By Chhoden Blau, Foreign Ministry of Bhutan, and Irene Nørlund, Metropolitan University College
Workshop coordinators: Irene Nørlund, Metropolitan University College, and Aase Mygind Madsen, VIA University College
Resource persons: Kanchan Lama, Coordinator WOCAN, Kathmandu, Nepal; Chhoden Blau, Nutritionist, Foreign Ministry of Bhutan, now based in Denmark; Anders Baltzer Jørgensen, Senior Advisor and social anthropologist, UTF, Ministry of Foreign Affairs;
Kirsten Havemann, UTF, Ministry of Foreign Affairs, Medical Doctor.
Session 1
The workshop started with a roundtable presentation of the participants with the purpose of knowing all the participants’ interests, background, experience and knowledge for the purpose of benefitting for all participants. The composition of the workshop was interdisciplinary and diversified in age and gender. All participants had broad experiences form developing countries, but from very different perspectives and different countries and regions.
Irene Nørlund introduced the workshop purpose and organization. A key issue for the workshop was to invite people from different fields to talk about how they perceive and work with the three issues: Poverty, food security and nutrition – as it obviously issues that are closely related, but each discipline take special interest in certain areas, and in practice there is very little cooperation between specialists working id different fields. In development related studies, nutrition is usually not more than superficially included in the attempts to create food security and to reduce poverty. On the other hand there is a tendency that most nutritionists are not very attentive to the broader frames in society, economically, politically, culturally, administratively, that are having an impact on nutrition.
Food is important in reducing poverty and seeking to obtain sustainable livelihoods. All too many people, in particular in rural areas in developing countries, experience daily insecurities with regard to daily food supplies. Many attempts to address this have failed in the sense that little change has occurred and presently it is yet highly unsure, if, for instance, the MDG's objective to eradicate extreme poverty and hunger will be fulfilled.45 However, addressing food insecurity is not only about increasing the amount of food produced and/or consumed, but also food with the correct nutritional content, as well as food with the nutritional content that can provide a healthy diet for people in different age-groups. Food also has to be culturally acceptable and well tasting. Quantity can't replace
45 Goal 1a aims in reducing the proportion of people living on less than one dollar a day to the half by year 2015.
quality and preferences. The challenges are related to the many actors involved, whether be the local population, the direct producers, and particularly women who often prepare the food and nurse the children, agricultural extension officers, providers of seeds and inputs, traders, local government and health workers - both governmental and NGOs.
A new challenge in developing countries is now obesity and the effects on health deriving from obesity. The population living in cities is increasing rapidly, and new unhealthy lifestyles are spreading, both due to the healthy food like fruit is more expensive for poor people, and for the more wealthy, fast food is expanding due to limited time for preparation of traditional food.
Four models related to food and nutrition security were presented:
Food and nutrition security, model by Grossman 2000
Causes for malnutrition by WHO
FAO/FIVIMS framework for linking of food security with the overall development context, food economy, households and individual measures of well-being
Sustainable Livelihoods Models, as developed by IFAD
www.fau.dk/Konference10/Dokumenter/Food_and_Nutrition_Models.pptx
All the models are interested in improving the well-being and health of people, most of them developed by international organizations, and yet they have different focus. The most important in respect of the workshop is that the three first models or approaches include both food and nutrition, whereas the fourth model is not mentioning nutrition as a specific factor to pay attention to at all. Both approach/model no three and four are pointing to the importance of the broad context of societal factors, and yet this difference in focus. One of the reasons is that the third model from FAO is taking more notice of the individual and households levels, and specifically interested in the food security, whereas the Sustainable Livelihoods approach is more concerned with the social structures.
One explanation why food/nutrition and sustainable livelihoods are focusing at different issues is partly due to two very different approaches on the individual and the life cycle on one hand and on the societal structures and forces on the other. There is need for a framework which can embrace both types of factors, as this gap is most common preventing the various approaches to interact in the attempts to improve livelihoods, wellbeing and health for poor people. The workshop aims at bridging this gap. There was general consensus among the group that no one particular framework was perfect and included all aspects of the cycle of development, livelihood and good health and nutrition.
