## Devi Sridhar

Print publication date: 2008

Print ISBN-13: 9780199549962

Published to Oxford Scholarship Online: January 2009

DOI: 10.1093/acprof:oso/9780199549962.001.0001

Chapter:
Source:
The Battle Against Hunger
Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780199549962.003.0004

# Abstract and Keywords

This chapter describes how hunger is addressed by the Bank nutrition team. It examines the interlacing of economic ideology and politics in World Bank nutrition policy through focusing on the periods 1971-1980, 1980-1993, and 1993-2006. It concludes that undernutrition is constructed as a matter of choice for households.

It's easy to exaggerate the exceptionalism of health. I've been dealing with public health people for twenty years, and they tend to overdo that. What's unusual about health is just that it's a peculiar asset, because you can't sell it, you can't give it away, you can't get many spare parts for it, and while your body is in the hospital, you can't go get a loaner body the way you can when your car is in the shop. The biology never goes away, but the economics has to be there.

Philip Musgrove 1

Former Health Economist at the World Bank from 1990 to 2002

Chief Architect of the 1993 World Development

Report Investing in Health

How is hunger addressed by the Bank nutrition team? And, how does nutrition fit into the Bank's wider aims and programmes? Complementing the previous chapter's focus on biomedicine, this chapter explores the economic influence, specifically orthodox, neoclassical economics, on the World Bank's approach to hunger. Ngaire Woods notes,

The similar graduate training shared by staff in each organization [World Bank and IMF] gives them a shared, albeit narrow, methodology and particular understanding of the world, its problems, and their solutions… The term profession… is widely used by neoclassical economists. It underscores the extent to which this kind of economics is a discipline, like medicine or law, requiring the command of a specific body of abstract and complex knowledge, which is then brought to bear on a particular case. 2

The underlying concern addressed throughout this chapter is whether nutrition is different from other areas the Bank works in.

# (p.85) Mainstreaming Nutrition into an Economics‐Dominated Organization: 1971–80

As noted in Chapter 2 , the Bank began to fund stand‐alone nutrition projects under the presidency of Robert McNamara who brought to the Bank an agenda outlining the moral imperative of foreign aid both for humanitarian and national security purposes. This section examines the reasons why the Bank decided to fund nutrition‐related projects. The history of why the Bank chose to make loans for nutrition is extremely relevant as it partially explains how the Bank addresses hunger. It then considers how economists have influenced nutrition methodology, for example, through the derivation of a metrics of nutrition. The section concludes by examining how basic economic principles such as market failure and information asymmetry have affected how the Bank nutrition team approaches nutrition.

In 1971, experts from various fields and government officials from several countries gathered at the Massachusetts Institute of Technology (MIT) for the first International Conference on Nutrition, National Development, and Planning. That same year Alan Berg, then working for Food for Peace, published a paper in Foreign Affairs arguing that nutrition planning was crucial for development. This led to the Council for Foreign Relations sponsoring Berg for a year at the Brookings Institution to write a book on nutrition and national development. Published in 1973, Berg's The Nutrition Factor is viewed as catalysing the emergence of food and nutrition policy and nutritional planning on the international stage. Berg gave a presentation on his book to the Board of Brookings, which included Bank President McNamara.

McNamara was intrigued by the economic arguments Berg presented regarding the urgency of addressing undernutrition in developing countries. He contracted Berg to write a policy note on nutrition and economic development. This brief was crucial as it convinced the Bank's Board and several senior managers that the Bank should start lending for nutrition. Berg made two arguments to the Bank. The first was that nutrition was a development concern that impacted on productivity. It was not just a medical or social welfare issue. Second, he argued that nutrition needed the involvement of managers. It needed to move away from its association with ‘medical, biochemist, welfare’ types. The latter issue, the move from the medically oriented approach to the development planners approach positioned nutrition in the domain of economics. Berg (p.86) argued that there needed to be a switch to ‘macronutrition’. By this term, he meant a move from clinical and laboratory approaches to undernutrition to ones of development planning in institutions such as the World Bank. The mainstreaming of nutrition in development brought it into the domain of economists who dominate the development apparatus in the Bank. 3

The Bank management was hesitant to engage with nutrition because of its complexity, its inter‐sectoral nature, and ‘the nature of the Bank's system for assessing and rewarding staff’. 4 Health‐related projects were viewed as a ‘bottomless pit’. However, with McNamara's urging, the Bank's Board of Executive Directors decided to finance the implementation and evaluation of certain largely experimental actions in countries with high priority. The Bank's main objectives were to draw the attention of government officials to the problem, to assist in planning, to further the development of rigorous project analysis, and to provide enough resources to make significant interventions possible.

Berg and others involved in nutrition during the 1970s and 1980s recount how difficult it was to convince the senior economists to lend for nutrition, calling it an ‘uphill battle’. As one staff member noted,

Nutrition has always occupied a strange position, I mean, economists think it's too complicated and there are no clear demonstrations of success. They think the evaluations are ineffective and that food subsidies are a bad idea. During the retreat on this, sceptics want to trash the nutrition programmes so we have to fight quite hard for it. Nutrition goes through cycles at the Bank. The biggest problem is the complexity, and task managers and leaders not knowing how to do it, how to get the project approved, how to push through such a complicated thing.

The final section of this chapter returns to the final point concerning the tactics employed by Health, Nutrition, and Population staff to get projects approved by senior economist managers. Similarly, another staff member explained,

The bureaucratic politics of mainstreaming nutrition, what a story. There were very very high objections and resistance on the part of senior economists who were more concerned with transferring money than what you did with it. They wanted a return. So the nutritionists turned arguments against them and created productivity numbers, they wanted numbers so we played that game… of course you could say that spurious economic analysis such as using unrealistic gains in nutritional status was used to get economists to approve nutrition lending.

