di Giovanni Mottini, Università Campus Bio-Medico di Roma - “Individual Population Nutrition”, AAVV – SEU, 2010

International Organizations: WHO, UNICEF, FAO to name only the best known, have always underlined and addressed in their intervention plans the importance of food in the fight against poverty and for the promotion of human development in the most disadvantaged countries in the world. planet.

If you review the list of ten essential components for the implementation of Primary Health Care, defined in thechiaration of Alma Ata of 1978, it will be noted how the inalienability of the promotion of an adequate food supply system and proper nutrition[1] for maintaining an acceptable level of health of a population. In this way the food-health correlation is reaffirmed; which makes it clear that an adequate disease prevention strategy must be based above all on the preservation of the essential conditions for the existence of the human organism.

Alma Ata's statement, despite its brevity, however touches on another non-secondary aspect of the food problem; and that is the fact that the adequate feeding of a human community cannot be guaranteed if this is not in the social and economic conditions such as to be able to procure the food it needs in a logic of self-sustainability.

In fact, the spirit and the letter of Alma Ata underline how the "health" of a population, in the broadest sense of the term, rests above all on its capacity for autonomy, self-determination and spirit of participation.

What has been said so far may appear quite obvious and not decisive in the eyes of a pragmatist of our times, and this is partly true. However, it remains equally true that not even operational pragmatism, when it wanted to imbue the logic of aid intervention to developing countries, was able to achieve more satisfactory results than the deplorable declamatory immobilism of international institutions.

The lesson that can be drawn from the facts is that the logics of intervention, in their methodological neutrality, remain detached from reality, and therefore ineffective, if they are not truly endowed with a key to understanding it. And a key to understanding is grasped; we could say metaphorically: one "gathers" only when one is inside, when one travels through the system, and not outside of it.

To state that those who are poor most likely eat too little, and badly, seems quite clear to everyone. On the other hand, the opposite correlation is less evident: that those who eat little and badly become poor. It is therefore a question of an affirmation which, although equally true, requires an explanation and further study. And this is already getting on the right track to find the key.

Malnutrition and poverty

The correlation between malnutrition and poverty is to a large extent a partial application of a now well-known model, which sees disease and poverty interconnected in a vicious circle mechanism. The main pathologies with a strong social imprint that afflict the countries of the so-called third world: malaria, tuberculosis and AIDS (called precisely: the Poverty Related Diseases) are responsible, in addition to damage to the human organism, for a marked impairment of its relational dimension[2]. If we take the family nucleus as a model, even in its dimension as the primary cell of sociality, we can see how the presence of a disease such as AIDS that affects one or more of its active members (father, mother, other adults contiguous for kinship, as often happens in the extended African family) soon comes to mean: invalidity, incapacity for work, dramatic decrease in already precarious economic income, social marginalization and promiscuity, costs for treatment and medicines, lack of assistance for children, school dropout and inevitably inadequate nutrition for the whole family. In other words, the signs and symptoms of poverty. The consequences of these wide-ranging social effects will be an increased physical and relational fragility, and therefore a greater exposure to new diseases which, generating new incapacity and eroding the family's scarce economic resources, will thus close the circle of the vicious circle and they will strengthen the mechanism.

In this panorama, nutrition certainly occupies a significant and unavoidable place in various respects. Its insufficient quantity and poor quality, together with a poor variety, are in fact a reliable indicator of socio-economic degradation both ofingjust as, equally significantly, of a community that has been sucked into the vortex of the vicious disease-poverty cycle. In the wake of Alma Ata, it can be said positively that guaranteeing adequate nutrition means carrying out a highly effective preventative intervention, and therefore a priority (and less expensive) compared to all possible forms of treatment and rehabilitation, however effective these may be.

The vicious circle disease-poverty just illustrated also highlights two other aspects of primary importance for the purposes of our analysis.

The first is the confirmation of how the food factor is always closely intertwined with a multiplicity of anthropological, behavioral and socio-cultural dimensions, both in deprivation and in well-being and satiety; and how it can therefore be ineffective, or even harmful, to single out food intervention from the other components in a purely technical-practical preventive or rehabilitative logic.

Human nutrition, as has been underlined by many, but whose consequences are too little declined by those who work on the ground, is a phenomenon that intercepts values ​​and meanings that go beyond the simple satisfaction of a need for subsistence.

The second observation is instead addressed to the characteristics of the actors who move on the stage of malnutrition. Looking at this phenomenon with the eyes of a human development expert leads us to realize that women, and above all children, are the human categories most exposed to the damage of malnutrition.

