Rio, then Basel and Berlin. I am just flying back from a Medicus Mundi one-day symposium on the right to health in Basel, and some fundraising for the People's Health Movement in Berlin. On the sidelines, Basel allowed me to get to see the enormity of the Novartis and the Roche empires by the Rhine; they are each mini-cities in themselves. Berlin exposed me for the first time to the streets of what was East Berlin and the Brandenburg-Gate-become-tourist-attraction.

Last month I reviewed with you the WHO World Conference on the Social Determinants of Health held in Rio de Janeiro, as a long-standing member of the People's Health Movement. The conference was also the subject of a news story on the Association's home page. This month I look forward to another world conference being held next June, also in Rio. This is the 'Rio+20' Conference on Sustainable Development, whose website is at http://www.uncsd2012.org/rio20/

The overarching declared purpose of Rio+20 is once again, to raise consciousness of and arouse conscience concerning the environmental dimension, which until late last century was more or less forgotten or at most neglected. Veterans of world summits on any topic have reason for scepticism, but they are needed, and we must all do our best to see that Rio+20 really does mark a time when we all move towards living in ways that are fair and sane.

People in the streets in Oakland, (left, protected against teargas) and (right)
in London, acting against casino capitalism. There is a lesson for us here

Adequate nutrition is smack in the middle of sustainable development. Neither is possible without the other. But as I consider these issues, like you, I am also reflecting on what has been and is happening this year in the streets all over the world. This year has been and is one of direct action, and I believe that the unrest, riots and uprisings that we see and that some of us have experienced, whatever their immediate and obvious cause, all have a common origin. This is awareness that we are living in a world whose political and economic governance – or rather lack of governance and surrender to corporate greed – has gone wrong and has broken down.

The prevailing governance structure of the globe ignores the several crises the planet is facing, as well as the social, economic and political determinants behind them. Food insecurity (1), preventable child and maternal deaths (2), price barriers to access to medicines (3), collapsing health systems (4), all have one fact in common. This is that there are enough resources to provide for them, but these resources instead flow to over-consumption, military expenditure, and obscene wealth for a small elite (5).

The UN Food Price Index, from 1990 to date. The most notable features are low and stable prices until 2007, followed by high and wildly fluctuating prices

To take one example: food insecurity. In my June WN commentary on food prices, I reproduced the graph shown above. This shows that the prices including of staple foods all over the world remained stable from 1990 to 2007, since when prices have rocketed and fluctuated wildly. One reason, as pointed out by Olivier De Schutter, the UN special rapporteur on the right to food, is the recent vast increase of speculation in food commodity futures prices. The results early this year, were food riots in many impoverished countries, leading to uprisings in North Africa that threatened and toppled governments. Most people probably would approve of the overthrow of the Mubarak and Gaddafi regimes. Time will tell. My point here is that the triggers for the unrest that escalated very rapidly in a number of grossly unjust societies, were uncontrolled and chaotic food prices, in countries whose rulers had failed to protect their people by the use of regulations and controls that could have stabilised the cost of staple foods, as wise rulers throughout history have done.

The privatisation of education and the consequent outrageous increases in tuition fees, have provoked students to rise up in many countries, from my original home land of Chile, to the UK. Last month a news story from Valparaiso on the Association's home page reported that the government of Chile persists in evading legislation designed to regulate, limit or prohibit advertising to children of junk food mostly manufactured by transnational corporations, despite the evidence that 90 per cent of the population want such laws passed and enacted. The brave students on the streets of Santiago and Valparaiso may soon be joined by their parents.

The latest manifestation of this year's phenomenal series of direct actions is the Occupy movement, which includes the Occupy Wall Street movement. This began in the South in Kuala Lumpur, Malaysia on 30 July, began in the North in Zuccotti Park in New York on 17 September, and by early November had spread to 600 communities in the US and around 2,500 cities worldwide. Statements of respect for or even support of Occupy have been issued by political and other leaders even up to head of government level in many countries, including in the US and in the BRIC countries of Brazil, Russia, India and China.

