Access the pdf of this correspondence here
Access the pdf of the February commentary here

Sir: We are depressed by the February WN commentary on professional competence. It amounts to an attempt to avoid difficult choices and challenges. It focuses on the more achievable areas of impact in nutrition work, laying out a relatively easy, technical path that we think is not very different from what our students are taught now.

The commentary is, despite its claims to the contrary, reductionist rather than holistic. The whole piece reflects the sad fact that so many public health nutritionists still give only lip service to the world outside their fields of technical expertise.

We cannot understand how, in 2012, the issue of the right to nutrition can be omitted in any discussion about training our future colleagues.

The insights of the commentary are said to come from an early 2000s study on 'Competencies identified by an international panel of public health nutritionists from the US, Europe and Australia'. We see no defendable reason to leave out the views and opinions of colleagues in the South. Further, almost all references to the commentary are from authors in the North. A vast amount of work has been done by colleagues in Asia, Africa and Latin America. We attach a link to just one example here.

Public health nutrition work must balance between being primarily technical, with few political overtones, and being primarily political, with attention to technical challenges. For example, micronutrient malnutrition has more of a potential for 'silver bullets' to work. Conversely, solutions to protein-energy malnutrition are outside the field of nutrition itself. Public health nutrition work has to adopt different strategies and requires different skills, approaches and tactics, depending on context and on the nature of the issue(s) being addressed.

Those who will follow us must be trained to understand and confront the underlying and basic causes of malnutrition, and not merely its immediate causes. They must be trained to work for the policy changes that are more controversial and more political, not merely those that are easier as they do not disturb the established order and the powers that be.

Public health nutrition is not merely clinical nutrition at a community or population level. It is a branch of public health, with all this implies. If our students don't get this, we are lost.

Let us be clear. The time is over for nutritionists merely to teach mothers to feed themselves and their families, when the real issue is that so many communities in the South are starved of cash and resources. The time is over for nutritionists merely to seek to change individual behaviour without paying attention to what people really want and need. It is time to end the 'get that capsule/pill/ready-to use supplementary food/fortified salt into the mouth of beneficiaries, and it is done' attitude. We have a duty to convey this to our students and young colleagues.

Protein-energy malnutrition does not respond unless its immediate, underlying and basic causes are tackled simultaneously. Interventions at each individual level are necessary but not sufficient (1). Sufficiency requires the simultaneous empowerment of communities to engage in actions identified and selected by themselves, so as to achieve more self-reliance and sustainability (2). This knowledge has to be passed on to future generations of public health nutritionists.

Young people choose careers partly in terms of their interests; but also partly in terms of their temperament – and this includes the level of stress and frustration they sense they can handle. For this reason alone, students of public health nutrition need to be taught about the ethical and political aspects of their future work. They need to be warned of what lies ahead. If they are shielded from these realities in their training, or if their teachers are themselves ignorant or blinkered, we see little hope that our profession can play a significant role in the battle against malnutrition in the world.

Without political and social awareness we may become technically more competent, but will be professionally almost irrelevant. Changes will come about without us and despite us.

Important challenges that will be faced by our young and upcoming colleagues are now usually not spelled out in their undergraduate and graduate training, and are ignored in the WN commentary. The training of public health nutritionists has to move away from its bias towards mostly engineering (3-5).

The authors seem to dream that societal maladies can be resolved if public health nutritionists do their technical work better and more efficiently. This is a mistake. Quasi-medical treatment does not solve the problems of populations and communities whose rights are being violated. This approach makes us accomplices in a process of the 'modernisation of poverty'.

Bottom line, here we have a commentary that is overwhelmingly technical. It could be used as much for the training of nurses in the pay of Nestlé, as by professionals working in the public interest.

It is easy to be a spectator, and tough to be an actor. Past, present and future nutrition work was, is, and will be hampered by the crushing impact of unjust governance. We have to see this.

At the beginning of the commentary, we were led to believe that we were being given firm guidance for the future. At its end we were told that it is work in progress. We certainly hope so.

Please cite as: Schuftan C. Jonsson U. Competence: for what, and so what? [Letter] World Nutrition, March 2012,3, 3: 81-84. Obtainable at www.wphna.org

Editor's note. The authors of the commentary will respond in next month's issue of WN.

References

1. UNICEF. Strategy to achieve nutrition goals. [Chapter 4] In: Strategy for Improved Nutrition of Children and Women in Developing Countries. A UNICEF policy review. New York: UNICEF, 1990.
2. Schuftan, C. The community development dilemma: When are service delivery, capacity building, advocacy and social mobilization really empowering? Community Development Journal 1996, 31, 3, 260-264.
3. Berg, A. Sliding Toward Nutrition Malpractice: Time to Reconsider and Redeploy. Martin Forman Memorial Lecture. Presented at the annual general meeting of the National Center for International Health, Washington DC, 24 June 1991. Washington DC: National Center for International Health.
4. Berg A. Malnutrition and 'nutrition engineering' in low income countries: A rejoinder. International Journal of Health Services 1993, 23,615-619.
5. Kavishe F. Investing in nutrition at the national level: an African perspective. Proceedings of the Nutrition Society 1995, 54, 367-378.