Session 2
Irene Nørlund then presented the project ‘Community Managed Livelihoods &
Development Programme in Khanh Vinh, Vietnam’. She took part in an evaluation mission of this programme during august 2009, and a slide presentation was shown concerning the specific part of the programme which dealt with nutrition of children in the communities of the programme. What was remarkable about this programme is that it combined nutrition
and health in the frame work of sustainable livelihoods at community level. This focus is not very usual, and had a history behind this fact. When the Medical Committee the Netherlands-Vietnam, which is the organization (NGO) implementing the programme together with the local authorities in an ethnic minority dominated district in Central Vietnam, started to work in Vietnam in the 1970s, it was mainly interested in providing support to heath to the poor, as that was considered the most essential factor to improve the wellbeing and living standards. After two decades of work, the organization realized that there were other factors at stake than health which prevented people from improving their situation, and the new approach to combine livelihoods and the larger frames with health and nutrition. The slide presentation was produced by the director of the programme, Ron Marchand.
www.fau.dk/Konference10/Dokumenter/Malnutrition_combat_trials.ppt The group discussed a number of issues:
the definition of food security: food security is not necessarily the lack of food per se, but increasingly, the eating of ‘wrong’ energy dense, nutrient poor food and thus not limited to the developing world alone
that obesity and non communicable lifestyle diseases were increasing in the developing world, particularly in young urbanites and in urban slums
that gender inequality needs to be integrated into the framework of livelihood problems
that nutrition is generally seen as a ‘health’ issue with no relation to agriculture and economics of a country
that socio-cultural beliefs often played a defining role in the causes of malnutrition, especially in women
the definition of livelihood includes the management of risks e.g. farmers had immense risks
Kirsten Havemann challenged the group on how to define 'health'. The workshop participants reacted differently according to their education and training background, and KH referred to the definition by WHO, which has a very broad definition that could be accepted by most of the represented disciplines in the workshop: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".
She gave a presentation on ‘Empowerment and Social Cohesion: Overseen links to better nutrition’. She has worked in health for 22 years in Africa for various development cooperation organizations (including the World Bank), she has particularly worked and lived in Kenya for in total 40 years. During that period she became increasingly interested in and realized the importance of nutrition, particularly community nutrition in the 1990s.
She had nevertheless experienced that in most nutrition programmes for children, 60 percent would slide back to where they were before after three months. These experiences made her look at the broader context of social determinants, and she got the chance to implement some of her ideas in a World Bank Health & Education programme in Kenya, including 12 rehabilitation centres for malnourished children. The programme took place in cooperation with the Ministry of Culture and Social Services in 14 districts. The
results were most promising, which made her embarked to write a PhD about her experiences.
One of the conclusions is that the problems had to be analysed and seen in a broader context, and that the process has to work. In her case the core problem came out to be social disunity, and the village voices had to be heard and included. One of the means to find solutions was through participatory education theater. It came out to be an advantage to work with the Ministry of Culture and Social Services, which was trusted more than the Ministry of Health. The programme resulted in women taking more care of the children and men chose to spend time with their families with a very positive result for the children. The participatory process lead to greater social cohesion in the communities. And the costs were low both for the pilot phase, and it would be even lower for a longer-term programme.
Some overall conclusions pointed to the problem that health and social sector planners do not take sufficient account of the social determinants of health when seeking to improve nutritional and health outcomes. The case study from Kenya, examined the link between use of participatory educational processes to promote social cohesion and the reduction in child under-nutrition. Kirsten Havemann indentified factors at local and national levels that helped or hindered nutritional and health outcomes. Social and public health planners are still neglecting the interface of social dimension and health and nutritional outcomes.
