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Natal, Rio Grande do Norte, Brazil. This month my hero is Samuel Langhorne Clemens, known to us all as Mark Twain, he of the splendid moustache. He is often said – even by others with a claim to the title – to be the greatest US writer, because of his genius in delineating what it meant and means to be born, bred and bold in the USA. As in previous months, his relevance for us is indicated with a quotation at the end of this column.

The main item this month continues what now turns out to be a three-part account of the nature, scope and purpose of nutrition as a science and profession, to be completed next month. Last month (1) I said why it is an error to imagine that we humans are separate from the rest of the living, natural and physical world. When this mistake is corrected, it becomes obvious that nutrition is a social (including economic) and environmental as well as a biological and behavioural science. This makes our work more valuable, and much more interesting.

This month I see nutrition from the point of view of the South, by telling the story of how I saw the light in 2007 in Amazonia. Next month I tell how this vision took shape during conferences in 2008 and 2009 in Hyderabad and Istanbul. This column is also infused with my new experience of Brazil. It is being drafted each morning starting before dawn, on the Atlantic littoral south of Natal, the capital of the state of Rio Grande do Norte. When I step outside I see the Atlantic Ocean from what was, when I lived in Britain, the other side. Now I am on that other side, for where I am now is not, as it once was, 'that side'. It is this side. What side are you on?

Reference

1. Cannon G. Big pictures, and other items. [Column] Website of the World Public Health Nutrition Association, February 2011. Obtainable at www.wphna.org

Visions from Amazonia (1)

Power for the people

The Amazon – or to be more exact the Amazon region – may change you. It did me. The picture above was taken from a restaurant on the bank of the Rio do Pará, the continuation of the Tocantins River, outside Belém, the capital city of the Amazonian state of Pará. With the flash turned off, my little camera, steadied on top of a fence, took maybe five seconds to make the picture as the ship chugged slowly by. Ever since, this image has reminded me of Amazonia where, for anybody not from the north of Brazil, so much is different from anything you have experienced before, and so where so much is not what it first appears to be.

Then the change may come, and you start to see from the point of view of the Amazon, which may be the best place to be, as the greatest surviving part of original nature. With its tributaries, this river affects the whole of the north of Brazil. The climate, customs and character of these regions are very different from that of south Brazil, and from anywhere else in Latin America. Amazonia has an epic quality.

Package tours have no such lasting effect, because most of what you will see has been made safe, clean and nice for tourists whose notion of roughing it is a three-star eco-lodge with uniformed waiters serving caipirinhas (1). On the other hand, you won't need to go so far as to explore a river where no white man had before paddled a canoe, beset by rapids, murderous natives and porters, and bichinhos (1) that bite and burrow into any and every part of the body (2). All you need is to be with Brazilians who know their way around, as I usually am with my wife Raquel, and to be not just visiting, but involved with where you are, with work to do.

Immensity and poverty

No, I have not yet had a job to do on the Amazon river itself (3).But in late 2007, and then in late 2010, I was working in and around Belém. As with the neighbouring state of Amazonas, the first hard-to-grasp fact about Pará is its immensity. Its area of practically 1,250,000 square kilometres approaches the combined areas of Portugal, Spain, Holland, France and Britain, the five European powers that once controlled or dominated parts or all of Brazil, which all together amount to 1,400 square kilometres. And this is just one of the 26 Brazilian states! Then, there is the fact of its population, which at 7 million contrasts with 194 million of the five European countries. Then, its poverty measured in money terms. Of all Brazilian states, Pará is one of the poorest (number 22) in money terms, with an average annual income per person of around $US 4,000 dollars, contrasting with around $US 40,000 in the European countries that have exploited it. You get the drift of these statistics.

As in sub-Saharan Africa, a first thought of a visitor to Pará may be that its situation is desperate or hopeless. But who best makes such judgements, a stranger or a native? Most of the people of Pará don't have much money or many possessions. So what? Then, if you are there to work and learn, the light of its more remarkable citizens begins to shine.

