Miscommunicating metabolism: hunger, method and the practice of public health
Over the past five years I have been conducting research on everyday eating and the emergence of Non-Communicable Diseases in the West African city of Dakar, Senegal. Working with home cooks I have explored how the presence of “new diseases” at the heart of the households challenges people to procure, prepare and share food in new ways.[1] As diabetes and hypertension has become more and more visible in Senegal, my focus of my research has expanded, shifting from kitchens to include clinics and public health settings where new interventions were imagined with the goal of promoting “healthy eating” and the effective management of the symptoms of chronic disease. In these contexts, conversation often turned to where “new diseases” came from. What was driving the emergence of chronic conditions on the periphery of the city, and why did these diseases seem to be focused on food insecure and precarious households? When colleagues working in public health sought my opinion on why rates of chronic disease seemed to be rising in Dakar, I would say that the issue was highly complex, that I thought that chronic impairments emerged at the intersection between ecological, biological and social processes and needed to be understood in situated ways. To these observations I might also add that I believed that chronic diseases were driven by forces that were hidden, or whose workings might be invisible. Unsurprisingly, many of my interlocuters found this answer unsatisfactory and obscurantist.
My Senegalese colleagues also struggled to provide adequate answers and useful knowledge for how people should live with chronic conditions. When I travelled to a rural community with a nutritionist from a Senegalese university, for example, my colleague was confronted by an exasperated older man who argued that just as a pharmacist prescribed medication for specific ailments, a nutritionist should surely be able to offer similar advice on how what foods a patient should choose based on the symptoms the patient was experiencing. Like me, my nutritionist colleague cared very deeply about producing meaningful interventions and useful knowledge. We were not, like the global nutrition actors described by Emilia Sanabria, producing forms of nonknowledge in order to create a “continued deflection” of responsibility back on unknowing or otherwise deficient eaters’,[2] or at least not deliberately. In many cases, however, our strategies of knowing and our striving for holistic knowledge about eating in Senegal failed to meet the expectations of our interlocuters and collaborators.
In this piece I investigate a few of the ways that my “metabolic thinking” on the origins of chronic disease failed to connect with the priorities of public health in Senegal and how, on occasion, it caused frank offence. In conversations with public health workers and nutrition specialists I sought to operationalize “metabolism” as an analytic that could help to capture the manifold complexities and contingencies of “eating”, by including a consideration of how food was grown, accessed, selected, transformed, rejected, shared, fed to others, and digested. It seemed urgent to me to understand eaters in relation to their environments and to interrogate large scale ecological changes that had shaped regional histories of food access. To my Senegalese colleagues, however, it sometimes appeared that I was denying the significant and enduring challenges of scarcity and hunger, or that by shifting analytical focus to environmental change over time, I failed to create an agenda for meaningful action in the present. Focusing in detail on one specific failure of communication, I argue that what is at stake here is something more than the vagaries intrinsic in the shift from theory to practice. Historians have drawn attention to the distance between the abstractions of nutrition and everyday ways of knowing and valuing food and eating.[3] This gap between expert knowledge and African people’s experience was often due to the incommensurability between a complex, abstract and highly technical nutrition science focused on improving dietary quality, and the challenges faced by populations struggling with subsistence.[4] The failure of colonial governments to close this gap, or to find solutions that recognized the scale and severity of food crises had far reaching and sometimes consequences, increasing the mortality and human suffering associated with famine. If my interest in socio-ecological and metabolic analyses appeared at times to reproduce the obtuse concerns of that elitist science, what might that tell us about metabolism as a concept?