(p.87) An example of this tactic was the presentation of data by Bank staff showing a possible reduction in low birth weight infants from 23 to 4.5 per cent if projects were implemented in India. According to the National Institute of Nutrition of India, these projected figures are unrealistic in the given time frame. 5 Returning to the emphasis on numbers, several nutrition staff would argue that the Bank's main contribution to nutrition was quantifying the economic and social benefits of involvement in this sector.

Econometrics is defined as the application of statistical and mathematical methods in the field of economics to describe the numerical relationships between key economic forces such as capital, interest rates, and labour. In the push to convince Bank managers to fund nutrition in the late 1970s, a new metrics of nutrition was created in which theoretical models were used to draw relationships between nutritional gains, labour, discount rates, and productivity. Using these models, the previously unquantifiable, such as the value of adequate nutritional status, could be numerically expressed and thus enter into calculations. Economists were uncomfortable with the complexity of nutrition and the difficulty in evaluating the economic gains from nutrition projects. To make nutrition comprehensible to senior economists, production functions were employed such as:

$Display mathematics$ (1)

In Eq. (1), Q stands for output, A stands for conversion coefficient, L is labour, K is capital, l is the per cent increase in output per 1 per cent increase in labour, and k is the per cent increase in output per 1 per cent increase in capital. 6 Once this was established, a second equation was derived that included food consumption as a proxy for nutritional status:

$Display mathematics$ (2)

In Eq. (2), N(d f) stands for the expected number of low‐income individuals who move from ‘poor’ diet to ‘fair’ diet, N(dy) is the number of low‐income individuals at risk multiplied by the change in real income of each participant, dc is the change in participant food consumption associated with a change in real income, dy is the family income, dq is the estimated proportion of households with ‘poor diets’, and dc is the current level of food consumption. 7 Once N(df) is estimated, then the change in labour can be estimated and entered into Eq. (1). Using these two equations, (p.88) a direct mathematical link can be drawn between an increase in food consumption and an increase in output per person, or productivity.

In addition, by using the proxy of food for nutrition in this time period, Berg could gain the attention of economists:

[E]conomic distinction commonly is made between food and nutrition—ranking food ‘high’, nutrition ‘low’; or food ‘essential’, nutrition ‘welfare’. Food has obvious tangibility features that nutrition lacks. Food costs and supplies can be measured, subjected to economic analysis, and entered into the national accounts. Nutrition in contrast often is invisible and dimly understood, and it seldom commands a price, especially among those who need it most. 8

Berg had difficulty convincing the senior economists that the Bank should make loans for nutrition. For example, his initial policy paper for President McNamara was neglected for many months since there was an oil crisis in 1971 that diverted attention away from nutrition. 9 Since this time, the numerical equations used to describe productivity gains from investment in nutrition have increased in complexity. Economic functions have been continually used to justify Bank involvement in nutrition as well as to increase the likelihood of management approval of nutrition lending.

Concerning nutrition metrics, since this time period, the Bank has emphasized the use of production functions to justify involvement in nutrition. This dialogue is the only one that is permitted and used. This can be viewed as an ‘econometrics of suffering’, the situation where mathematical analysis of production relationships is used to determine the magnitude of nutritional deprivation and provides justification for spending to alleviate this destitution. Quantification makes hunger real to economists and to planners.

The previous section discussed how the language of nutrition metrics is one defining influence economists have had on nutrition‐related projects. This section examines another influence: how the economic principle of information asymmetry led to a particularly favoured intervention by the Bank to improve nutritional status in developing countries. One of the key concerns in economics is the nature and extent of public sector involvement. 10 The Bank tends to favour the private sector as ‘public sector institutions have often been found to operate less efficiently than those in the private sector’. 11 The World Bank argues that government involvement can only be justified in specifically defined cases. These include where there are identifiable failures in the market (i.e. (p.89) the private sector), which arise in the case of public goods, externalities, and imperfect information, or where income redistribution is considered desirable. 12

Bank nutritionists have perceived market failure as one of the key reasons why malnutrition rates are extremely high in South Asia. 13 In this framework, government expenditure on nutrition has been justified on the basis that markets have failed. 14 Information, in the form of nutrition education, mass communication, or counselling, has been viewed as an adequate government response to this market failure. Behaviour modification is expected to occur through nutrition education. This approach is still evident today. As a 2006 Bank nutrition report states, ‘People do not always know what food or what feeding practices are best for their children or themselves… the need to correct these “information asymmetries” is another argument for government intervention.’ 15

Since the pilot projects of the late 1970s, nutrition education, using the tools of growth monitoring and supplementary feeding, has been the base of certain Bank projects such as TINP. The underlying assumption has been that once individuals and households have the necessary information, behavioural change will occur and malnutrition rates will drop. 16 Proponents of this perspective have used ‘positive deviance’ (children who grow much better than the median of their community) to argue that even in conditions of deprivation, households can adopt strategies to improve the nutritional status of their children. As a 1996 Bank document notes, ‘Improvements in child nutrition so often depend on changing feeding and care‐giving behaviours in the home.’ 17 Thus, the economic influence on the Bank's approach to nutrition is apparent through the emphasis on nutrition education to correct the information asymmetry as well as the significance given to rate of return on investment.

# Health as a Commodity and Health as an Investment: 1980–93

As a result of McNamara's presidency, which ended in 1981, the Bank moved closer towards the role of a development agency. To publicize its new position, the Bank focused its 1980 World Development Report on the importance of investing in the social sector since improved health and nutrition would accelerate economic growth. Human capital theory (p.90) achieved prominence during this time. This framework justifies nutrition loans on the basis that they are an investment in the future productivity of a nation. Human capital theory employs an instrumental, rather than intrinsic, approach to project beneficiaries. This will now be explained.