Listening to other people

Two of the most memorable people I have ever met are Israel Corrêa Perreira, left, above), trained as a nutritionist, who is responsible for the public health planning of the whole state of Pará, and José Edmar Urano de Carvalho, (right, above), senior agronomist at the research station of the government agricultural agency Embrapa located outside Belém, responsible for the study of Brazilian tropical fruits.

Urano believes that Brazilian tropical fruits and their products amount to a national treasure that needs to be protected, for the benefit of Brazil and its people. With colleagues, he patiently plants and nurtures many types and varieties of fruit tree indigenous or unique to Amazonia, in the sandy soil of forest clearings. He measures how well they do in different conditions, and investigates their nutritional and medicinal qualities. Much of this work is not a national Embrapa priority. But the trees are his responsibility and, as if his children, always need his care. When necessary he works for free or uses his own money, in addition to his other duties. If he did not do so, the young trees would not flourish, their value would be lost, and later the forest floor would become barren desert.

What can Israel possibly do that has any effect in the many Paraense municipalities that have no money and little equipment? This was my question. He laughed. He laughs a lot. Israel tem carisma – he is a charismatic character, a magnet in any room he enters. He was trained as a nutritionist in top schools in São Paulo and Ribeirão Preto, and then in Rio de Janeiro at Fiocruz, the Brazilian official national public health institute. He could have had a comfortable career at one of the most prestigious Brazilian universities or research centres. He chose to return and give what he had learned back to the people from whence he came. He answered my question. The chief resource needed for primary health care, he said, is committed and energetic people living and working within their communities. With these qualities, training is easy and equipment is secondary. The Brazilian Sistema Único de Saúde (SUS, the national health service) can be rudimentary, most of all in remote rural areas, but it works, and is protected as an inalienable right of the people by successive socialist federal governments. And himself? He laughed again. 'Gosto muito de estudar!' he said, which is to say, I love to learn.

Development and independence

One of the reasons I take pictures of people I meet, is that this reminds me of them and what I can learn from them, which may take years. Now, I am looking at Israel and Urano, as you with your mind's eye may look at people you admire. Would they and their work be changed if they were given big loans from the World Bank? Not for the better, I believe.

Yes, Brazilian tropical fruits potentially amount to a national treasure comparable with sugar, gold and coffee, and given what is now a real Brazilian independence from 'the great powers', their value can be realised for the sake of its people and the place of Brazil in the world. But this won't be achieved by the munificence of strangers with their own agenda. Urano knows what he is doing. What he and his colleagues need, in my view, is a gradual practical appreciation of the value of their work, which at first can mean a shifting of the priorities of Embrapa to give more importance to Brazil's own native and established tropical fruits. This doesn't need much money. People are more important. It starts with an idea of what Brazil is and can be.

Much the same applies to Israel's work. The idea I am still struggling with here, because it's hard for somebody who is a native of any materially privileged country to grasp, is this. Yes, Brazil remains a country with shocking internal inequities, not merely to be measured by contrasts of money. Yes, too many populations of the original Brazilian people live in misery (4). Yes, the relatively impoverished parts of Brazil are still in need of reliable sanitation, clean water, protection of their own natural resources, universal elementary education especially of girls, employment with a decent basic wage, basic primary health care including vaccination and essential drugs, cash transfers in cases of need, and as a cause and consequence of all this, food security, which should imply stable supply of locally grown produce. All true.

But now that the crushing burden of foreign debt has been lifted from Brazil, by the efforts of successive governments, Brazil is getting there. It is no longer a servant country. In a vitally important sense, Brazil is all right now (5). The rhetoric of intervention and change and development as usually understood, which mostly means more money – 'give me 15 billion dollars and I will conquer malnutrition', that sort of attitude – does not apply (6).

Here is one of the lights I saw and see as a result of my experience of Amazonia. While it is foolish to romanticise poverty, and while impoverishment into misery (not the same thing) is a crime against human rights, people living with relatively few material resources can have a decent way of life just the way they are. And even when they do not, it does not follow that their conditions of life will be improved by external intervention, especially if this is undertaken by foreigners whose main interest is to use natives as subjects for research. This is all the more so, when populations and communities live in a generally benign climate, value family life, support one another, and when their country is gradually becoming fully independent.