Finally, the presentation drew lessons learned for further development and improvement of health and social sector policies. One question is to be asked: “Are health and social sectors planners being adequately exposed and trained to effectively respond to the root causes of ill-health and poor nutrition?” She raised the question if a wholesale re-tooling of the public health work-force is needed that can balance the individualistic biomedical and economic view of the world with a collective, social justice focus that include perspectives of communities and social structures. Food is a very political issue whereas nutrition is seen as non-political.
http://www.fau.dk/Konference10/Dokumenter/kirsten_presentation.ppt Major points discussed included:
how is health defined by the various disciplinary approaches, and the WHO definition
the importance of cohesion and the different ideologies in the concept of cohesion
the difficulty in asking questions in the hierarchical feudal system of social cohesion
the political nature of food security vs. the non political nature of nutrition
the vast difference between the definition of health and the health sectors’ goals
nutrition security vs. food security
the benefits of using participatory education theatre in the marketing of social messages
Session 3
Chhoden Blau made a presentation on the National Nutrition Programme in Bhutan. She was trained as the first nutritionist in Bhutan, and took her degree in Australia. The presentation highlighted some of the successes of the nutrition programme since its beginning, as well as the areas that required continued attention. The approach reflected her training as a nutritionist, and showed how nutrition programmes in cooperation with the international organizations after Bhutan became member of UN (UNDP, UNICEF, WHO and FAO) was focused on core basic problems which were spread as mass programmes.
Several programmes started in the 1970 and 1980, like the iodine programme in salt; the deficit of iron which lead to a programme. The first nutrition programme to place from 1985 with the aim to improve the nutritional status of underweight; to raise awareness through improvement of hygiene, variety in diet, for instance through home gardens, and encouragement of breast feeding; capacity building through monitoring and nutrition education and inter-sectoral cooperation between various sectors like agriculture, trade, education and the monks, the latter who are an important culture factor.
Later surveys have shown considerable progresses in areas like iodine deficit, iron deficit and the percentage of underweight children decreased. However, there are still problems.
Bhutan has specific historical circumstances being a small country and a small population, and the resources have not been exploited like in many other countries. The Nutrition Programme was closely connected with the health system infrastructure set up in the country.
Chooden pointed to some strengths and weaknesses of the situation in Bhutan.
Strengths:
The existence of political will in improving the nutrition status in Bhutan
The existence of a Public Health Department within the Health Ministry focusing on nutrition and other public health diseases
The integration of nutrition into the existing health system making it easy to provide nutrition guidance and services to the population as well as increasing ease in monitoring and providing training to the auxiliary health staff
Gender equality is better than in many other countries Weaknesses:
The mountainous terrain
Low literacy levels
Lack of storage facilities for grain and other produce
Effect of diseases and infections stemming from poor hygiene and sanitation
Nevertheless, Bhutan faces some of the same problems as found elsewhere. That includes a high birth rate and migration to the cities; land fragmentation is taking place;
continued poverty at a rate of about 23 percent in 2007; and a challenge of the climate changes which will have an impact on water resources causing problems for agriculture
and forestry. New diseases might spread like malaria and dengue fever, and problems with HIV/AIDS are also appearing in Bhutan today.
www.fau.dk/Konference10/Dokumenter/THE_NUTRITION_PROGRAMME.pptx
The discussion following the presentation focused on:
the continued lack of gender disaggregated data available for most countries, and the possible reasons for higher gender equality in Bhutan
the reasons for the political will in Bhutan to improve the health and nutrition
the importance of different political systems in respect of solving livelihoods problems and nutrition and health problems
problems related to emigration of people
different nutrition preferences based on culture and practices
how inequalities in land access can be addressed
the importance of being able to measure the various factors in order to tackle the problems and the impossibility to measure everything
how to analyse nutrition, which both has a very personal agenda, but also has a social dimension
the cultural dimension of how things should be done based on localities and local systems
role of home gardens to improve nutrition is not universally applicable and more useful in semi-urban areas, not in rural areas. The forest may provide much better resources for nutrition
Modernity is spreading, but is often counter productive to nutrition
Conclusion:
Discussions in the group were lively and contributions were made by all participants.
Summing up, the participants agreed that:
inequality should be measured
all data should be disaggregated, also in gender
insofar as population growth was concerned, family planning was becoming of decreasing importance
borrowing from the successful use of branding in the private sector, branding of social messages would make them more appealing to the public
although we already know what is required to be done in improving the nutrition status in populations, nutrition problems continue to exist
the creation of a global fund to help nutrition would be of great help
gender discrimination continues to be a major factor in the cause of malnutrition in women and girls in many countries
nutrition has a personal dimension
we should continue working together to create opportunities from different backgrounds