In general, health economists have used two alternative models for describing the attainment of ‘good health’. 18 The first is health as one of several commodities over which individuals have well‐defined preferences, that is, the intrinsic approach. Health can be viewed as a commodity that individuals use their available resources to acquire. 19 The second approach to health is the human capital approach which constructs health as stock, or a future investment in an individual, that is, the instrumental approach. 20 The economic definition of human capital theory is that individuals allocate resources at one point of time in order to bring about certain outcomes at another point of time. 21 In this model, health and good nutritional status are valuable because the body is used as a productive resource. The more health one is able to acquire, the more valuable this will be in the future.

As noted earlier, health as investment was first emphasized by the Bank in the 1980 World Development Report on poverty. Since this time, the Bank nutrition team has predominantly relied on the human capital framework to lobby governments to take loans for nutrition‐related projects. Applying the concept of human capital to health, Alan Berg argued in 1981 that nutrition and national economy were linked through investment in human beings ( Figure 4.1 ):

Recently…the concept of capital has been extended to human beings. Development of the new theory was prompted by the discovery that ‘increases in national output have been large compared with the increases of land, man‐hours and physical reproducible capital.’ Investment in human capital is probably the major explanation for this difference. 22

Berg then described the many economic benefits of investment in child nutrition. 23 The first is that of savings on medical costs through reduced demand for curative medical services (e.g. hospitalization). The second benefit is that of reduced productivity losses caused by the debility of the labour force: ‘The failure to meet basic needs for nutrition means higher death rates and a less productive population.’ 24 Although conceding that the assumptions were ‘heroic’, Berg noted that productivity losses could be measured through a comparison of a country's average caloric need to average national caloric consumption. A country's average caloric need (p.91)

Figure 4.1. Nutrition and human capital (Wilson 1973: p. 138)

could be calculated through the occupational distribution of the labour force. The shortfall in national working capacity could be used to estimate the productivity losses from nutritional deficit.

However, Berg acknowledged the methodological difficulties with estimating productivity losses. First, using an indicator such as physical growth is made complicated because of infection, possible genetic factors as well as the reference used for comparison. Second, using an input‐based indicator has problems due to recall, intrahousehold allocation of resources, the special needs of individuals, micronutrient deficiencies as well as food waste. Third, nutritional status is seasonally dependent indicating that it is hard to relate it to human performance at any given time. Finally, the relationship between income and nutritional status has been shown to be weak.

The third benefit of investment in child nutrition is the extension of working years, malnutrition reducing the number of productive working years. Other economic benefits of nutrition investment include a decrease in the incidence of infectious disease, better care for children, and returns on other investments in human capital, such as education. Thus, an economic case was made to ‘upgrade the potential productivity of those masses of unskilled, landless, adult workers who have dim prospects of (p.92) gainful employment’. 25 Nutritional investment and subsequent economic development will ‘get the person out of the isolated village and change their fears, beliefs and attitudes’. 26

Thus, in the human capital framework, initially propagated by the Bank in the early 1980s, child nutritional well‐being and health are directly tied to future labour and productivity. This approach is still employed today. For example, in 2005, the World Bank estimated that malnourished children have at least a 10 per cent reduction in lifetime earnings. Thus, investing in child nutrition will have fruitful payoffs in the future when the child becomes an adult member of the workforce.

A 2005 Bank nutrition document, titled ‘To Nourish a Nation: Investing in Nutrition with World Bank Assistance’ that is used for lobbying governments states, ‘The challenges of development require a strong human resource base—a workforce that is physically strong, mentally alert, and healthy. But malnutrition robs a country of these resources.’ 27 It continues with the following section titled, ‘Children's Growth = Economic Growth’ which discusses how ‘Children with retarded growth become stunted adults who are less productive… these problems have implications for human achievement and economic development’. 28 It then presents data on how iron deficiency, anaemia, causes, ‘a 10–15% reduction in work output in many different occupations. Thus, the productivity of entire populations is needlessly reduced’. 29 Using this framework, the Bank nutrition team estimates that returns on nutrition investment are as high as 84:1. 30

In the case of countries like India, the World Bank nutrition team estimates that GDP lost to malnutrition is as high as 2–3 per cent. Worldwide, the Bank nutrition team estimates that malnutrition costs at least US$80 billion per year, and for India, at least US$10 billion. 31 Thus, health and nutrition have been directly linked to economic growth. The initial productivity arguments that Alan Berg used to convince the Bank's Board to invest in nutrition‐related projects are still being employed today.

Using productivity gain estimates and the human capital framework in the 1980s, the Bank nutrition team created ‘target groups’ of individuals who should be the beneficiaries of nutrition projects. 32 Since their creation for the pilot projects, the composition of target groups has essentially remained the same. These target groups should be viewed as economic constructs. They were defined by the age and gender that would most impact on economic growth in the future. In the creation of target groups, individuals were identified as a beneficiary or an individual ‘at (p.93) risk’ based on a single characteristic, such as age or pregnancy status. The beneficiaries were chosen based on their instrumental importance for the economy, rather than for their intrinsic worth as individuals.

World Bank nutrition projects have generally specified three main target groups as beneficiaries: preschool children and pregnant and lactating women. 33 Preschool children have been targeted because it is during the first few years of life that a child's most rapid physical and intellectual growth occurs. 34 Thus, the ‘benefits of nutrition and other inputs are… maximised when they are timed accordingly’. 35 A World Bank nutrition paper titled ‘Nutrition and Economic Sector work’ (2005) states,

Undernutrition's most damaging impact occurs during pregnancy and in the first two years of life, and the effects of this early damage on health, brain development, intelligence, educability, and productivity are largely irreversible. Actions targeted at older ages have little, if any impact… Governments with limited resources are therefore best advised to focus actions on this small ‘window of opportunity’, between conception and 24 months of age. 36

The World Bank nutrition team has targeted its projects at preschool children because improving their nutrition and investing in their human capital will have the strongest impact on productivity.

