Macro and micro causes of malnutrition
Diagnosing the causes of hunger and malnutrition
The role of ideology (4)(5)
A critical look at nutrition planning
Working with the community
Hunger and Society, Vol.1, Chapter 3, Cornell Intl. Monograph Series No.17, 1988.
This chapter attempts to look at how we can identify the major causes of hunger and malnutrition, reviews the principal characteristics of these determinants, and explores how we can convince others (peers, beneficiaries, and decision makers) of the implications for action that the profound understanding of these causes has, especially in terms of our attitude towards them as committed professionals active in different disciplines and contexts.
This examination of malnutrition (undernutrition) as the biological translation of a social disease with historical roots, all determinants of the social and economic conditions that lead to the malnutrition of a sector of the population will be considered macro determinants. The more immediate causes responsible for malnutrition will here be called micro determinants.
Most macro determinants of hunger and malnutrition are conditioned by the overall policies that govern national economics (both Internally and in their foreign relations and trade). Macro determinants are more indirectly related to malnutrition. They are always related to international, national, and village level constraints. Macro causes explain most malnutrition in societies with capitalist or pro-capitalist modes of production. Malnutrition or nutritional vulnerability is a manifestation of a society's inability to produce its livelihood adequately - not because modern medicine has rendered it overpopulated or because agricultural productivity is not sufficiently high, but because the underdeveloped societies struggle for their own livelihood by producing the livelihood of other societies. (1)
Macro causes usually relate to the major dialectical contradictions in a given society, especially in the agricultural sector. Macro causes imply objective constraints to meaningful changes.
If one were to characterize macro determinants negatively, one would say that they correspond to those causes of malnutrition that are not removed or even touched by traditional nutrition intervention programs. In the long run, the fight against hunger and malnutrition becomes, therefore, an eminently political struggle and not a technical one. Technology cannot achieve the fundamental structural changes needed to end hunger and malnutrition.
Removal of a few (or even one) of the main macro causes is more likely to alleviate malnutrition than acting on many micro determinants simultaneously. Nowadays macro determinants are very frequently mentioned and identified by planners analyzing specific situations, but the plans they devise seldom attack these determinants frontally.
Micro determinants are more directly related to the physiological condition of malnutrition. They include health, environment, and educational determinants, which are those most frequently identified and selected for direct intervention by western planning approaches. Emphasis on this technical approach to nutrition planning has also in the past justified the need for western-trained experts who often come with ready-made analysis. Every expert brings his own view of development, and the suggestion for development programs will reflect that ideology.
(Hunger + Society, Vol. 1, Chapter 3, Cornell Intl. Nutr. Monograph Series #17, 1988)
Taken together, any attack on micro determinants only leads to a package of solutions or interventions that pretend to be apolitical and free of ideological connotations or influence. However, despite the fact that the spectrum of choices is a continuum, in the final analysis, one either bows to the system or objects to it, totally or partially. Any of these are political stances.
Nutrition planners keep inventing new "more comprehensive" or "multisectoral" approaches to old problems as if these would change the major contradictions and the distribution of power within the system that is causing the problems to begin with.
It should be clear that we cannot agree on the content of nutrition planning if we do not share the same understanding of why people are poor and mainourished. Different socioeconomic contexts call for different nutrition planning approaches. This does not imply that only macro causes should be identified and acted upon. An appropriate understanding of hunger and malnutrition will include consideration of a mix of macro and micro determinants.
The challenge to the planner is to determine, in each national (or regional) context, how much and what kind of macro changes are necessary for the micro changes to have some prospect for success. The connections between macro and micro causes must be made explicit so as to justify the needed macro changes. This unequivocally means that any plan or program geared to ameliorating malnutrition as a public health and social problem will have to include a mix of interventions designed to affect change in both macro and micro determinants. For example, technical measures in themselves are not tools for income redistribution, but they may have a partial redistribution impact as a side-effect, assuming that they reach the lowest income group.
In this context, the role of the nutrition planner is beyond doubt a delicate one. Sensitization and advocacy skills are perhaps more important than technical know-how. The type of strategy or plan that should follow a comprehensive diagnosis should be geared, first, to defining a set of specific activities directed to address and remove or minimize the effect of micro determinants, a classical approach, followed by an estimation of the potential of such a package of interventions to solve or address the major problems of hunger and malnutrition.
A list of the macro causes should be identified and a brief analysis made of why and how each one of them contributes to the persistence of malnutrition, so that anybody can understand these links. A list of possible interventions should be prepared that aim at removing some of the structural bottlenecks or constraints that are ultimately determining a state of chronic hunger in defined sectors of the population.