As my colleague Urban Jonsson rightly says, good people in what were the colonial powers of Europe and North America, feel of the people in what were the colonised continents and countries, something like 'We are OK and they are not OK, so we must give some of what we have to them'. The psychology of such charitable feelings is easy to understand, but they start from a wrong position, and the results more often than not are unhelpful or even disastrous. They can amount to a new form of colonialism. The fact that the motives are well-meant is not relevant. So were the motives of missionaries.

There is a fundamental lesson here for nutrition professionals from the North. Don't assume that you know best, or that what you know is readily transferred to other places. The nutritional status of populations is improved, maintained and made secure, not by donation of food – and in any case, as a rule there is no such thing as a free handout. The goal is achieved mainly by leaders who are natives of and who live in the countries themselves, supporting and encouraging their fellow citizens to use and strengthen their own resources, while at the same time ensuring their basic sanitary facilities, education, and primary health care. This is and must be a gradual process.

Notes and references

1. Caipirinhas (the name literally means 'little country maiden') are the standard Brazilian cocktail, offered in restaurants and to tourists. This is how they are made, for a party of 6. Crush lots of ice and put it in a big jug, and drain off any water. Then squeeze say 6 limes (not lemons) over the ice. Then add a lot of sugar. Then pour in most or all of a bottle of cachaça (also known as pinga or aguardiente), and stir until the ingredients are all mixed together. It's one of those drinks meant for hot evenings. Cachaça is the Brazilian national booze, distilled originally by slaves from sugar-cane, and so is somewhat like rum. It is made industrially, and also by small farmers as an artisanal product, and also as hootch. It usually has much the same concentration of alcohol as any other liquor. What makes caipirinhas seductive and dangerous (hence perhaps the name) are the other ingredients, which give an impression that you are drinking a very tasty fruit juice. If you make a habit of drinking four or more in the evenings, you will not remember much of Amazonia. Unless you ask specially, your caipirinha will be made from industrial cachaça that costs around $US 4.50 a litre in supermarkets. A little like single malt whiskies, artisanal cachaças made in the distilleries of small or family farms, of which there are literally thousands in Brazil, can taste very different, depending on all the usual variables of nature of terrain, source of water, type of barrels, whether or not the corpse of a cock or some other creature has been slung into the barrel, length of storage, and the skill of maker. Bichinhos (the name literally means 'little creatures') is a Brazilian word that has no exact English equivalent. It means insects, and also smaller fauna of any type.
2. As did Theodore Roosevelt in 1914, after his Bull Moose party bid for the US presidency failed. He nearly died in Brazil and was never the same again. But his route, previously known as 'the river of doubt' (Rio da Dúvida) was renamed the Rio Téodoro. The reference is: Millard C. The River of Doubt. Theodore Roosevelt's Darkest Journey. New York: Anchor, 2005. His companion and guide, Cândido Rondon, later had a Brazilian state named after him.
3. So what about the Amazon rain forest? Like all countries, Brazil lives with the misadventures of previous governments. Brazilians like to remind people from the US and Europe that much of their countries were once covered with forests. As with the US in the Wild West period, there are limits to what legislators can do to stop powerful foreign and national exploiters. What's needed above all is what the country now has got: a basically honest national government that is not about to sell off Brazil's resources, and a national economy that ensures real independence. Besides, with the Amazon rain forest, what's the choice? Ceding it to a consortium of foreign governments technically under UN auspices, co-ordinated by the World Bank or the World Economic Forum? No, I think not.
4. As with native North Americans, the conditions of life of far too many native Brazilians (always known as Indians here) remains a disgrace. Within Pará, some compensation has been given to the remnants of the native people, who live within protected reserves, some vast. The abominable attitude of European settlers to the native people of the Americas, which has a reflection in the attitude of materially rich nations to nations that may well be rich but not in guns and money, is characterised by the French philosopher Tzvetan Todorov. The reference is: Todorov T. The Conquest of America. The Question of the Other. University of Oklahoma Press, 1999. First published in French, 1982.
5. The idea that Brazil is all right now, is strange for almost all Brazilians themselves, who have been trained into a sense of national inferiority. 'But Brazil is very violent' they say, to which I reply 'So, what about World War I and World War II?' On relative states of corruption, Brazilians chuckle happily at the tales of the initial presidential 'election' of the younger George Bush, and such-like political hanky-panky in 'developed democracies'.
6. Some economists and other thinkers believe that 'development' involving 'aid' to materially impoverished countries, is a mistake, partly because this prevents those countries lifting themselves out of dependence and misery. Given the cancellation of foreign debt, there is much to be said for this view. Aid to the impoverished parts of Brazil should come from Brazilian public funds. A reference here is Easterly W. The White Man's Burden. Why the West's Efforts to Aid the Rest Have Done So Much Ill and So Little Good. New York: Penguin, 2007. Also look up Dambisa Moyo.