The protests are against what is now often accurately termed 'casino capitalism'. This monster has been created by what still remains the orthodox political and economic system known as 'freeing the market', which is technobabble for surrendering the responsibilities and duties of government, and letting transnational corporations use increasingly lenient laws they believe will increase their profits.

Until this abuse of governance is stopped and reversed, world summits on the environment, climate change, prevention of diabetes, cancer and heart disease, or the war on world poverty, are really hot air. They are also duplicitous, because the officials who organise them must surely be well aware of the big issue that is driving environmental wreckage, the melting of the Arctic and Antarctic ice-caps, and the outrageous combination of obesity, poverty and deficiency. The issue, is that world government is now trapped by the looters and wreckers of our world. Hence the Occupy movement.

What does this matter to us?

These seismic events are the context for the work of all professionals who, like us, are committed to doing our best to improve conditions in areas where we are competent. So I ask: If we are trying to make nutrition interventions in impoverished countries more sustainable, why is most of what is said, written and done having so little effect? Here are some answers:

• Our praxis, which is to say our application of principles and ideas, has become professionalised. In the process, we have devalued and demoted the proper role of popular knowledge and wisdom in our teaching and practice.
• Our prevailing values and attitudes as researchers and practitioners are arrogant. They have impeded us from respecting and acting as equals with our national counterparts in the countries we work in.
• We still seek to control knowledge as part of an elite class. We thus fail to obtain a deeper understanding that will guide more appropriate actions, which can only come from a process of genuine popular participation.
• Another reason for the irrelevance of many past and current approaches is that overall development education has continued to transmit societal values mostly as they are perceived in the North.
• The root of the problem is that real sustainable development involves process of popular enrichment, empowerment and participation which our technocratic project-orientated ideology by its nature fails to accommodate.

Those who teach or who taught us, inevitably teach us part of themselves and the frame of values that is part of their background. The context any teacher comes from has its own frame of assumptions about what is real, unshakeable and safe. These contexts can become cages.

Difficult problems tempt us to focus on their more manageable component parts. But this atomistic approach evades the more complex underlying and basic structural questions. This also prompts the 'exclusion fallacy', in which what we choose not to discuss is assumed to have no bearing on the issue (6). An uncritical, repetitive reliance on the same old shallow data in the interpretation of unresolved issues, which avoids seeing malnutrition as an outcome of complex social and political processes, will not and cannot work.

The predominant theories of development still see society largely as an organic whole that is normally in equilibrium. This view does not fit well with the facts. Instead, we need to view society as a complex of forces in tension and conflict, because of the divergence of interests that drive them. We should not assume that conflicts are resolvable within what is now the prevailing political, economic and social system (7).

There is now much talk about the need for 'multidisciplinary approaches'. In principle these are needed. In practice it often seems to be assumed that looking at problems from a 'wider' perspective will automatically lead to rational and equitable solutions. But the mere act of putting together disciplines, without taking into account where the 'experts' are coming from ethically, ideologically and politically, has not and will not by itself make a significant difference. This will be all the more so, if beneficiaries – who need to become claim-holders – are not fully involved in decision-making processes.

David Crosby and Graham Nash in New York streets (left) and (right) riots
in Denver. Back to the 1960s, with the protests now against corporate greed?

The Millennium Development Goals initiative will, we now know for sure, fail to halve the 1990 global hunger rate by 2015. This is more than just a wretched item of news. For far too long now there has been a block in the way of our realising that malnutrition in all its forms is in part driven by a model of development that is inherently unsustainable, as summarised in Box 1. The people in the streets may help us to become unblocked. But this calls for us being able to understand what they (and) we are seeking so that we are more likely to get where we need to be and, once there, to know what to do.