The similarities between Third World countries, being many, the following are some examples of nation-level manifestations of macro causes: low percentage of national income received by lowest 20 percent of the population (income maldistribution); land maldistribution; high percentage of landless agricultural laborers; rural unemployment; urban migration and urban unemployment; low minimum wage policies in all sectors of the economy, not in tune with the cost of a minimum diet and not following food price inflation; low farm-gate prices for food crops as opposed to their urban retail prices: produce marketing boards' exploitative practices towards small farmers, imbalance between cash and food crops (land allocation and incentives); low percentage of foreign export earnings reinvested in agriculture; food import policies contradicting national efforts to increase local food production; neglect of the primary sector with the share of agriculture In the national GDP slipping in favor of the secondary and tertiary sectors of the economy; credit bias towards the modern agricultural sector as opposed to the traditional agricultural sector; lack of agricultural input subsidization for small farmers, especially for food crops; foreign aid not reaching the neediest; women left outside development programs with little incentive to incorporate them in the money economy; little emphasis on the scanty budgets for genuine community development and rural cooperatives; low primary school enrolment rates; feeble efforts to increase adult literacy, especially for women; and scanty budgets for preventive health services.
Malnutrition as a social disease cannot be cured through medical interventions (not even in a wide comprehensive package) nor can it be cured through the latter plus a package of agricultural interventions.
Redistribution of resources and the consequent increase in purchasing power of the needy masses is a necessary, though not sufficient, solution to the problem of hunger. Moreover, poverty wears many other masks (e.g., cultural and educational deprivation, poor health, inadequate sanitation), and each mask has its own features. We should not be tempted, through lack of perspective, to try to improve only the features of the masks, without doing anything about the real face of poverty, which is socioeconomic deprivation.
Many planners have divided the remedial actions they finally propose into two groups: recommendations and interventions. The former, which often concern macro determinants and the need to change or remove them, are worded in very vague, general terms and have no specific implementation budget set aside; the latter, which often concern micro determinants, are prepared in more detail, have a fixed implementation deadline, and are usually budgeted for.
The frankness with which planners state the need for corrective measures directed to the macro determinants will depend on the political environment in which they are working. Political and professional risks are usually high,(2) and many planners feel that their positions in academe, government, or international or private organizations might be jeopardized if they demand radical solutions. They take a "survivor's" attitude, and this is disturbing. We actually need to stop thinking that we cannot contribute much to the selection and implementation of non-nutritional interventions that are outside our immediate field of expertise.
Macro determinants can be exposed in a number of ways, not all of which are dramatic or sensational. For example, the possible interventions that flow from the analysis of the macro determinants could be listed under a title that could read something like. "Conditions under which Interventions Addressing the More Immediate Causes of Malnutrition Will Have a Better Chance of Having an Impact."(3) This should be followed by a subjective estimate of the potential of each macro intervention to ameliorate malnutrition. The idea is to compare and contrast the potentials of the latter with the potentialities of the package of micro interventions to achieve the same or similar goals. In other words, what this kind of a presentation tries to emphasize is that if macro determinants are removed (or minimized) interventions that follow such removal and that are geared towards removing micro determinants stand a much better chance of having a real and lasting impact.
The above is the gentlest way of making this point clear; there are many other, more direct ways of highlighting the need for structural changes to eliminate hunger and malnutrition. Political and ideological constraints as well as the attitude and commitment of decision makers towards eradicating hunger will determine how far the planning team can go in this recommendation.
The major problem with this approach is that it might look too politically radical to some governments. If this is the case, then the particular governments are most probably not genuinely interested in solving the problems at hand. But this may be difficult to determine, given the frequency with which governments pay lip service to their commitments.
At the very least, a presentation such as the one proposed here has an educational value, especially if it is documented with some hard evidence, things that politicians and decision makers have probably known all along. (We sometimes wrongly assume that decisions makers are rational, righteous, and pious and will accept hard scientific evidence or react to outrageous injustice).
Technicians who have participated in the planning process may gain a new consciousness as a consequence of using this approach, a fact that is of value per se and that makes the effort worthwhile.
Nutrition seems to be as good an entry point as any other (employment, education, energy, natural resources, ecology, etc.) for getting involved in questions of equity in our societies. Nutrition can lead to global consideration if it is not seen as an isolated issue.
Malnutrition should not be attacked on grounds of utility, but because such an attack is morally necessary. What we need to fight for is equity not utility. Poverty should not be seen as an inevitable evil, but as a basic injustice to be corrected. In that sense, poverty is to be considered more as a relative rather than an absolute condition.
