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Ethics and child nutrition

Urban Jonsson


All problems in society have a scientific and an ethical aspect. Science tells us what can be done, whereas ethics tells us what should be, ought to be, or must be done. Actions that both should be done and can be done are do-able actions. Science is advanced mostly by observation and logical deduction or induction. Ethics, in contrast, is advanced by consensus through reflection, dialogue, enquiry, and sometimes struggle. Adequate care of children and women has only recently been fully recognized as a human right. The UNICEF triple-A approach of assessment, analysis, and action is designed to lead to more effective and better-focused actions for ensuring adequate care of underprivileged women and children. A rights-based approach, combining goal-based and duty-based ethical theories, is also proposed. Combined with the triple-A process, this provides a holistic response for addressing nutrition problems. The international goals of the World Summit for Children represent moral minima, accepted and supported by all major religions and political ideologies.

Science and ethics

Both science and ethics pursue unachievable goals. Science seeks the truth and ethics seeks the ideal society. In both cases it is fully rational to pursue these unachievable goals [1]. It is a scientific fact that iodine deficiency disorders (IDD) can be reduced by universal ionization of salt; it is an ethical choice of a government to decide to do so. It is a scientific fact that aggressive marketing of breastmilk substitutes contributes to the malnutrition of young children; it is an ethical choice of a government to decide to stop such a practice.

Theory and practice

Both science and ethics are driven and influenced by theory and practice. In science "we find what we look for" [2]. We all carry preconceived ideas about the nature of a problem. For years nutrition scientists thought that lack of protein was the primary cause of protein-energy malnutrition (PEM). They designed sophisticated instruments and methods to measure protein deficiency. They found what they were looking for. Today we know that in most cases, PEM is caused by a combination of inadequate dietary intake and the adverse effects of infection. Not until recently have nutrition scientists started to look for the prevalence and duration of exclusive breastfeeding.

Theory and practice of a scientific approach to nutrition problems

UNICEF's nutrition strategy [3] promotes an explicit theory or conceptual framework for the immediate, underlying, and basic causes of malnutrition in young children. This strategy also outlines an operational framework for how nutrition can be improved in practice (the triple-A approach).

The conceptual framework

The nutrition status of an individual, including any of the four major forms of malnutrition (PEM, IDD, vitamin A deficiency, and iron deficiency anaemia), is an outcome of complex biological and social processes, as summarized in the conceptual framework of figure 1.

Immediate causes

Inadequate dietary intake and disease are the immediate causes or determinants of malnutrition. The inadequacy may include total energy, protein, vitamins, or minerals. Inadequate dietary intake may increase the susceptibility to and severity of infection; conversely, many infectious diseases reduce dietary intake and nutrient utilization through loss of appetite and reduced absorption.

FIG. 1. Causes of malnutrition

Underlying causes

The numbers of possible underlying causes seem almost endless and their interrelationships complex. All, however, reflect a particular utilization of resources in the past and the present. One way of grouping these causes is to identify a set of outcome conditions necessary for adequate nutrition or, more precisely, for adequate dietary intake and absence of disease. Three such conditions can be identified: adequate access to food (household food security); adequate care of children and women; and adequate access to preventive and basic health services together with a healthy environment. Each of these conditions is necessary but not sufficient for adequate nutrition.

If all three are fulfilled, however, it is likely that dietary intake will be satisfactory, disease will be controlled, and adequate nutrition will be secured.

Household food security is defined here as "access to food, adequate in quantity and quality, to fulfill all nutritional requirements for all household members throughout the year." Household food security is an outcome of technical and social processes in society, but it ultimately depends on the availability, accessibility, and use of resources.

Adequate care of children and women has only recently been fully recognized as having an important bearing on the nutrition status of mothers and children. "Care" refers to caregiving behaviour such as breastfeeding and complementary feeding practices, food and personal hygiene, diagnosing illnesses, stimulating language and other cognitive capabilities, and providing emotional support. Care also refers to the support that the family or community provides to members of the family and to behaviours within the household that determine the allocation of the food supply to members of the household. In addition, care includes the utilization of health services and water and sanitation systems to create a healthy micro-environment for family members.

Care, like household food security, is the outcome of complex processes in society, but it ultimately depends on the availability, accessibility, and use of resources. Important causes of inadequate child care include poor health of the mother; lack of education and wrong beliefs of caregivers; lack of self confidence of the mother; inadequate social support from community, family, and husband; excessive workload of the mother; and mother's lack of control of available resources.

Access to health services, together with a healthy environment, is the third necessary condition for good nutrition. Prenatal and post-natal care, immunization (particularly against measles), oral rehydration therapy, distribution of micronutrient supplements, de-worming, family planning, and health education are all important health services with great impact on nutrition. Access to water and safe excrete disposal are prerequisites for control of diarrhoea and other diseases influencing the nutrition status of children. The achievement of the "health" condition ultimately depends on resources in the same way that the achievement of the "food" and "care" conditions does.