Similarly, during the nine months of pregnancy and six months of lactation, a woman becomes the target of nutrition interventions. The predominant reason for this inclusion is that it is during these stages that a woman is constructed as a mother or future mother. She must ensure the health of a future member of the work force. Her nutritional status is valued instrumentally, not instrincally. If her health was valued solely, then a woman would receive health services and food supplements regardless of pregnancy status. However, this is not the case as non‐pregnant, non‐lactating women have not been included as beneficiaries in nutrition project design.

Pregnant women have been viewed as instrumentally important to decrease the incidence of low‐birth weight infants. 37 The most critical determinant of low‐birth weight is maternal malnutrition, specifically protein‐energy and iron deficiencies. 38 Well‐nourished women gain, on average, 10 kg during pregnancy. Low nutrient intake and high caloric expenditure can compromise the health of the developing baby.

Lactating women have been viewed as instrumentally important to ensure that an infant is healthy during its first six months of life. Physiologically, breast milk is the best food for the child during this (p.94) period, preventing infection while also developing the immune and digestive system. The main interventions that the Bank offers are nutrition counselling (breastfeeding promotion) and supplementary feeding. 39 Although a moderately undernourished woman can produce an adequate amount of breast milk, a severely malnourished woman may produce 20–30 per cent less breast milk than her well‐nourished counterpart. 40 To address this problem, the Bank nutrition projects offer food supplements which replenish a woman's nutrient stores and ensure the child is being breastfed sufficiently.

The second benefit of targeting lactating women is that breastfeeding acts as a contraceptive. Physiologically, infant suckling inhibits ovulation. 41 In addition, cultural factors can result in post‐partum avoidance of intercourse. For example, Ayurvedic humeral ideology states that food is progressively transformed from a series of body substances from blood, flesh, and bone to breast milk and semen (dhatu). 42 As dhatu reserves in the form of semen become depleted through sexual experience, the body attempts to replenish these reserves. This leads to a reduction in the amount of breast milk produced. 43 Other cultural beliefs in India include that a mother's breast milk spoils if she has intercourse while lactating. 44 Thus, family planning could also have been a factor in the creation of the target group of nursing women in the 1980s.

# The Tool of Cost‐Effectiveness: 1993–2006

The Bank's shift towards addressing health and nutritional issues was firmly established by the 1993 World Development Report Investing in Health which was the first annual report to be devoted entirely to health. The report launched a new Bank framework for applying economic principles to health through the use of cost‐effectiveness and introduced other cost‐benefit analyses. Since the 1993 report, cost‐effectiveness in health has become the flagship tool of the Bank to evaluate various nutrition schemes. The report attempted to reconcile the specificity of health with the traditional methods of economics.

The Bank argued that the tool of cost‐effectiveness was essential in making the ‘right choices among sectors and among designs for any given policy and institutional context’. It was necessary to evaluate the different policy options to ‘eradicate’ hunger and determine which was the most efficient. 45 While attractive in rhetoric, the identification and measurement of costs and benefits for projects have been difficult for (p.95) the Bank to operationalize. Prior to the 1993 World Development Report, a 1992 World Bank report on cost‐effectiveness and nutrition presents limited information on the cost per death averted of select nutrition interventions then concluded that the existing data on cost‐effectiveness is inadequate to properly assess projects. It notes, ‘existing studies tend to cite over and over again data from the same few projects.’ 46

Within the Bank, since the turn towards cost‐effectiveness, there has been confusion surrounding an exact formula for measurement of costs and benefits. Discussing cost‐benefit analysis, a 1994 Bank document states,

Although it would be desirable to have a standard cost‐benefit methodology with precise rules for calculation for every situation, this is not the present case… [A]lthough the conceptual methods for identifying and measuring benefits are well‐established, the application of these methods depends crucially on a variety of judgements on both the measurement of benefits and their values. 47

The basic method for estimating benefits is first to identify the positive effects of an intervention on areas such as mortality, morbidity, work output, and productivity. 48 The benefits of reduced mortality are generally considered to be the value of lost productivity, of morbidity the value of lost productivity plus the savings in health care, and of work output and productivity the additional days of productive work and the additional productivity per day. The key step is the application of monetary values to each of these areas. Table 4.1 adapted from the World Bank Nutrition Toolkit illustrates the process.

Since 1993, the World Bank has emphasized the indicator ‘cost per death’ averted and since 1993 the ‘cost per Disability‐Adjusted Life Year (DALY)’ averted as useful measures of the cost‐benefit of a project. 49 World Bank staff members claim that, ‘Computing the cost per disability‐adjusted life year [DALY] of interventions provides an objective measure.’ 50 Table 4.2 provides an example of a typical Bank cost‐effectiveness analysis. The source given for the information in the table is ‘based on author's assumptions’.

When presenting a tentative loan for approval to senior managers, the focus has been on whether the design of the project is the most efficient and the most cost‐effective, to achieve the desired impact. For nutrition, projects have been assessed on the cost per death or the cost per DALY averted. The assumptions by which these numbers were computed are seldom investigated. These analyses are based on theoretical models and quantification which are presentable and understandable to (p.96)

Table 4.1. Benefit‐cost ratio of providing food to malnourished children a

Information

Value

Transfer of 50,000 calories to malnourished children leads to a height increase of

1 cm

Cost per 1,000 calories

$0.20 Cost per centimetre of height gain in adults$10

160 cm

Increase in 1 cm as percentage of average height

0.63%

Elasticity of labour productivity with respect to height

1.38

1 cm increase in height is associated with an increase in wages of

0.86%

Annual current income

$750 Increase in annual wages from an increase in height of 1 cm$6.45

Discount rate

0.03

Real wage increase

0.02

Productive years

18–55 years

The present value of additional lifetime earnings from an increase in height of 1 cm