The ideology and outlook on world affairs (largely determined by social class extraction) of the individual searching for the determinants of hunger and malnutrition play a vital role in the selection of the contents of the final in-depth analysis (one seems to see only what one wants to see). Once a certain level of consciousness is attained an action-oriented attitude usually follows. At this point there is a convergence of ideology and action that makes the difference between taking an observer's as opposed to a protagonist's role. Knowing about injustice does not move many of us: becoming conscious about it generates a creative anger that calls for involvement in corrective actions. The latter can only happen within the framework of an ideology consciously acquired. In the context of development, then, ideology carries the additional connotation of commitment, both emotional and intellectual, and action-oriented.
Ideology is not simply a body of ideas determining goals; it also includes the instruments, strategies, and tactics to be used in planning for economic and social change.(6)
Objectivity in the analytical stages of the planning process is nothing but a myth, and since the solutions proposed will heavily depend on the final diagnosis of the causes identified, there is no assurance that by following the procedures described above for the identification of macro and micro determinants one will end up with a better, more comprehensive plan to ameliorate hunger and malnutrition in any specific situation. The implications of this center on at least two issues.
1. Will the outlook for eliminating hunger and malnutrition in the world be any better without a concomitant process of political maturation of the people involved in nutrition planning?The possible answers to these two questions are again ideologically charged.
2. Would more efforts towards demonstrating the futility of ongoing food and nutrition programs initiate a new, more aggressive approach?
In trying to solve the problem of malnutrition, intraprofessional responsibility should not be neglected. This responsibility has to be taken up starting with a process that critically analyzes our professional affairs and goals with their inherent contradictions. Basically, nutritionists should be searching for a new ethos, a professional, political ethos. The sense of responsibility found in many scientists does' not seem to be sufficient to see necessary changes occur; it leads nowhere.
It may solve the conscience problems of the person who devotes time and effort to doing "something" to solve, malnutrition; however, it seems to have little effect on the real problems of the poor and the malnourished. An isolated emotional commitment is loose and romantic; ideological commitment is militant.
The concept of being socially responsible is nothing but a euphemism for what really should be called political responsibility. Political commitment is important precisely because governments function as political entities.(7) Political forces are fought with political actions, not with morals, or with technological fixes.
Nutrition planning as a technique, widely accepted for over 10 years has the exciting attractiveness and potential of broadening the horizon of nutritionists in the analysis of what is responsible for generating and perpetuating malnutrition. It seems to offer the possibility of understanding the deeper nature of the problems of the poor, especially the rural poor, and it opens avenues for sensitizing planners to the importance of macro determinants in the process of leading to malnutrition.
Nutrition planning was thus a more comprehensive and multisectoral approach to solving malnutrition than any strategy used before. Because of its broad-based approach it was much closer to a political approach (in the classical sense of the term) than were the technical interventions. Therefore, nutrition planning had greater potential for effecting change than any of the other approaches used before.
Nutrition planning, both as it has been developed in the West and implemented in the Third World, suffers from the basic flaw that, while it sometimes challenges the existing structure and demand change, it offers no concrete model of an alternative future.
Through nutrition planning the planner was confronted with evidence that suggested the need for more radical interventions (meaning going to the roots of the problem and not necessarily in the pejorative sense of the word radical used in everyday politics). If planners chose not to go that route they were deliberately avoiding the issue, not at a subconscious, but at a conscious level. This has tended to make their contradictions more visible, less sustainable and less bearable. This is the major new dimension that nutrition planning offered and that has seldom really been exploited, either because the planners have not been able to find or point out the macro causes or because they did not know what to propose to attack them. This may explain some of the disillusionment people have felt with nutrition planning.
It is precisely a misunderstanding of reality (or a partial understanding) that often reinforces the amoral position of some nutritionists. Or some of them may not really want to understand; they have, all too often and for all the wrong reasons, already made up their minds about one reality, thus often searching for the statistical "whats" instead of analyzing the "whys."(8)
Used as a technical tool nutrition planning offers no real solution, no matter how much new coordination between different sectors (e.g., health, agriculture, education) it succeeds in setting up at any or all levels. To continue pushing suprastructural measures is to perpetuate the problems. It will mean a waste of scarce resources and precious time in the vast majority of cases.
Critically speaking, nutrition planning will continue to offer us no more than a good diagnostic tool, a good framework to consider alternative intervention strategies, and a basis to validate ideologically stained policy decisions.