Basic causes

There are three main types of resources: human resources (people, their knowledge, skills, and time); economic resources (assets, land, income, and so forth); and organizational resources (for instance, formal and non-formal institutions, extended families, and child-care organizations).

Resources are available at different levels of society and are controlled in many different ways. At the household level, men usually control more of the resources, which often constrains the achievement of the necessary conditions of food, care, and health.

The use of resources depends on the way a problem is understood as well as on the perception and priorities of those who control resources. Education plays a particularly important role in determining how resources are utilized to secure food, health, and care for children.

The availability and control of human, economic, and organizational resources at different levels of society are the results of historical processes in society. These processes can be seen as the basic causes of malnutrition and can be divided into four groups:

-ecological/technical conditions of production, including the environment (soil and climate), the population-resource ratio, the level of technology used, and the levels of people's skills;
-social conditions of production, including such aspects as the ownership of the means of production, the division of labour, and power relationships;
-political factors (including state interventions), including policies on employment, prices, incomes, subsidies, health, education, and agriculture, as well as the legal system as a whole; and
-ideological factors, including habits, beliefs, cultural preferences, and all ideas that legitimize actions in society.

The development and interaction of these different factors explain the existing availability and control of resources, which in turn explain the degree of fulfillment of the three necessary conditions (food, health, and care) for good child nutrition.

The triple-A approach

Some of the problems causing malnutrition are amenable to effective actions at household and community levels. If decision-making at these levels were more supportive, more women and children would survive, and those surviving would be in better condition. Other problems can be addressed only with support from outside the community (for example, by medical services, which in turn require supplies that may need to be procured outside the country with foreign exchange). International economic and political relations affect decision-making at these levels, with implications for the strategies adopted at the national level and the conditions under which households make their decisions. It is clearly important, therefore, that the critical actions and decision makers be identified and their decision-making processes understood. Processes supportive of women and children should be encouraged and those detrimental changed.

Actions to improve the nutrition situation of women and children involve the reallocation of resources in their favour. Within households, this may mean more time spent by parents with their children, greater sharing of work among adults in the household, and a larger percentage of income earmarked for goods and services of benefit to women and children. At national and international levels, planning priorities might be changed and budgets reallocated. To make decisions to reallocate resources, those controlling the resources need information to justify their decisions.

Decision-making at all levels depends on an initial assessment, which is undertaken only when a problem is perceived and a commitment made to do something about it. Perception and commitment are dependent on the availability of information and the ability to understand the information. Analysis of the problem may be facilitated by the collaborative efforts of people most affected by and knowledgeable about the situation, together with people technically trained to undertake analyses of similar problems. Actions taken to improve the situation after this assessment and analysis may not lead to solutions of all aspects of the problems; they may, however, contribute to creating a new situation that is more conducive to actions that may not have been feasible before (fig. 2).

After this cycle of assessment, analysis, and action, the impact of actions is re-assessed and the situation re-analysed. For this process to take place, there must be an information system in place that must include information not only about the end result of the situation (malnutrition, for example) but also about its causes. In this way, the process will lead to more effective, better-focused actions.

Triple-A processes do not function in a vacuum. A number of factors are critical to their success and must be present to fuel their operation:

-perception and understanding of the nature of the nutrition problem. This influences, in particular, the choice of what is assessed, how it is analysed, and what actions are regarded as feasible;
-effective demand for nutrition-related information and motivation to act. Decision makers need information for designing actions as well as for convincing others that actions are necessary and feasible (creating coalitions);
-capabilities (primarily technical) to obtain information in assessment (monitoring) and to use information in analysis and design of actions;
-resources for the system, that is, for the establishment and maintenance of the nutrition information system, including human, economic, and organizational resources;
-resources for action. When there are inadequate human, economic, or organizational resources available to implement likely action, the focus of the nutrition information system must be to mobilize these resources.

Figure 3 illustrates how these factors influence the triple-A process.

FIG. 2. The assessment-analysis-action (triple-A) cycle

FIG. 3. Factors influencing the triple-A process

Theory and practice of ethics

Ethics or moral philosophy aims at the "understanding of moral concepts and justifies moral principles and theories" [4]. The French revolutionary slogan "liberty, equality, and fraternity" can be used to clarify the historical development of human rights. Liberty is represented by civil and political rights: the right of individuals to freedom from arbitrary interference by the state. Equality refers to social, economic, and cultural rights: the right to food, education, employment, shelter, etc. The state has an obligation to fulfil these conditions. Fraternity refers to rights of solidarity. The rights of developing countries to a more just world economic order belong to this last category [5].

