In the last 35 years, the World Bank has become the largest financial contributor towards health-related and nutrition projects, committing more than $1 billion annually towards the health, nutrition and population sectors. Other than as a lending agency, the Bank has innumerable unofficial functions, such as an advisory body, an intellectual research institute and a training centre for civil servants in developing countries. It is also the arbiter of development norms and meaning, combining intellectual prestige and financial power. Its annual World Development Report and staff working papers have established the Bank as an intellectual powerhouse, whose research represents the cutting edge of development.

Given the World Bank's significant role in the global nutrition community, a review of its 2006 report, "Repositioning Nutrition as Central to Development", is critical. International and national interests in nutrition have never been higher, as such concerns are tightly integrated into the Millennium Development Goals. The past few years have also witnessed several debates over "what works" in reducing undernutrition, such as the Save the Children UK's report on the growth monitoring model.¹ In addition, many developing countries like India are undergoing what has been described as the "nutrition transition": an increase in chronic and non-communicable diseases associated with overweight and obesity. As a result of these factors, nutrition is high on the development agenda.

The World Bank report makes several important points: it argues that nutrition should be mainstreamed into country assistance strategies and that nutrition policies should be developed in central institutions, such as the ministries of finance; it makes the explicit link between malnutrition and lost productivity (e.g., a 1-per cent loss in adult height as a result of childhood stunting is associated with a 1.4-per cent loss in productivity); and it advocates for increased fund to be directed towards nutrition. However, the report makes several assumptions that need to be examined.

The report identifies the mother's poor-caring practices as an underlying cause of malnutrition and notes that "access to and availability of food at the household level are not the major causes of undernutrition". It states that "poor-caring practices are the biggest worldwide causes of protein-energy malnutrition". It argues that women cannot tell when their child is becoming malnourished and that good nutrition is not intuitive, since there are high levels of ignorance about food choices. Thus, interventions should focus on improving maternal knowledge through counselling. Based on this representation, a behavioural change intervention is promoted using such educational tools as growth monitoring and promotion, supplementary feeding and intensive nutrition counselling, which are aimed at modifying detrimental childcare practices in developing countries.

This definition of undernutrition overemphasizes agency over structure, the individual over the community. While poor-caring practices can be viewed as an immediate cause of growth faltering, this can be attributed to the obstacles women face rather than as an indication of their lack of knowledge. Education is necessary, but insufficient. As Sabu George et al. note: "Almost all mothers desire to provide better care, but are overwhelmed by their workload and are often discouraged by the apathy of other family members towards the well-being of their children. In these villages, mothers felt helpless on many occasions because of frequent verbal abuse and, not uncommonly, physical violence, alcoholism and/or promiscuity of their husbands."

Women working in a resettlement slum in New Delhi. Photo courtesy of Devi Sridhar

Given the key role women play in child nutrition, it is also important to examine this representation of nutrition from a gendered perspective. During my fieldwork in India, women often mentioned lack of time, money or control over household expenditure to explain why their children were not healthy. This is similar to Cecilia van Hollen's observations on breastfeeding in India. She noted that poor women, who must work in the field all day and therefore do not breastfeed for more than eight hours, felt that their breasts were engorged and the milk was sour. But out of fear of being chided if they asked for formula, they would give the baby sugar water, or cow milk or water buffalo milk. These substitutes increase the risk of infection and are even more detrimental to the child's health. This anecdote reflects the preoccupation with behavioural change education over an enquiry into the social conditions that force women into work arrangements that do not provide them the time or space for breastfeeding.

It has also been shown that men in many developing countries are the decision makers in the household, but despite this dominance their role in child nutrition is not reflected in the report, which I term the "missing men" or the "missing fathers" phenomenon. Thus, women must go to work and earn money, as well as take full responsibility for their children's health. The continual emphasis on changing the caring practices of women can be viewed as part of a framework of blame: essentially a mother is admonished by health workers because she did not do something correctly. As one woman said, "I am sorry for working, but I have no choice. I have to leave my children alone". Since undernutrition is seen as preventable, women must bear the burden of responsibility. They face not only a double job of doing both public and domestic labour, but also a burden of blame for not having certain attributes, such as knowledge or patience, to care properly for their children.

While it is a valid assumption that women are the major caregivers of children, a behaviour change strategy targeted at women neglects the fact that gender roles are constructed and malleable. As Ann Whitehead has argued, it is the routine assignment of men and women to certain tasks that become intimately connected with what it means to be a man or a woman in a specific context. The concept of structural violence provides a useful framework with which to examine development interventions. Using this concept, undernutrition and other morbidity outcomes are viewed as the embodiment of structural inequality, such as poverty, gender discrimination or lack of access to water. Instead of focussing on the event itself, attention is paid to understanding what the inequalities are and how they can be addressed. It acknowledges that undernutrition is both a biological and social event, but instead of framing hunger as a disease to be eradicated, it focuses on how social forces and processes come to be embodied as biological events.

Given the lack of consensus in nutrition policy and planning, evident in the contradictory evaluations of the Bangladesh Integrated Nutrition Project, it is of utmost importance that more attention is given to building a solid evidence base. Each recommendation on improved nutrition should be followed by the question, "What is the evidence this works", with a review of all relevant studies, not just a selective use of information. Specifically for nutrition, impact data should include both quantitative and qualitative measures, as well as a balance of anthropometric indicators with social welfare indicators.

As a final note, it is worth placing more emphasis on health solutions that are not considered nutrition schemes per se, but have a significant effect on child health and well-being. Malnutrition is a complex outcome of infection and insufficient dietary intake, and ultimately a reflection of social, economic and political forces. For example, the 2006 Human Development Report notes that unclean water and lack of sanitation are significantly implicated in child undernutrition through the link of diarrhoea, estimated at 5 billion cases each year in children in developing countries. In addition, social protection programmes, such as conditional cash transfer schemes, address the root problem of poverty by increasing household purchasing power and income to acquire food. These, most notably PROGRESA, have shown a significant effect on child nutritional well-being. Even broad political instruments, such as land redistribution and minimum wage legislation, have improved social welfare. The World Bank report correctly notes that nutrition should be mainstreamed into development. Now is the time to act on these recommendations.

Note 1:
See the report: Thin on the Ground: Questioning Evidence Behind the World Bank-funded Community Nutrition Projects in Bangladesh, Ethiopia, and Uganda. Save the Children UK, 2003.
www.savethechildren.org.uk/foodsecurity/documentation/pdfs/chennai.pdf