- ingyears of hunger

Hunger and malnutrition are terms that are often used indiscriminately to understand the same phenomenon. It's actually well distinguere chiaramind their meaning, also to better understand their correlation.

Hunger is a subjective state of need and malaise from deprivation of necessary food; while malnutrition is the objective physical condition and pathophysiology deriving from the consequences of insufficient and inadequate nutrition.

As surprising as it may be, in spite of the aforementioned confusion, a datum of common experience must be kept in mind which has its foundation in the mechanisms of homeostasis of the organism; and that is that hunger, as an alarm bell of nutritional need, is the first and most natural preventive means of malnutrition. Evidence therefore that, although they often go together, they are not the same thing.

This does not prevent the mechanisms that hunger triggers from always being the most pertinent to solving the food problem.

The behavioral response that the subject is able or tends to implement to the stimuli and solicitations of hunger, when this occurs acutely or chronically, then depends on a multiplicity of factors, both psychological and of cultural and socio-economic context .

In a reality of human underdevelopment, such as that of a developing country in the south of the world in our times, this response fully reflects the paradigm of contradiction and contrast that characterizes it: rural context-urban context, country village-slum, tradition-modernity, marginalization-overcrowding, isolation-promiscuity, illiteracy and the internet….

Perhaps the most complete expression of this paradigm of contradiction in the food sector is the so-called junk food: foods and drinks accessible to almost all budgets, high-calorie and unbalanced in components, suspiciously laconic and unreliable in terms of excipients, dyes and preservatives, imposed by the import market logic of large multinationals. By now established in the streets and in the houses of the suburbs of the megalopolises of developing countries, they are spreading to the most remote villages more easily than medicines and basic necessities.[3]

Inggoing hungry in this way does the junk food  one of the main suspects of a phenomenon on which the most prestigious nutrition scholars worldwide are sounding an alarm bell: the epidemic of obesity, diabetes and consequent cardiovascular pathologies which is spreading in the southern hemisphere and which is becoming a new emergency for the health of developing countries (PVS) and a new heavy burden of care[4]- [5]. A health problem which joins the more traditional epidemiological frameworks of tropical infectious diseases and which paradoxically coexists with an ever-higher prevalence, both in the countryside and in the slums  of the suburbs of big cities, of the classic syndromes of infantile deficiency malnutrition: marasmus and kwashiorkor.

Malnutrition and human development: putting children first

The central role of children, or more correctly of the mother-child pair, in the drama of human malnutrition has already been mentioned in the description of the vicious circle of disease and poverty.

The high infant mortality experienced by developing countries finds one of its main direct causes in the high incidence of severe malnutrition, and the indirect effect this has on the increase in susceptibility to many lethal infectious pathologies is perhaps even more significant and almost unfathomable. child: malaria and tuberculosis first.

However, there is also a less obvious but equally devastating effect of malnutrition which concerns its impact on the intellectual and learning capacities of the child who has experienced or is experiencing conditions of more or less severe malnutrition.

The correlation between a child's serious food deficit and effects on his intellectual abilities is an observation datum that dates back to the sixties; that is, since the attention of world public opinion to the living conditions in the developing countries and therefore to the search for effective solutions to these problems has become more intense.

From an in-depth meta-analysis of the early 70s[6] the evidence emerges that in children who have gone through severe conditions of malnutrition under the age of two years the indicators for assessing intellectual status: intelligence quotient, intersensory competence and analysis of a broad spectrum of abilities linguistic, perceptual and motor skills showed significantly lower levels compared to control groups of children or classmates of the same age and living conditions.

Further evidence has emerged from studies on models of cerebral development both in animals and in humans, which show the existence of greater intellectual damage where the period of malnutrition occurs in the phases of more rapid development and maturation of the cerebral system; which in humans appears to occur from about mid-pregnancy to at least the ninth month of life.

Hence also the consideration of how the effects of intrauterine and intergenerational malnutrition should not be overlooked; in which therefore it is the mother-fetus dyad that must be the object of intervention, with all the social repercussions, in terms of educational strategies and the promotion of women and family protection, as well as public health, which this entails.

It has also been found that an adequate state of nutrition is essential for maintaining a good level of attention and for an appropriate degree of responsiveness of the child to the relational context, both towards the animate and inanimate world. Indeed, one of the most obvious clinical manifestations of severe malnutrition in childhood is the dramatic combination of apathy and irritability that malnourished children show[7].