Visions from Amazonia (2)

Protection of food systems

In Belém I have also seen the light concerning food systems. A big attraction within the city is the Ver-o-Peso market (its name means 'check the weight'). Most tourists miss the main event, which is the arrival of the small boats (like those above), beginning before dawn, bringing baskets of açaí berries to be sold to local dealers. The açaí palm grows only near the banks of rivers and in wetlands. The fibrous berry contains a substantial amount of protein and various micronutrients, and when pulped and sweetened, can be a staple food. Together with the guaraná berry, which contains stimulants, açaí is the fruit unique to Amazonia which when pulped and sweetened – usually with guaraná syrup – has become a national and international commercial success.

The two pictures above are glimpses of early stages of the food system that brings açaí from the jungle to the 'health food' shops and now also the supermarkets of North America. The painting (above, left) shows a typical riverside house of a family that grows and harvests açaí. When the family has a sufficient crop, and has filled a quota of baskets woven from another palm tree, marked with the number of their little farm, the men bring it to the Ver-o-Peso market, unload the baskets on the quayside (as you see, above, right), and do deals with the local traders. The system depends on trust, because the producers receive money only after the traders have sold a big consignment to the local pulping factories. If there was a glut and the price paid by the factories drops, that would be tough luck for the producers. If the dealer is a crook and makes off with the money, this would also be too bad.

And what if there was a microbiological scare, possibly ramped up by rival commercial interests, which resulted in the US Food and Drink Administration banning the import of açaí? The livelihoods of many producers would be destroyed, and part of the economy of Belém would slump. Without protection from national governments, and genuine fair trading, food systems, especially those that depend on export sales, are fragile.

A lesson here, and not only for nutritionists, is that to separate consumption from production of food, and from its social, economic and environmental circumstances, makes no real sense. Açaí is a small crop in world terms, and not a staple food except for some of the poorer people in and around Belém. But the same points apply to the economies of producers of cash crops, including staples like corn and rice, and tropical fruits also, throughout the South. We as professionals need to know where food is coming from; otherwise we will remain part of the cause of fluctuations of prices, and so the immiseration of the producers on whom we depend, and in turn the rise in obesity and decline in health of impoverished populations everywhere who, when the price of fresh food rises, subsist on ultra-processed calorie bombs.

Visions from Amazonia (3)

Fundamental and elemental health

Now I come to my third Amazonian vision. My work in and around Belém in 2007 was taking me the tropical fruits research station of the national agricultural organisation Embrapa, to learn from Urano and his colleagues. (See the first item above). The road through the jungle was blocked for a while. Ironically, the reason was that the weight of a big truck loaded with Coca-Cola for delivery to the natives had destroyed part of the dirt road that cannot bear such heavy loads, and was embedded up to its chassis (left, below). While the driver and his mate waited for rescue, the two young girls introduced us to their family and friends, and (right, below) sat eating cocoa fruits from the trees in their garden.

We found ourselves in a small community. In the garden of another house where we had been invited to enjoy local hospitality, there was a large pool, leading to a river, in which children were playing. So I took a lot of pictures, like the one above introducing this item, some very charming.