Vocally opposing and manifesting against old ways is not enough. The current movement needs a new conceptual framework, a new system of principles and values. These need to be concrete, cogent and compelling. Debates about past historical rights and wrongs should be mainly to guide us to come up with more coherent propositions for tomorrow. We need a vision firmly embedded in a practice. We must not walk away from these debates.

In our own work we need to open new space to discuss and agree what now must come about. We need to take full account of all causal levels of malnutrition in impoverished countries and settings. These are summarised as social, economic and environmental causes, or else immediate, underlying and basic causes. Vision must move to mission and to real work with tangible outcomes. 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 point to a route, and to take into account a lot of unpleasant realities.

That is to say, a vision is of no use unless it serves as a guide for effective actions. These will need to be biased towards the oppressed, because it is their rights that are being trampled. We ought to express and manifest solidarity towards the oppressed. Only then will our vision be shared with them and gain weight and credibility in its commitment to equity and justice. 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. Windows of opportunity have a way of slamming shut (8).

It is hard for many of us to maintain political agility in a hostile environment. But the role of an avant-garde is to cause ferment. Let's not assume that somebody else is going to take care of issues that engage and involve us. We have to get active. A strategic overhaul of our actions requires a crisis in our thinking. This I believe is what the Occupy movement is encouraging.

The future of our work in nutrition cannot be a simple extension of the past. Business as usual is no longer an option and in the times we now live in, has little if any meaning. Tuning the engine won't work. It needs to be taken apart and put together again, for new purposes (9).

We have to work towards checking the malign forces that propel us as professionals in the generally hopeless direction we are moving. The fundamental changes now needed, can be brought about only by organisations and people that have no vested interest in the survival of the non-sustainable development system as it operates now, and that oppresses dependent countries and their impoverished people (10,11).

A new professionalism will emerge when we become explorers, always asking what and who will gain, or lose, from our choices and actions in our work in nutrition. New professionals 'who put the last first' already exist, but we remain a minority. Now we need to multiply, and interact, coalesce and organise dynamic networks among ourselves and between us and grassroots organisations.

A mere extension of what most of us have already been doing in public health and in nutrition is not strong enough to insert nutrition within sustainable development. Our big task now is not only to have conceptual breakthroughs, but also to design strategic plans that specify all necessary institutional changes.

More protests against casino capitalism in New York (left), France (right).
Are these popular uprisings a sign of fairer and more equitable times to come?

What's in store, and what's to do?

So what should we do now? I have already given this some thought (12,13). In this one column I can't attempt much more than a wake-up call at a very significant time in history, when so many ordinary decent citizens are expressing their outrage on the streets. How can we all make progress towards genuine sustainable development, based on principles of justice and equity, which is most likely to preserve Earth for our grandchildren and their grandchildren? Here are some possibilities, which I regard very much as thoughts in progress, to be improved by discussion and exchanges.

• We need to de-professionalise our work. This will mean seeking, re-valuing and incorporating popular knowledge and know-how into planned actions.
• In this process, our local counterparts, and local civil society organisations, need to take a more visible lead, even at the cost of some possible mistakes.
• All relevant knowledge needs to be shared from the very start with the beneficiaries who in the process become claim-holders.
• We need to move away from the project-oriented approach and move towards processes of popular enrichment and empowerment.
• We now need to depend less on academicians and professional practitioners, and listen more to the everyday sufferers from the prevalent inequitable system.
• They should define the changes that are needed. Action plans are thus to be negotiated and finalised in the neighbourhoods and fields, not in our offices.
• Education has to be from the claim holders' perspective with their choice of contents and priorities. We have to be more open to their needs and values.
• Our analyses need to incorporate the structural causes of malnutrition as part of the 'big picture'. This includes changes made by economic globalisation.
• We will thus be forced to face the complex social and political forces of oppression that prevent populations and communities from improving their own nutrition.
• We have a duty to confront head-on and to expose the malign forces that oppose greater equity so as to neutralise them, from local to global levels.
• We need to use the internet to build networks of like-minded colleagues who can consolidate a strong worldwide solidarity movement.
• We have to confront the types of bilateral and multilateral aid – often no more than tinkering – that perpetuate inequitable and disempowered societies.
• We have to play a part in forcing institutional changes in aid agencies, the UN system included, so as to make them more democratic and transparent.
• We need a whole new curriculum for public health, nutrition and development professionals, to prepare a new generation of more enlightened professionals.