It is also intuitive, as well as easily experienced by anyone, the fact that insufficient nutrition, and in particular in schooled children, leads to greater fatigue and the inability to sustain the physiological times of mental attention.

The missionaries of many African countries who run schools for less well-off children in developing countries know something about this: the first thing a schoolboy needs as soon as he arrives at school, often after walking several kilometers on an empty stomach, is a nice glass of milk , or a plate of cereal porridge; without which any didactic effort risks being lost time and wasted breath…

Malnutrition never comes by itself. It is a statement that condenses the constant experience of those who work in the field in the context of the different scenarios of a developing country: slums of megacities in the southern hemisphere, refugee camps, rural areas…

It should be better said that it represents the tip of an iceberg, the epiphenomenon and stigma of a phase of the biographical path in which the subject enters - and leaves - inevitably touched and marked in all its dimensions.

In the diagram shown here

Table I: the vicious circle of poverty-malnutrition and the factors involved

all the factors capable of influencing the determinism of the physical condition of malnutrition are highlighted. As can be seen, malnutrition is directly or indirectly affected by both socio-economic factors that generate poverty, with the accompanying causes that in turn determine it, and more sociological aspects such as social exclusion and promiscuity up to touching the influence of parenting roles and early school leaving. In turn, malnutrition, as we have seen, is able to negatively and permanently mark the physical and mental development of the child, thus influencing his future in terms of opportunities and work skills.

The following diagram also helps to understand how a specific form of malnutrition such as kwashiorkor is revealing of the social and cultural specificities of the family context in which it occurs. A constant datum such as inadequate weaning, the direct cause of this form of malnutrition, in fact refers to social stigmata, food habits and taboos, beliefs, the mother's school level, ways of life, level of education. 

Ultimately, a vicious circle of poverty-malnutrition is established which is none other than the more applied and analytical version of the aforementioned vicious circle of disease-poverty. 

Table II: The factors that contribute to the manifestation of the kwashiorkor

We find this analytic model particularly interesting precisely because of the prominence it gives to the relational aspects and the role of the family. In fact, positively with respect to the model, it can be deduced that the presence of parental figures and the stability of the family structure are undoubted protective factors against the risk of malnutrition-illness for the child of a developing country.

In fact, for its harmonious psycho-physical development, the mere presence of food is not required, but a presence, the maternal one, which guarantees an adequate and constant supply of those psycho-affective stimulations which accompany and give meaning to food intake and which , ultimately, are training for life.

As has already been pointed out elsewhere, the fact also applies here that "the mother figure has an essential role ... since food constitutes the bond in which, for the child, the reality of care and tenderness becomes tangible, without which a human being cannot develop an attitude of trust towards the world”[8].

This "trust in the world" of which Rof Carballo speaks, and which may appear to be a rather generic and obvious expression, should in reality be interpreted as an essential sign of recovery from malnutrition; healing from that "existential" dimension of the malnutrition phenomenon which is less apparent but just as real.

As proof of this, the aphorism coined by a scholar of the sector to indicate the first sign of recovery of the child in nutritional rehabilitation therapy is valid: the child who smiles is on the road to recovery[9], undoubtedly the result of field experience with surprisingly suggestive contents on an anthropological level.

Fight against malnutrition: it starts from life

It is clear, at this point, that if malnutrition never comes by itself, it would be wrong to think that it can be "pushed away by itself", or prevented solely on the public health level as a simple epidemiological phenomenon.

In a suggestive study on a new nutritional formula for the rehabilitation of severely malnourished children, carried out in a hospital in northern Uganda, the importance of a non-purely nutritional rehabilitation approach is underlined[10]. Limiting oneself to administering, for the entire time necessary for the recovery of normal conditions, a nutritional milk produced in the West and supplied by international development agencies, and then returning it to the mother and her social context, without the rehabilitation intervention affecting the " real life” of the latter, probably means saving a child from starvation today to make him a candidate for a new malnutrition tomorrow. The entire human context in which the problem arose must be "rehabilitated"; starting with the involvement of the mother in the rehabilitation process, which therefore also becomes formative-educational, up to the preparation of a nutritional preparation designed on the agricultural and natural products of the life context of the beneficiaries; that is, such as to guarantee its real and permanent availability in a spirit of self-sustainability.

The DREAM project of the Community of Sant'Egidio moves along the same logic, albeit in the context of assistance support. The fight against malnutrition is seen as a tool to guarantee a real effectiveness of the antiretroviral therapeutic intervention, not only as a support component to the therapeutic protocol, but as a factor of success in the treatment relationship and for its positive effect on the patient's attitude in towards the desire to live and to face the obstacles of an existence compromised by illness, but not for this vain or insignificant[11].