$174 Benefit–cost ratio 17.4 a Adapted from Phillips and Sanghvi ( 1996 ), p. 87. Table 4.2. Cost per death/DALY averted in iron interventions a Parameter Iron supplementation of pregnant women Iron fortification Target group Pregnant women All people Number 4,000 100,000 Average rate (%) b 63 50 Programme effectiveness (%) 75 75 Deaths averted 10 10 Immediate productivity gains (%) 20 20 Programme duration (days) 200 Year round Programme costs (US$)

8,000

20,000

Discounted wage gains (US$) 221,280c 1,682,720 d DALY gained 624 e 4, 520 f Wage gains divided by programme cost 27.7 84.1 Cost per DALY (US$)

12.8

4.4

Cost per death averted (US\$)

800

2,000

a World Bank ( 1994 ), p. 66.

b Rate of anaemia for iron supplementation of pregnant women; rate of iron deficiency for iron fortification.

c Calculated as the product of the number of anaemic participants times disability times wages times effectiveness times employment, plus the product of the number of deaths times wage times employment times productive life expectancy.

d Calculated as the product of the number of adult participants times disability times effectiveness times employment times wages, plus the product of the number of deaths times wage times employment times productive life expectancy.

e Calculated as the product of the number of deaths times life expectancy, plus the product of disability times number of malnourished participants times effectiveness.

f Calculated as the product of the number of adult participants times the rate of anaemia times disability times effectiveness, plus the product of the number of deaths times life expectancy.

(p.97) the economist managers. An example of this from Table 4.2 is the use of the indicator ‘the present value of additional lifetime earnings from an increase in height of 1 cm’ in which height has become a form of capital, like land. The body has been commoditized to have a certain economic value. Bank staff acknowledge the lack of rigorousness of these indicators and the implicit value judgements that they are based on. However, those in the Health, Nutrition, and Population sector have been forced to present projects in this manner, they argue, to conform to the Bank mandate as well as the related ideology of the Bank.

Both cost‐benefit and cost‐effectiveness analyses in nutrition suffer from methodological difficulties in practice. First, the impact of nutrition interventions normally occurs over a long period of time compared to immunization or other short‐term health interventions. 51 In addition, most nutrition interventions do not occur in isolation. Nutrition education, growth monitoring, and supplementary feeding often occur in conjunction with health services, food subsidies, and school feeding programmes. This makes it difficult to conduct a proper assessment of the nutritional impact of a project. Third, the use of the indicator ‘cost per death averted’ is an extreme measure of outcome neglecting the toll of malnutrition on well‐being and general health. It does not include a measurement of the quality of life for survivors or the ‘dark side of child survival’ which refers to excessive morbidity. Other problems with analysis are difficulties with data collection in the field and the use of different standards for measuring malnutrition, which are both part of the general problem of large‐scale quantitative analysis in nutrition.

Given these methodological problems some academics have argued that the use of cost‐effectiveness in decision‐making processes can be essentially useless. Development economist Alice Sindzingre notes that models and econometrics work at such a high level of aggregation and use such broad categories that although they may always be proven true (non‐falsifiable), they are still meaningless. 52 Although cost‐effectiveness can serve a useful allocative function, the conclusions reached are dependent on the values entered into the equation. For example, suppose that two projects are being evaluated to determine which is more efficient in achieving a death averted. If there is a clear preference for one, it is possible to first determine what the outcome should be then work the equation backwards to determine the value of the variables to achieve the preferred options. Reflecting on this, William Ascher notes ‘The staff member can, consciously or unconsciously, convert personal (p.98) disagreement with policy into technical caveats about the applicability of the policy in specific cases.’ 53

Despite its limitations, cost‐effectiveness is still a key determinant of a project's approval by the World Bank. The 1993 World Development Report used the term over 200 times to reiterate the Bank's contribution to health, namely in quantification of costs and benefits. Due to its subjective nature and value‐added calculation, the label ‘cost‐effective’ has served as the Bank's ambiguous symbol. It has been purposefully ambiguous such that it could reflect a diversity of interests and approaches. In each particular situation, depending on certain circumstances, cost‐effectiveness could assume the form needed to justify involvement and garner support or to indicate a flawed design. In addition, ‘Power relations may use this very indeterminacy to select particular descriptions and present them as “the truth” (scientific) because the claim of scientificity (of being the exclusive truth) is a helpful tool for the exercise of power.’ 54 Cost‐effectiveness has not been employed as a conceptual tool; it has been used as a tactical one.

The Bank nutrition team presents its analysis as technical and objective, and based on sound, economic research. However, the assumptions entering calculations include several value judgements taken by Bank staff, both during McNamara's presidency and today. These have been disguised in models and productivity functions which can be used to justify a particular involvement by the Bank in a nutrition project. As Paul Nelson notes,

Economic doctrine helps the Bank shape discourse about development around technique and science rather than values and politics. The presentation of economic theories as scientific formulations shields them from criticism, permitting the Bank to exert financial leverage to promote not ‘its’ way but a certifiably ‘correct way’. 55

# Ideology and Politics in the Bank: 1971–2006

While the importance of lending for nutrition is constantly in flux at the Bank, the Bank's nutrition team has continued to promote the TINP approach. The final section of this chapter addresses the question, ‘Why does nutrition have to be addressed in this way in the World Bank?’ In particular, it examines the ideological and political factors that have influenced lending for nutrition.

(p.99) During the negotiations with economists over nutrition‐related lending in the 1970s, nutrition staff had to make tactical concessions which pushed them towards econometric models. And, to ensure the survival of lending for nutrition, Health, Nutrition, and Population staff have continued to translate their case into economic terms: ‘the weapon of choice was numbers’.

