The actors : institutions, social groups and individuals

Figure 1 is particularly helpful to reexamine where, at what level, we are mostly active in our attempts to combat malnutrition. Are we doing enough or anything at all at the underlying and basic levels or are we acting upon the consequences at the more immediate causal level? If the latter is the case, why do we continue to do so? Do we perceive the futility of such actions when carried out in the absence of more profound structural changes? Have we gone from confrontation to accommodation? It is here where our ethics and ideology play a decisive role; their heavy influence permeates not only our behavior as individuals, but also of our institutions and the social groups we belong to (2).

Institutions:

All bilateral and multilateral development institutions channel their aid through governments. The state, in third world capitalist-dependent countries where most aid flows to, is, more often than not, sustained by the local dominant class that has shown little genuine interest in altering the status-quo beyond keeping the overall situation in the country politically under control. Thus, for example, the urban-biased and capital-intensive policies we see in so many of these countries come as no real surprise.

Under such circumstances, isn’t most official aid from abroad doomed to at least partial oblivion from its very conception? How much foreign aid in rural development is actually only patching up the "holes" of a process of internal exploitation of the primary sector (3)? Moreover, all along, international organizations have been and are pushing development in the third world coring from their own (western) biases often acquired in previous development work on other continents and under totally different circumstances. These models are too often enthusiastically adopted by the ruling elites of these new recipient countries, basically because they do not erode their power base and still give them an aura of commitment. If this aid would somehow dent their power base, governments would flatly reject them, even if grants would have to be foregone. International organizations, nevertheless, actually do exert some kind of pressure on third world governments -in the name of the "world's public opinion"- that the latter can hardly refuse nowadays i.e. the adoption of primary health care and its components.

I think we urgently need to share, give and receive advice on strategies and tactics to face international organizations and governments in the third world to avoid the continuation of this perpetuation of maldevelopment. The strategies to face transnational corporations need to be explored in this same context as well. Are stringent conditionalities in the macroeconomic area fostering explicit income redistribution measures, the way to go, both at the national and international level? (of course, even this can be misapplied and the end result may be even worse...). The ideological barrier, once again, stands in the way of an assured success of such actions.

There are some exceptions of institutions that are working towards a more equity-oriented development. Perhaps two or three of them are independent UN agencies, but most of them are non-governmental or private volunteer/organizations (NGOs, PVOs), both national and international. The more the latter are connected with work at the grass roots, the more they tend to be such an exception. Other PVOs, on the other hand, are nothing but appendices or the executing arms of traditional western bilateral agencies.

Social groups:

Short of an overt class struggle, a number of grass root organizations (sometimes called people's development organizations, PDOs) have begun springing up and taking fate and future into their own bands; some more successfully so than others. Cooperatives, labor unions, consumer unions, popular organizations, women's organizations of many types and purposes have started to look into food, nutrition and health issues. It is to this phenomenon and its potentialities that we should definitively be paying more. The efforts to bring together, melt and distill these individual experiences to face common challenges is to become a higher priority for all of us. A new alternative is emerging. We need to explore it. Perhaps you may want to join in the effort. Reading a copy of the Manifesto of the World Food Assembly is perhaps a first step (4).

Individuals:

If not directly involved with one of the above social groups, I think that we are often being used in one way or another and are thus, knowingly or not, at the service or status- quo. We get involved in pat solutions, often dreamed up in a vacuum. We often even begin to believe in these solutions coming from our own ideological biases which are not too different from those of western donor agencies. In so doing, we legitimize this process. Ideological barriers act as a stained glass through which all of us look at one reality drawing different conclusions. Worse even, many of us never leave our ivory towers to look outside and see what is happening in the real world. As nutritionists, for instance, we have not succeeded. Malnutrition has not decreased. We have even failed to show a more decisive support and to speak up for the more successful experiments in countries trying to tackle infectious diseases and malnutrition with efforts at the macro level. Some of them are even right now in jeopardy through external aggression and would need our full support. So, what have we been achieving all these years? Have we been using the appropriate too l s, strategies and tactics in the battle against hunger, ill health and malnutrition?

We need to revise our role as advocates and genuine change agents; how our own personal ideological inclinations, may be hampering us to become such agents. As health workers, we can ill afford having split allegiances when we are out there trying to solve the problems of disease; hunger and malnutrition. We cannot afford to say - this is what science has taught me to do, I do it and anything beyond is not up to me and thus, none of my business. Who are we cheating? Ourselves? The people we pretend to work for? Both? Much of the present day chaos results from the tendency of the average good person to "let George do it". As a start, the question is: Are we ready to listen to each other as peers? On substance, on substantial issues, as equals facing common challenges and opponents (all, those who have a stake in the status-quo). By now, we know what and who these opponents are; we have hit oar heads against the wall often enough. Next, we have to make sure that we keep our discussion action-oriented and not academic - the latter a deviation we tend to fall into too often. We should, not primarily aim at developing a political economic approach to the study of ill health and malnutrition. We need to come up with a concrete and sensible recommendations and with a renewed commitment to see them through.

The mass media could also be considered as actors of sorts in this battle against ill health and malnutrition, even if it is by default. The media too often distort development issues In the third world due in great measure to their own western (northern) ideological bias. Or, they simply do not report on some crucial issues about health and malnutrition, short of whatever can be exploited with sensationalism. Unfortunately, we have little leverage to redirect this biased outlook the media are bringing to our radios, television screens and newspapers on a daily basis. The media should become one of our targets for lobbying and advocacy in the immediate future. UNESCO's experience in this field and the US's response to it should not deter us.