What has been said about the close interactions between nutrition, intellectual development of the child, parental functions and the "global health" of the family nucleus and its social surroundings leads to the conviction that the privileged scenario for implementing an effective strategy for the prevention of malnutrition and promotion conditions and healthy lifestyles is a primary and ubiquitous institution like the school.

In it we find the main players in a strategy for building the future of a people: families, teachers and pupils. In this triangle each vertex is called upon to perform a function both as an active protagonist, on the double side of dispenser of training processes and messages (even the pupil towards the parents!), and as monitor and sentinel on the risk situations that can affect members of the school community. In this way, the school assumes the dual function of a place of promotion and protection for its members.

The school itself, however, in turn needs to be promoted so that it can be invested with this crucial task. This can only happen in countries with a socio-economic system that is not necessarily thriving but sufficiently healthy and balanced to respect and support the priorities for the well-being of a people: education, health, internal economic development. Rather than defense armaments and commercial concessions to foreign economic powers, as is the case for many developing countries.

The peoples of the developing countries are almost entirely included in those three billion people that the estimates of the Integrated Pollution Prevention and Control define as living in rural areas and dependent mainly on agriculture[12]. The agricultural and therefore food production potential of many of these countries is still largely unused and, where it is, it has not been designed not for the benefit of the local population but for foreign trade and the prerogative of the economic interests of a few .

The recent global food crisis has significantly triggered the protests of the representatives of the developing countries who demand a genuine commitment of the international community for the promotion of rural development and the improvement of local agricultural production rather than the massive but sterile recourse to external food aid. Trade, not aid has become the motto of this current of thought.

But economic and agricultural development are in any case phenomena and mechanisms which, in order to act virtuously in favor of the development of a people, and not at their expense or above it, need local, competent protagonists aware of their social responsibility.

Once again, therefore, a forward-looking and authoritative educational strategy returns as a priority.

Food and its safety, agricultural development and its environment, but above all an authentic attention to the territory and its people (education system and community that is the protagonist) therefore remain the pillars of the human development process that the present time entrusts to us as task.  

 


[1] OfchiaraAlma Ata Action on Primary Health Care, chapter VII – par. 3, Alma Ata, USSR 6-12 September 1978

[2] See on the topic: Farmer P., Infections and inequalities, the modern plagues. University of California Press, 1999.

[3] The term "Westernization" of the diet of African, Asian and South American populations of the world was coined to identify the effects of this phenomenon of displacement of the traditional habits of these peoples in favor of foods and drinks introduced by the 'external. Phenomenon that has evident causes in the globalization of markets and commerce and in human migrations. See Sobngwi E., Mauvais-Jarvis F., Vexiau P., Mbanya JC., Gautier JF., Diabetes in Africans. Part 1: epidemiology and clinical specificities. Diabetes Metab. 2001 Dec; 27(6): 628-34.

[4] Popkin B., Global nutrition dynamics: the world is shiftinging rapidly toward a diet linked with noncommunicable diseases, Am. J. Clin. Nutr. 2006; 84:289-298.

[5] Mendez M, Popkin B., Globalization, Urbanization and Nutritional Change in the Developing World, Journal of Agricultural and Development Economics, Vol. 1, No. 2, 2004, pp. 220-241.

[6] Birch H., Malnutrition, learning and intelligence, Am J. Pub. Health 1972 June; 62 (6): 773-784 .

[7] Amcoff S., The impact of malnutrition on learninging situation, in: World Nutrition and Nutrition Education, UNESCO-Oxford University Press Publication, Oxford Medical Publication, 1980

[8] Rof Carballo J., Urdimbre afectiva y enfermedad. Introduccion to a dialogical medicine, Labor, Barcelona, ​​1961

[9] DeanRFA, The effects of malnutrition on the growth of young children, Mod. Probl. Pediatr., 5:111-122, 1960

[10] Greco L. Balungi J., Amono K., Iriso R., Corrado B., Effect of a low-cost food on the recovery and death rate of malnurished children, J.Ped. Gastr. Nutr. 43:512-517, October 2006, Philadelphia

[11] Magnano San Lio M. et al., The DREAM model's effectiveness in health promotion of AIDS patients in Africa, Health Promot Int. 2009 Mar; 24(1):6-15

[12] Min. Foreign Affairs, Italy with the UN against hunger in the world, Official Italian celebrations of World Food Day 2008, p. 9