As the evidence presented in this chapter demonstrates, nutrition has been framed within the Bank as an issue of human capital. In nutrition projects, the worth of project beneficiaries has been based on their contribution to the economy and thus to social welfare. This can be demonstrated by the economist function that puts a monetary value on years lost to mortality through using the individual's expected wages and by the creation of target groups. The target group of preschool children has attracted considerable health investment. This has been justified by the World Bank nutrition team on the grounds that proper nutrition is crucial for both ‘physical and mental functioning’ in their adult years. 56 A healthy child has been defined as a ‘public good’ in that ‘it’ (the child) has welfare effects for society as a whole. 57 Likewise, the target group of pregnant and lactating women has been given importance because of the functional role of mothers in raising children to be productive adults.

The human capital framework for nutrition within the Bank is a general reflection of the dominance of economics in public health development projects, which can be viewed as the ‘economic gaze’. The economic gaze refers to the process by which those individuals working within the Bank on public health as well as the beneficiaries of public health projects have been disciplined and regulated through the constraints of economic theory. This has resulted in a situation where staff members design projects in a manner consistent with human capital and other economic principles in order to gain loan approval from senior managers as well as be promoted.

The emergence of economics in public health can be traced to the creation of the World Bank. Within the Bank, the discipline of economics can be viewed as hegemonic, the only way of examining problems, of defining their essential features and suggesting solutions. The strength of economic knowledge is seen to lie in its ability to manage the details of a local issue, reduce the complexity, and extract indicators and specific policy goals. 58 Local knowledge is considered messy, complicated, political, and incomprehensible to the institution. Thus, an economic approach reduces problems, such as nutrition, to their core elements so that the professional expertise can digest them objectively and prescribe solutions.

(p.100) For the above reasons, the Bank has been described as an ‘economic fortress’ by its staff 59 where internal operations and activities are dominated by economic paradigms and frameworks. This is true within the Bank's Health, Nutrition, and Population sector, which has often been run by an economist who ensures that potential project loans are designed to be consistent with the Bank's economic framework and legal mandate. This principle is a constraining factor on staff who would like to justify loans or Bank involvement on other, that is, human rights, grounds.

It has been argued that economists are diverse, so classifying them into a single group is misleading. While this critique is acknowledged, within the Bank, there is an overwhelmingly Anglo‐Saxon approach to economics. 60 Unlike other United Nations agencies, English is the working language of the Bank. 61 Thus, this requirement favours graduates of institutions that teach in English. As fluency in English is ‘tended to be correlated with preferred economic and social status’, the Bank's composition primarily is composed of elites. 62 A 1991 study of the high‐level staff in the Policy, Research, and External Affairs Departments of the Bank shows that roughly 80 per cent had trained in economics and finance at institutions in the US and UK. 63 Ascher notes that the economists in the Bank behave very much alike, whether they are Indian, Brazilian, English, or Canadian. 64 Thus, ideological divisions within the Bank do not reflect a conflict between North and South as much as between the Chicago School and the Sussex School.

The Bank has also been described by its staff as a ‘church protecting an orthodox bureaucracy’. One of these principles, a legacy of McNamara's presidency, is quantification and measurability. As one staff member put it, ‘If you can't measure it, then it doesn't exist’. The emphasis on quantitative language has resulted in staff becoming bureaucratic entrepreneurs and attempting to develop packages that can be sold to the economists on the operational teams. Alan Berg used this technique in the 1970s to convince economists that nutrition was an issue of lost productivity and bring a health issue into the realm of capital and economic growth. Bank nutrition staff felt that they could gain the attention of senior economists through presenting ‘hard numbers’ and models.

As Bank nutrition staff are all too aware, lending specifically for nutrition is an issue within the Bank which has not had a stable or powerful position. Some economists have argued that the Bank should be a bank and not a health development agency and that it suffers from ‘mission creep’. They have argued that the Bank is a financial institution. It was (p.101) created to address solvable problems with measurable returns using lending instruments. One staff member noted that there has been continual resistance on the part of senior economists who have been more concerned with transferring money and delivering lending on time rather the quality of lending.

Despite the push to lend fast, economists have wanted a measurable return. This leads to a further problem that economists have had with nutrition: the effects of nutrition interventions are generally hard to discern, difficult to measure, and long term. In the Bank, Task Managers need to sell a package internally and ensure that it is judged successful by the Operations Evaluation Department. Thus, staff are urged to think ‘backwards’, to pay attention to assessment. However, nutritional status is a complex outcome of multiple forces thus making short‐term returns unrealistic to obtain. Reflecting on this tension, one staff member noted, ‘It is much harder for the Task Leader to target and follow the money… In countries with weak capacity or failing governments, it is impossible to show results.’

Over the past 35 years, the approval of a project, as well as the career and survival of a staff member, has depended on his or her marketing success in making social problems economic ones. This has been done by creating equations and models out of complex issues. However, economic ideology alone does not explain the Bank's approach to nutrition. The internal politics of the Bank has been just as critical.

The importance given to nutrition lending has constantly been in flux at the Bank. It has never been as prominent in the Bank as it was with Berg. During the 1970s, Alan Berg was highly successful at marketing nutrition using McNamara's support advantageously. This big name gave his projects credibility. One anthropologist within the Bank stated that this was the ‘pragmatist’ way to get things done, to go through unofficial channels using celebrity names to garner support.

However, nutrition continued to be important during the 1980s with an additional focus put on micronutrients. In the 1990s, the Bank's Health, Nutrition, and Population sector turned its attention towards health systems evidenced by a decline in Bank lending for nutrition. 65 Part of the reason for the loss of interest in nutrition has been the difficulty in showing impact, as discussed earlier.