Cultural relativism is another area in which human rights activists face problems. An increasing number of governments, accused of human rights violations, defend themselves by claiming that outsiders should not interfere with the internal affairs of a society, that these alleged violations are part of their internal culture, and that human rights cannot be universal. This raises the question whether the whole concept of human rights is "Western." There is no strong theoretical foundation for proving that this is not the case. It has been argued that when there is an international consensus about a particular set of rights, these rights exist and are universal [6].

Eide [7] has defined three types of state obligation. First, states must respect the freedom of individuals to take actions by using the resources they control. Collective or group actions must also be respected. Second, states must protect individual freedom of action and use of resources from other more assertive or aggressive subjects. Individuals need to be protected from, for example, powerful economic interests and from unethical trade and marketing practices. Finally, states must fulfil the expectations of all to enjoy their rights, either indirectly, by providing opportunities, or directly, by providing commodities or services needed by the individual. The obligation of the state in relation to solidarity rights must be some form of sacrifice. Solidarity reflects an ethical position that poor people and nations have a right to get out of poverty as a matter of principle, even if it would mean reduced economic growth for the richer countries. Solidarity is a right; charity is not.

Towards a rights-based nutrition strategy

Politics has often been influenced by two different kinds of political theory: goal-based theories and duty-based theories. Each of them is founded on correlative moral theories (teleological vs. deontological). Both are forward-looking, both aim at improving the lives of people, and both can pursue goals. But they are different in the different emphasis given to the goal itself and to the means to achieve the goal. They are also different in the approaches of their promoters. Promoters of the first type of strategy more often use scientific arguments, whereas promoters of the second use ethical ones.

Nutrition strategies reflect the same difference.

Goal-based nutrition strategies emphasize the prime needs to achieve certain goals. These goals are legitimized when such an achievement is put to use. Better-nourished children need fewer health services, learn better at school, and grow up to be adults with higher productivity and income. The World Bank is pursuing such utilitarian goal-based nutrition strategies. It often means that the "unreachable" children among the poorest of the poor are left out in the name of maximizing the number of beneficiaries.

Duty-based nutrition strategies emphasize the quality of the process towards achieving goals. Such strategies promote participation, ownership, empowerment, and sustainability. They often focus on the poorest and the unreachable rather than maximizing the number of beneficiaries. Promoters of such strategies tend to be deeply committed and involved in assisting individual poor people. Many non-governmental organizations have adopted this type of strategy.

A rights-based strategy would provide an alternative not yet explored. Such a strategy would include some elements of both a goal-based and a duty based strategy. Psychologically most people find rights more acceptable than duties. Duty for duty's sake is absurd, while rights for their own sake are not. A rights-based strategy would first of all be people based. Poor people would be recognized as key actors rather than as passive beneficiaries of transfers of services and commodities. Participation would not mean that "they" participated in "our" project, but rather that "we" were allowed to participate in "their" work. This would, of course, require a new kind of development worker-someone who knows how to listen and learn, rather than preach and command [8].

The most fundamental right is that of individuals to choose how they shall live. But this can only be a prima facie right, because one person's choice can reduce another person's choices. This will require constant compromises of the kind that only a democratic society can accommodate.

Rights imply goals. In other words, the achievement of a certain goal is a necessary, but not a sufficient, condition for the realization of a right. The World Summit for Children (WSC) nutritional goals represent moral minima, accepted and supported by all major religions and political ideologies. They are what Sen calls "cross-cultural moral minima" [9]. A rights-based strategy requires that these goals be achieved, but that the process of their achievement satisfy deontological criteria, such as empowerment, ownership, and sustainability.

As mentioned earlier, UNICEF promotes a Triple-A approach in its nutrition strategy. Assessment, analysis, and action are influenced not only by the objective understanding of the problem (i.e., a conceptual framework) but also by ethical considerations. This is symbolically illustrated by the heart in the middle of the cycle (fig. 4).

The Convention on the Rights of the Child (CRC) ensures that children have a claim against the state to be well-nourished. A rights-based nutrition strategy promoting the fulfillment of these moral minima would contribute to the development of a non-ethnocentric ethical consensus [10].

A first step has already been taken to initiate a global movement for promoting nutrition as a human right. In May 1994 in Florence, Italy, the World Alliance on Nutrition and Human Rights (WANHR) was launched at a meeting of people from national and international non-governmental organizations and institutions dedicated to pursuing the condition for fulfilling human nutrition needs through the enjoyment of economic, social, and cultural rights.

Countries are used to being compared on the basis of their economic development. Now the time has come when countries should be compared by the way they take care of their children: how well they respond to the obligations they accept when they ratify the CRC. Gradually information from improved monitoring systems can be expected to contribute to an increasing global embarrassment for those countries that have the resources but avoid the necessary political choices to achieve the goals. This will eventually contribute to an environment where it becomes "good politics" to ensure the rights of children and "bad politics" to deny children their rights.

FIG. 4. Ethics and science in the triple-A process


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