Twenty-five years into the century, the central question I think we are not often enough asking ourselves is, ‘If we are trying to insert health and nutrition interventions in the Third World more in the realm of sustainable development, why is so much that has been said, written, and spent on this having so little (lasting) effect on the problems that our actions are seeking to address?’

I think this question is particularly pertinent since, in this day and age, it behooves us (including the Meers readers) to think and act in accordance with sustainable development that should be kept at the center of our praxis. Here, I want to challenge our readers to react to what is said here about the relationship of our respective professional work to genuine, sustainable development.

The answer to the question above, I think, lies on various fronts, among them, more often than not:

  • Following Northern-led approaches, our praxis has become professionalized, and, in the process, we have devalued and demoted the role of popular knowledge in our fields of expertise;

  • Our prevailing values and attitudes as researchers and practitioners in this field have prevented us from acting as equals with our Third World national counterparts;

  • We still control knowledge as part of the elite and thus fail to get a deeper understanding that will guide more appropriate actions; the latter can only come from a process of genuine popular participation.

The root of the problem is that sustainable development is about processes of popular enrichment, empowerment, and participation, which our technocratic, project-oriented view and practice have simply failed to accommodate.

Also contributing to the irrelevance of many of our past and current approaches is the fact that overall development education has continued its traditional conservative role of transmitting society's values, mostly as they are perceived in the North. The time has come to demand profound changes that accommodate more multi-centric new approaches.

Those who teach us inevitably teach us part of themselves and the frame of values that is part of their background. Each context they come from has its own frame of assumptions about what is real, what is unshakable, and what is safe. The problem is that sometimes these contexts become cages, especially in my type of work in health and nutrition. The time has also come for new frameworks to break the old thinking patterns and make health and nutrition work more genuinely participative.

Unfortunately, difficult problems have the power of leading us to focus on their more manageable components, thus totally avoiding the more complex, underlying, and basic structural question. This is known as 'the exclusion fallacy', in which what we choose not to discuss is assumed to have no bearing on the issue. (McDermott)

We cannot, therefore, continue supporting an outlook on the future that is partly based on presumptions and forecasts rooted in desires from outsiders (no matter how well-intended); we need facts about the whole picture, not only about health and nutrition.

But an uncritical, repetitive reliance on the same old shallow facts in the interpretation of unresolved issues (i.e., not considering preventable ill-health, malnutrition, and deaths as outcomes of complex social and political processes) has equally foreseeable conservative consequences. Outlooks stemming from such vantage points particularly suffer from an inexcusably narrow understanding of the nature of control processes in society (both in the North and the South).

The predominantly functionalist theories of development we mostly still fall back on see society largely as an organic whole that is normally in equilibrium; dialectical theories view society as a complex of forces in tension and conflict because of the divergence of their interests. The functionalist theories, which I criticize, assume that conflicts are resolvable within the existing social system. In dialectics, conflicts are supposed to lead to systemic change, to a more fundamental break with the existing order. (Langley)

Among the most prominent newer components of functionalist theories are all sorts of 'multidisciplinary approaches' to solve the problems of, in our case, preventable ill-health, malnutrition, and deaths. There is nothing wrong with this concept, only that it gratuitously assumes that looking at the problems at hand from a 'wider', 'pluri-disciplinary' perspective is going to automatically lead us to better, more rational, and equitable solutions... Just by putting together disciplines and putting together brains 'sown' differently—without considering where they are coming from ethically, ideologically, and politically—has not, is not, and will not, by itself, make a significant difference in the outcome and in the options chosen (for sure so, if also not incorporating beneficiaries in the decision-making process).

The need for a more critical and visionary attitude

Our failure to reach ‘Health For All’ already back in the year 2000 (as well as to halve the global 1990 malnutrition rate by the same year) has been more than a wretched fact in history. As far as I am concerned, it has been an ice age in our thinking on how ill health, malnutrition, and deaths are deeply linked to an overall unsustainable development model. Now, we need to think about what ought to follow during the current thaw that has lasted 25 more years. [To use a cliché: If we know what we are looking for, we are more likely to get there and to know when we do.]

In this endeavor, opposing the old ways is not enough; we have to set out a counter-concept. The present moment is still full of promises because the old conceptual clarities are breaking down; an era is expiring. Openings are being followed by partial closures.

Debates about historical rights and wrongs are to guide cohesive propositions for tomorrow. If there is no cohesion in our vision, though, the campaigners will weary and the campaign will perish; we thus need a vision firmly embedded in a practice. To walk away from these debates is a luxury we cannot afford. We need to wedge open a space for the larger discussion of what ought to follow, a discussion that looks at all levels of causality of ill-health, malnutrition, and deaths in countries rendered poor, from immediate to basic (structural) causes.

Yes, this will mean changing the terms of the discussion, because 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 suggest a route, and this requires that it take into account a lot of unpleasant realities.

A vision is of no use unless it serves as a guide for effective action. These actions will, once and for all, have to be biased towards the oppressed, because it is their rights that are being trampled upon. We ought to express and manifest solidarity towards them, because only then will our (joint) vision 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. (Gitlin)

I am aware it is still very difficult for some of us to maintain our political agility in a hostile environment. But the role of an avant-garde is to cause fermentation. We cannot fall into the trap of believing someone else is going to take care of these things for us; we have to get active. A strategic overhaul of our actions requires nothing less than a crisis in our thinking, and if by now there is no such crisis on the horizon, we have to perhaps create one.

The future of our work in health and nutrition cannot be a simple extension of the past. If we try to pursue a path of business-as-usual, we will find some altogether unusual consequences. However much we may engage in fine-tuning the engine, this will not suffice unless we redesign certain sizable parts of the motor itself. (Myers)

The future will inevitably have to differ. It is of unpostponable critical importance to deliberately concentrate on neutralizing the known social forces that are propelling us in the hopeless direction we are moving towards, both at the national and at the international level. Changes as fundamental as the ones at stake can only be promoted by people who have no vested interest in the survival of the non-sustainable development system as it operates now to the detriment of the dependent countries and their poor. (Herman, Bracho)

The brick wall of political will (the lack thereof) is best tackled through practical actions that take into account who will win and who will lose. A new professionalism will emerge only if we are explorers and ask, again and again, who will benefit and who will lose from our choices and actions in our work. New professionals who put the last first already exist; the hard question is how we can multiply and, most importantly, how we can interact, coalesce, and organize dynamic networks among ourselves and between us and grassroots organizations.

In sum, I reiterate that a mere extension of what most of us have already been doing is not powerful enough to really achieve the goal of inserting health and nutrition more into a sustainable development path to be achieved. Not only do we need to come up with conceptual breakthroughs, but we also need to provide blueprints for the needed institutional changes that will support the new arrangements.

We need to act as what Antonio Gramsci called ‘organic intellectuals, whose work is directly connected with the popular struggle. ‘Orthopraxis’ (the right action) is ultimately more important than ‘orthodoxy’ (the right doctrine)...even if it means temporarily retreating for tactical reasons: One who stands at the edge of the cliff is wise to define progress as a step backwards...

An afterthought

Making prescriptive recommendations on what each of us needs to do to contribute our grain of salt to making health and nutrition interventions more effective and sustainable would be presumptuous on my part (although I have attempted it elsewhere). This article has no such intention. It is just a wake-up call for some and always a timely reminder for others. It is about being more critical about the sustainability of what we do and see as a basis to develop our own vision for the future in our own specific settings and to share it to act together accordingly.