Nutrition has also had to compete with other social issues for attention. For example, one staff member noted that due to the leadership of the UK in the G8 in 2006, the primary focus has been on debt relief and HIV/AIDS in Africa. However, as a result of the centrality of health (p.102) to the Millennium Development Goals and their international importance, nutrition has been able to keep its place at the table. The Acting Director for Health, Nutrition, and Population in 2006 explained this trend:

Right now, to illustrate the centrality of this discussion and how meaningful it is to us and why we're attaching the kind of importance that we are, we will be having… what we call the Annual Strategic Forum. It's a small gathering of Mr. Wolfensohn, our Managing Directors, our Vice Presidents from all over the institution, and a few other Bank staff to try to set out the strategic tone… And the exclusive topic… is around how the Bank can do its part to contribute to faster progress on the Millennium Development Goals… And within the Millennium Goals and the way in which the corporate priorities of the Bank have been defined, there are several themes where nutrition figures very, very prominently… [These things] are really preoccupying Mr. Wolfensohn as he entered the middle of his second term and looks at what kind of legacy he'll leave to the Bank and in development. It's very clear to us who work closely with him or hear from those who work closely with him that trying to make the focus of what he does over the next couple of years and what his institution does very much around not just measuring the Millennium Goals but trying to do something to change what happens by 2015.

As the Acting Director's comments reflect, for nutrition to be important within the Bank, it must be framed in a way that attracts the interest of the President and senior management. The position of nutrition within the Bank seems to depend highly on the nutrition spokesperson within the Bank, his or her charisma, and his or her ability to form personal connections and manoeuvre the system. As a Bank consultant noted, raising the profile of nutrition in the Bank requires a Task Manager who is ‘capable of making the economic arguments for investing in nutrition, and who has networking skills and an entrepreneurial approach’. 66 These qualities are found in the current Bank nutritionist who has successfully focused attention on nutrition in 2008 to such a level that it featured on the World Bank's homepage.

As discussed earlier, Bank staff have had difficulty adapting their tools and frameworks to address social sector issues. Undernutrition poses a particularly difficult area since it is a highly complex and multifaceted phenomenon. The biomedical understanding of hunger as a disease and (p.103) the economic framing of hunger as an issue of human capital interlace to form the Bank nutrition team's approach to undernutrition. This particular approach can be viewed as reflecting the Bank's imperative to create a problem that its own instruments can address.

The framework that was used in TINP and continues to be used by the nutrition team is based on a combination of biomedical and health economic models. As a Bank Health, Nutrition, and Population Economist in Delhi said, ‘We use the medical model but bring in the cost aspects.’ In the powerful institution of the Bank, the twin hegemonies of biomedicine and health economics interlace to form an unquestioned approach in development to ‘curing’ malnutrition that has become ‘common sense’ in development circles. Biomedicine and economics can be defined as hegemonic since they have achieved

the permeation throughout civil society… of an entire system of values, attitudes, beliefs, morality, etc. that is one way or another supportive of the established order and the class interests that dominate it… to the extent that this prevailing consciousness is internalised by the broad masses, it becomes part of ‘common sense.’ Thus, [they] operate in a dualistic manner: as a ‘general conception of life’ for the masses and as a scholastic programme. 67

In reading of the secondary literature, even academics are hesitant to question the design of TINP since it has been affirmed as ‘physiologically successful’ by biomedicine and as ‘cost‐effective’ by health economics. These two frameworks are complementary in the sense that both disciplines are perceived as technical, apolitical, and universal.

The disciplines of biomedicine and economics are quite similarly placed and tend to reinforce each other's power, as shown in Table 4.3 . It can be argued that biomedicine is hegemonic in the health sphere, much as economics occupies a privileged place in development policy. It is not surprising that when the World Bank, the most powerful development agency, decides to venture into nutrition, commonly viewed as a public health issue, an interlacing of biomedical and economic framework occurs.

It seems as if the Bank's approach to nutrition goes unquestioned since it has been derived from a ‘technically accurate’, scientific, that is, biomedical and economic, framework. In addition, both biomedicine and economics are applied universally. Local factors, such as the extent of gender inequality, the use of alcohol, proper access to safe water sources and sanitation, and food symbolism and classification, are ignored.

Table 4.3. Biomedical and economic influence on the World Bank

Biomedicine

Economics

Main actors are

Medical doctors, biochemists

Health economists

Agents self‐described as

Technicians

Technocrats

Hegemony in realm of

Health

Development

Institution symbolically associated with and mainly composed of

Men

Men

Does this institution fit Mary Douglas's ‘Strong grid, Strong group’ model?

Yes, strictly conformist, strongly integrated, and rigid boundaries vis-á-vis outsiders

Yes, strictly conformist, strongly integrated, and rigid boundaries vis-á-vis outsiders

Knowledge considered

Scientific, objective, technical, rational

Scientific, objective, technical, rational

Mission is to help

Patients

Beneficiaries

Symptoms

Efficient treatment of symptoms

Nutrition framed as

Disease

Element of human capital

Undernutrition framed as

Medical problem (individual)

Educational problem (individual)

Institutional home

World Health Organisation

World Bank

Constructs

Functional groups

Target groups

Women defined as

Mothers

Mothers

Mothers important for

Children to be healthy

Children to be productive

Reliance on visual

Growth charts, anthropometry

Quantitative analysis, statistics, models

Foucauldian framework

Clinical gaze

Economic gaze

An additional similarity is the focus on the individual over community. As discussed in Chapter 3 , the biomedical influence on the understanding of undernutrition results in a focus on ‘curing' the individual, while economics’ methodological individualism results in the modelling of rational, calculated, self‐interested individuals. Both orthodox biomedicine and economics privilege agency over structure. 68

The Bank frames nutrition using biomedical and economic inputs because it ultimately has to construct a problem that its own instruments can address. The Bank is in the lending business, making time‐limited, repayable loans. Any Bank actions have to fit within the overall Bank goal of lending for growth. Thus, loans have to be made for profit‐creating projects that have measurable economic returns. To address undernutrition, the Bank has to ensure that it is constructed as a ‘curable’ problem (a disease) that will have an impact on GDP and economic growth (human capital).

