen (for sure so, if also not incorporating bene-
ficiaries in the decision-making process).
THE NEED FOR A MORE CRITICAL AND VISIONARY ATTITUDE
Our failure to reach Health (and Nutrition) For All by the Year 2000
has been more than a wretched fact in history. As far as I am con-
cerned, it has been an ice-age in our thinking on how ill-health and
malnutrition are deeply linked to an overall unsustainable development
model. Now, we need to think what ought to follow during the current
thaw. [To use a clich�: If we know what we are looking for, we are more
likely to get there and to know when we do]. In this endeavor, opposing
the old ways is not enough; we have to set out a counter-concept. The
present moment is still full of promise, because the old conceptual
clarities are breaking down; an era is expiring. Openings are being
followed by partial closures.
Debates about historical rights and wrongs are to guide cohesive propo-
sitions for tomorrow. If there is no cohesion in our vision, though,
the campaigners will weary and the campaign will perish; we thus need a
vision firmly embedded in a practice. To walk away from these debates
is a luxury we cannot afford. We need to wedge open a space for the
larger discussion of what ought to follow, a discussion that looks at
all levels of causality of ill-health and malnutrition in poor coun-
tries --from immediate to basic causes. Yes, this will mean changing
the terms of the discussion, because a vision is not much good if it
simply stays in the air as something devoutly to be desired; a vision
of that sort is a mirage: it recedes as you approach it. To be of use,
the vision has to suggest a route, and this requires that it take into
account a lot of unpleasant realities.
A vision is of no use unless it serves as a guide for effective action.
These actions will have to be biased towards the oppressed, because it
is their rights that are being trampled-upon. We ought to express and
manifest solidarity towards them, because only then will our (joint)
vision gain weight and credibility in its commitment to equity and jus-
tice. We can no longer abandon the have-nots to the dollar-dispensing
Northern bilateral or multilateral agencies. The moment cries for us to
press for more. Widows of opportunity have a way of slamming shut.
(Gitlin)
I am aware it is still very difficult for some of us to maintain our
political agility in a hostile environment. But the role of an avant-
garde is to cause fermentation. We cannot fall in the trap of believing
someone else is going to take care of these things for us; we have to
get active. A strategic overhaul of our actions requires nothing less
than a crisis in our thinking and if by now there is no such a crisis
in the horizon, we have to perhaps create one.
The future of our work in health and nutrition cannot be a simple ex-
tension of the past. If we try to pursue a path of business-as-usual we
will find some altogether unusual consequences. However much we may en-
gage in fine-tuning the engine, this will not suffice unless we redes-
ign certain sizable parts of the motor itself. (Myers)
The future will have to inevitably differ. It is of un-postponable
critical importance to deliberately concentrate on neutralizing the
known social forces that are propelling us in the hopeless direction we
are moving, both at the national and at the international level.
Changes as fundamental as the ones at stake here can only be promoted
by people who have no vested interest in the survival of the non-
sustainable development system as it operates now to the detriment of
the dependent countries and their poor. (Herman, Bracho)
The brick wall of political will (the lack thereof) is best tackled
through practical actions that take into account who will win and who
will lose. A new professionalism will emerge only if we are explorers
and ask, again and again, who will benefit and who will lose from our
choices and actions in our work in health and nutrition. New profes-
sionals who put the last first already exist; the hard question is how
we can multiply and, most importantly, how we can interact, coalesce
and organize dynamic networks among ourselves and between us and grass-
roots organizations.
In sum, I reiterate that a mere extension of what most of us have al-
ready been doing is not powerful enough to really get the goal of in-
serting health and nutrition more in a sustainable development path
achieved. Not only do we need to come up with conceptual breakthroughs,
but also to provide blueprints for the needed institutional changes
that will support the new arrangements.
We need to act as what Antonio Gramsci called "organic intellectuals" -
-intellectuals whose work is directly connected with the popular strug-
gle. "Orthopraxis" (right acting) is ultimately more important than
"orthodoxy" (right doctrine)...even if it means temporarily retreating
for tactical reasons: One who stands at the edge of the cliff is wise
to define progress as a step backwards...
Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.org.vn>
Endnote: Making prescriptive recommendations on what each of us needs
to do to contribute our individual grain of salt to making health and
nutrition interventions more effective and sustainable would be pre-
sumptuous on my part (although I have attempted it elsewhere). This ar-
ticle has no such intention. It just is a wake-up call for some and an
always timely reminder for others. It is about being more critical
about what we do and see as a basis to develop our own vision for the
future, in our specific settings, to share it and to act (together) ac-
cordingly.
--
Send mail for the `AFRO-NETS' conference to `afro-nets@usa.healthnet.org'.
Mail administrative requests to `majordomo@usa.healthnet.org'.
For additional assistance, send mail to: `owner-afro-nets@usa.healthnet.org'.