And then the thought came to me. How can we be sure that the children of these children will have abundant clean safe water to drink, use, and enjoy? Without water security, the edifice of nutrition is undermined and crumbles. So, as since then I have been constantly saying in conference presentations, here is a profoundly important integrated biological, social, economic and environmental challenge for our profession.

What stayed with me in particular was the dimension about which there was most discussion and initial doubt at the 2005 workshop meeting that created The Giessen Declaration (1): the environment. As said in my column last month (2), the more I have thought about this, the more it seems to me that putting up barriers to separate humans from other living things, and from the natural and physical environment, and the biosphere, is insane. In general, there's nothing new in this thought, it's what ecologists have been saying for a century and more. Indeed, as well as leaders of the native American nations, it's what natural scientists (the original term for philosophers) have been saying throughout recorded history. Since the rise of Big Science, linked with technology and industry, which has ensured the hegemony of Europe and then the US (3), such farsig

In the jungle outside Belém in 2007 I realised, as so many people already know, that the natural resource and public good that most needs protection, to ensure security of food and nutrition, and also of society and the living world, is water. This led me back to the mediaeval concept of the four elements – air, earth, fire, as well as water.

Fortunately, the next year and the year after, 2008 and 2009, I had the opportunity to reason such issues out, with many distinguished colleagues in two big international meetings. One of the concepts we came up with, was that of fundamental and elemental public health – including public health nutrition - which, we agreed, now needs to be the main focus for all relevant professionals. This is the main subject of my next column.

Mark Twain

Delight

Yes, I remember wild blackberries also, in the fields outside Cockfosters, or was it Uxbridge, stations at the end of London Underground lines where, aged about 10, with a couple of chums, I'd secretly travelled from Finsbury Park. In those days a journey of any length cost the same; or we may have ducked through the barriers and not paid. The blackberries proved to us that we'd been there. They made our adventure authentic, and their bushes and thorns and stain and taste is what I remember – my mouth waters now. There was another time of wild blackberries also, but that was much later.

My fellow columnist Fabio Gomes regularly celebrates fruits in season, usually by quoting fine writing about their delights. He is right to do so and I hope you think so too. His habit is challenging, because in implicitly claiming that such passages are relevant, he is expanding what 'nutrition' and 'health' are now usually taken to mean, to include mental, emotional and yes spiritual as well as physical aspects. Plus I included the final sentence in the quotation above, written by Mark Twain, whose reputation now is at a new peak (2), with reference to his childhood in Hannibal, Missouri, to remind us that there is more to well-being is than physical comfort.

Ah, a scientist may say, but how do you measure such things? Well, I believe there are organoleptic indices. But why should all aspects of nutrition – let's use the term nourishment – be measurable? If it is a defining characteristic of science that it deals only with what can be measured, doesn't that confine science and make it less interesting and significant than we like to think it is?

But perhaps it's just a matter of being more imaginative about measurement. A study could for example be undertaken of the number of times Brazilian poetry celebrates the delights of the table as part of family and social life, compared with English poetry. But that, I accept, would be one for the qualitative literature. Or, two cohorts of people aged around 60 could be formed, one who as children gathered and ate lots of fresh fruits, and the other whose childhood diets were processed products. The purpose of the study would be to discover how vivid their childhood memories were, and what evoked the most touching memories. This for me would be all about nutrition and health, and indeed might well bear on mental function in later life. Quantifying all the factors would be lots of fun. There are whole university departments and journals waiting to be established, to study such stuff. And just think of all those delicious confounders!

References

1. Twain M. Autobiography. Volume 1. Los Angeles, CA: University ofCalifornia Press, 2010.
2. Churchwell S. Mark Twain: not an American but the American. The Guardian, 30 October 2010

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Cannon G. Visions from Amazonia, and other items. [Column] Website of the World Public Health Nutrition Association, March 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Barrie Margetts and Fabio Gomes. Special thanks to Israel and Urano, and all the people in and around Belém – especially the children – who helped me to see the Amazonian light. Thanks also and always to Google, Wikipedia, and Guardian On-Line.