Given the significant role the World Bank plays in the global nutrition community, both as a financier and as a norm setter, it is critical to understand how its nutrition policy is formulated within the (p.105) institution. My key point is that the nutrition policy is a reflection of the political pressures and institutional constraints operating within the Bank. Technical economic expertise is moulded by the political, institutional, and bureaucratic incentives. The prevailing policy is ultimately shaped by ‘economic analysis, institutional constraints, and bureaucratic organisation’. 69 But to return to the initial question, how is undernutrition understood and addressed by the nutrition team of the Bank? As has been argued in both this chapter and Chapter 3 , hunger is viewed as a matter of choice to be addressed at the individual level. This underlies the World Bank nutrition team's approach to undernutrition.

# Notes

## Notes:

(1.) Musgrove ( 2005 ), pp. W5–334.

(2.) Woods ( 2006 ), p. 54.

(3.) Mosse ( 2006 ) discusses the dominance of economists within the Bank in relation to the activities of anthropologists. Selowsky ( 1978 ) argues that it was not until the mid-1970s that economists became interested in malnutrition. Buse and Walt ( 2000 ) discuss how one of the challenges facing the Bank in the health sector is the influence of health economists.

(4.) Quote from Alan Berg ( 1987 ). This relates to the difficulty in evaluating nutrition, showing quantified outcomes, and moving money fast.

(5.) Rajivan ( 2001 ), p. 134.

(6.) Wilson ( 1973 ).

(7.)

(8.) Berg ( 1973 ), p. 30.

(9.) Although a major shock to economists, it was also of grave concern to nutritionists as the price of food increased dramatically.

(10.) Phillips and Sanghvi ( 1996 ), p. 15.

(11.) Jack ( 1999 ), p. 271.

(12.) Phillips and Sanghvi ( 1996 ), p. 15.

(13.) World Bank ( 2006 ), p. 9.

(14.) Behrman ( 1995 ), pp. 32–52, World Bank ( 2005a ).

(15.) World Bank ( 2006 ), p. 9.

(16.) Berg ( 1987 ), p. 6.

(17.) Griffiths et al. ( 1996 ).

(18.) Jack ( 1999 ), p. 55.

(19.) Davis and McMaster ( 2004 ).

(20.) Jack ( 1999 ), p. 50.

(21.) Davis ( 2003 ), p. 55.

(22.) Berg ( 1981 ), p. 17.

(23.) Berg ( 1973 ), p. 18.

(24.) Berg ( 1987 ), p. 95.

(25.) Berg ( 1973 ), p. 22.

(26.) Wilson ( 1973 ).

(27.) World Bank ( 2005c ), p. 1.

(28.) Ibid. p. 2.

(29.) Ibid. p. 2.

(30.) Ibid. p. 11.

(31.) Measham and Chatterjee ( 1999 ), p. 4.

(32.) See Cernea ( 2004 ), p. 7.

(33.) See Phillips and Sanghvi ( 1996 ), p. 34.

(34.) World Bank, p. 9.

(35.) Ibid. (2005c)

(36.) World Bank ( 2005a ), p. 1.

(37.) Elder, Kiess, and de Beyer (1996), p. 25.

(38.) Other determinants include smoking and alcohol use by mother, genetics, congenital abnormalities, or infections, and age of mother.

(39.) Elder, Kiess, and de Beyer (1996), p. 29.

(40.) King and Burgess ( 1993 ).

(41.) Delgado et al. ( 1978 ), pp. 322–7, Huffman et al. ( 1978 ), pp. 1155‐7.

(42.) Semen refers to the substance that both women and men release during intercourse.

(43.) Nichter and Nichter ( 1996 ), p. 16.

(44.) Ibid. p. 121.

(45.) World Bank ( 2005c ), p. 8.

(46.) Horton ( 1992 ), p. 24, quote from p. 5.

(47.) World Bank ( 1994 ), p. 62.

(48.) Ibid. p. 62.

(49.) For nutrition, other indicators used include ‘cost per case of child stunting averted’, ‘cost per 0.1 kg increase in birth weight’, ‘cost per child removed from third degree malnutrition’, etc. See Levinson et al. ( 1999 ), p. 121.

(50.) de Beyer et al. ( 2000 ), pp. 169‐76.

(51.) Horton ( 1992 ), p. 3.

(52.) Sindzingre ( 2004 ), pp. 233–49.

(53.) Ascher ( 1983 ), pp. 415‐39.

(54.) Sindzingre ( 2004 ), p. 233.

(55.) Nelson ( 1995 ), p. 112.

(56.) World Bank ( 2005a ).

(57.)

(58.) Woods ( 2006 ).

(59.) This phrase is from Michael Cernea who was the Bank's first in‐house sociologist in 1974. Cernea ( 2004 ), p. 9.

(60.) This paragraph is based on information given in Woods ( 2000 ), pp. 823–41.

(61.) Early in the history of the international financial institutions, the United States ensured there would be no national quotas for hiring and that English would be the working language. Woods ( 2003 ).

(62.) Quote from Woods ( 2000 ).

(63.) Stern and Ferreira (1997) cited in Woods ( 2000 ).

(64.) Ascher ( 1983 ), p. 437.

(65.) Heaver ( 2006 ), p. 11.

(66.) Heaver ( 2006 ), p. 18.

(67.) Gramsci quoted in Martin ( 1987 ), p. 23.

(68.) See Humphries ( 1998 ).

(69.) Woods ( 2006 ), p. 56.