If little can be expected from nutrition planning at the central level then community-level (grassroot) organization around food and nutrition issues may be the only viable answer in the long run.
Popular participation is absolutely fundamental to success in nutrition planning, but planners have disregarded this central issue persistently. What is needed is more dedication to working directly with the poor so they can tackle the causes of their poverty and malnutrition themselves. This calls for nutritionists to go, as much as possible, back to fieldwork and out of their offices or laboratories. Only there can the strengths needed for a change in direction and perspective be found. Nutritionists need to learn from the people and from their perceptions of the problems, establish links with local mass movements and participate in their consciousness raising.
The participation of the affected population begins with creating awareness that they have a problem, to be followed by ample discussion about what can be done about it. Here, the outsider's role is to ask the right questions and not to point at what he thinks is wrong.
It is only through praxis that political consciousness can be strengthened, and it is only when people are convinced that change is in fact taking place that they will listen and learn the abstract concepts dial must be actualized in experience.(9) In our work with the community we have to pass from a mutually shared analysis and understanding of the local micro determinants of malnutrition, which should be more easily identifiable and perceived by the community at the beginning, to the analysis and understanding of the local and then general macro determinants of that condition.
For the latter to be possible, the community will probably have to go through a slow process of political maturation before effectively gaining consciousness of the role of the social and economic constraints that determine malnutrition in their milieu but are more difficult to understand. People have to he made aware of their problems in a specific context first and then in an ideological one. The exposure of macro constraints should, in the first instance, lead to generating social commitment to effecting the needed structural changes. It is important to demonstrate to the masses that it is in their power to change not only the physical reality that surrounds them but the social reality as well.(10)
There are three levels of possible involvement in fieldwork.(11) At the first level, one solicits the participation of the community in a given project. Participation has turned out be harmless for the vested interests and is, therefore, a regular appendage of every government project. A second level calls for outright consciousness raising among the population. At the third level, an effort is made towards the mobilization of the masses and the effective empowering of the poor.
Because village problems are often not the governments' problems, local felt needs have to be converted into concrete issues so that a course of action to address them can be mapped out. This may involve developing functional knowledge about people's rights, or challenging public agencies landlords or other powerful people or institutions by filing specific demands or claims. A new type of community-oriented nutrition planner is needed for this Herculean task: one that plans with people to get organized to work together in solving the problems.
We need to move in the direction of training nutrition planners as trainers of others so that their own experiences can be reproduced at many levels in each country, given the limited geographical coverage per planner that this approach from the bottom inherently has. The shortcomings of this approach are many, not the least of which is the fact that it is a very slow process, based on mutual trust in each community and that its replicability is, therefore, also very slow even in the best cases. The dangers, of course, are also significant, especially when the political government is hostile.
The question that still remains at the end of our discussion is whether this approach is realistic or not. If it is not, let us keep in mind that not being realistic is a judgment that history can change: what might sound unrealistic today can very well become true tomorrow, if we work for it with decision.
1. N. Makhoul, "Agricultural Research and Human Nutrition: A Comparative Analysis of Brazil. Cuba, Israel and the US". Intl. J. of Health Services. 13, 1:15-24 (1983).
2. W. Chossudowsky. "The Neoliberal Model and the Mechanisms of Economic Repression", Coexistence. 12, 1 (1975).
3. C. Schuftan, et at., Recommended national food and nutrition plan for Liberia, mimeo (Interministerial technical committee on food and nutrition planning, Monrovia, 1982)
4. C. Schuftan, "Nutrition Planning - What Relevance to Hunger?", Food Policy. 3, 1:59-55 (1978)
5. C. Schuftan, "Ethics, Ideology and Nutrition", Food Policy. 7, 2:159-164 (1982).
6. W. David, Management. Administration and Politics in the Development Process: With Special Reference to Nutrition, mimeo, (Meharry Medical College, Nashville. Tenn., November 1985).
7. B. Winikoff, "Political Commitment and Nutrition Policy", in B. Winikoff, ed., Nutrition and National Policy. MIT Press. Cambridge, MA, 1978.
8. R. Critchfield, "The Village: The World as It Really Is...It's Changing", USAID Agenda. 2, 8, (1979).
9. K. Constantino-David. "Issues in Community Organization", IFDA Dossier. 23:5 (1981).
10. A. Rahman. "Science for Social Revolution", IFDA Dossier, 4 (1979).
11. H. Bantje, Constraint Mechanisms and Social Theory in Nutrition Education, mimeo, presented at the XI Intl. Congress of the IUNS, Rio de Janeiro, August 1978 (BRALUP, Dar es Salaam, 1978).