The processes that can lead to real sustainability, to the fulfilment of the human right to nutrition, and to equitable societies, can and should start with small direct actions that we can help bring about more easily.

Actions at grassroots level can take many forms. These should always include examination of who is losing and who is winning, and why. At higher levels, most of us have more experience on how to start discussions leading to change. We now have to follow through. We have to commit ourselves, in a more active and even militant way, to get and to keep the process of popular empowerment moving, always confronting the status quo that gives the impression that nobody cares.

Examples where some of these elements have worked exist. Some of these, like the Indian state of Kerala, and Sri Lanka, Cuba, and Costa Rica, are well known. Others, like the primary health care work done in Iringa in Tanzania, and the Indian Jamkhed comprehensive rural health project in the state of Maharashtra, are also sources of insight and inspiration. They all have in common bottom-centred, gender-sensitive, empowering approaches and a political choice to tackle the underlying deep roots of poverty, injustice and ignorance.

The road to real development indicated here requires that we break with the old development paradigm, as summarised in Box 1. This will mean stepping on the toes of many powerful vested interests. This has always been so.

Geoffrey Cannon, who reviews my columns before you get to read them, has kindly let me use the slide reproduced above. It shows the great US black emancipator Frederick Douglass, who rose out of slavery to become an inspiration to Abraham Lincoln, and it reproduces one of his most resonant statements, one that speaks to us now as it did in his time.

I rejoice to see the people, especially the young people, now in the streets, sometimes passionately debating with courageous establishment figures who come to reason with them, and learn from and sometimes join them. The present moment is full of promise. The old ideas are broken. An era is ending. We are in for an exciting new era. We need all the courage we can muster. It's time, I believe, that we all stopped being mere bystanders and become actors.

References

1. Holt-Gimenez E. The world food crisis: What's behind it and what we can do about it. Food First 2008. Institute for Food and Development Policy, Oakland, California.
2. Hogan M. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards the Millennium Development Goals, The Lancet 2010, Early online. doi:10.1016/S0140-6736(10)60518-1
3. 't Hoen E. The global politics of pharmaceutical monopoly power, drug patents, access, innovation and the application of the WT Doha Declaration on TRIPS and public health. Dieman 2009, AMB Publishers.
4. WHO. Everybody's business: Strengthening health systems to improve health outcomes, WHO Framework for Action. Geneva: WHO, 2007.
5. Milanovic B. Global inequality recalculated: The effect of new 2005 PPP estimates on global inequality, Washington DC: World Bank, 2009.
6. McDermott W. The forbidden agenda, Transnational Perspectives 1989, 15:1, 6-8.
7. Langley W. Liberation theology and the politics of transformation, Transnational Perspectives 1989, 15:1, 23-29.
8. Gitlin T. After the thaw, Tikkun 1988, 3:6, 50-53.
9. Myers N. New Economics 1987, 1, 1, 8.
10. Harman W. Redefining global development, Development Forum 1989, 17:2, 21.
11. Bracho F. The common cause for worldwide sustainable development: A Southern view, IFDA Dossier 1990, 63-67.
12. Schuftan C. Hunger and malnutrition: Outlook for changes in the Third World, Journal of Tropical Pediatrics 1985, 31: 6, 299-300.
13. Schuftan C. Multidisciplinarity, paradigms and ideology in national development work, Scandinavian Journal of Development Alternatives 1988, 7:2-3, 241-290.

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. Nutrition and sustainable development. [Column] Website of the World Public Health Nutrition Association, December 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, to whom thanks for the extract from one of his columns, and the slide with the Frederick Douglass quote.