Early on in my fieldwork I attended an event in a shaded courtyard in one of the old fishing villages gathered up into Dakar’s suburban sprawl. A group of women and their babies had gathered to learn about nutrition. The women present had been referred to community organizations because they had sought prenatal care during their pregnancies and been identified as receptive to public health messages about birth spacing, breastfeeding, hygiene and nutrition. The women listened to the community health worker’s speech in attentive silence and agreed to let the workers monitor their baby’s development via a mid-upper arm circumference measurement. In exchange, they were given a bowl of sweetened millet porridge. The intervention was designed to support breastfeeding mothers, but I suspected that the food would be decanted into the bowls the women had brought from home and would be taken back and carefully divided between members of these women’s extended family. The community health worker held the babies in her lap and used a tape measure extended from the shoulder to the baby’s elbow. She marked the mid-point on the baby’s arm with a pen and looped the tape around the arm at this point, pulling the tape until it showed green, for healthy development, amber for risk of malnourishment, or red for acute malnutrition. Another community worker, Tapha, who was teasing and bantering the women, wanted to show that he had a better and more precise technique for taking the measurement and he called on one of the women present whose child had already been measured, to let him demonstrate the advantages of his method. The woman agreed, somewhat reluctantly, although I was close enough to hear her add in a warning undertone “don’t shame me” as she handed over her baby. Instead of finding the halfway point by using the tape measure, Tapha took the measurement from shoulder to elbow with a piece of string, which he doubled up and used to find a point on the child’s arm just below where the first measurement had been taken. This time the tape edged into amber portion, indicating a child at risk. The mother protested “you’re pulling it too tightly”, and the community health worker quickly loosed the tape’s tension, before turning to me and giving a confident diagnosis: he’s small but he’s not ill.
It was, briefly, shocking to see the deployment of the tape, a tool used to detect severe malnutrition in emergencies, wielded in the suburbs of Dakar and wrapped around the arms of these patient and generally healthy-looking babies; but, as the community health worker reminded the women assembled: “women must be vigilant: for as long as our country is underdeveloped, malnutrition will always be with us”. The fuzzy way that the measurement was deployed did not mean that it was not a highly powerful form of triage, distributing access not to care, but to punishing and often humiliating nutritional interventions. When I described this scene to a public health worker and nutrition specialist, Madame Niaye, she explained to me the “protocol” for those triaged into high risks groups. Her voice shaking with anger, Madame Niaye told me that the mothers of children deemed too small were forced to feed their children an unappealing peanut paste. The women were perceived as so untrustworthy, so unsophisticated and so unskilled in nourishment, that at the end of the week they had to return the empty packaging to prove that all of the paste had been consumed. Madame Ndiaye mimed a woman tossing the crumpled packaging and turning on her heel, indicating in her brief sketch, how it might be possible to maintain one’s dignity in the face of such egregious insult.
Madame Niaye had worked in grassroots nutrition work on the periphery of Dakar for many years. For her, the blunt instrument of the tape was obscuring another story. In the communities she worked in she observed unpredictable patterns of growth in children, and new distributions of illness among adults; two trends that increasingly appeared to mirror and converge upon one another, although their relation was difficult to understand. Madame Ndiaye described a community in which children were born to mothers with the same levels of education, lived surrounded by what she described as the same habits, and were raised according to she understood to be exactly comparable living standards and identical dietary practices. Some of these children flourished while others in the cohort required intervention for malnourishment. Talking to Madame Niaye about the intervention I had observed and the measurement of children’s bodies, I agreed that the measurement-work was not satisfactory. Measuring the healthy development of the youngest members of households couldn’t clarify the situation that puzzled Madame Niaye: the question of how different kinds of unpredictable changes to the body extended over the life course. Perhaps, I said, the situation that she wanted to better understand could be analyzed “scientifically”. Madame Niaye interrupted my speculation with an explosive, interrogative “Science!?”, and she gave me a long, hard look that made me think that I hadn’t been listening.
Harris Solomon writes about how chronic diseases discourses in India have “aperture effects”: they bring into sharp focus individual bodies and subjects while making the context and background fuzzy.[5] The subject, abstracted in this way from the context in which they live, comes to be understood as possessing and standing in for a metabolism that they must regulate through forms of disciplined self-care. When I speculated to Madame Niaye about the possibility of a rigorous and “scientific” analysis of eating in the context of long-term transformations in community health, I sought to manipulate these aperture effects, bringing back into focus the social context. Moving beyond questions of food “intake”, I wanted to think about bodily growth and collective flourishing as a possibility embedded in the historical conditions and the ecological, sanitary and infrastructural contexts that support eating.
How to methodologically and qualitatively bring the “environment” (broadly defined) into the picture was in practice, however, very unclear. Nutrition and global health researchers I consulted with in the UK had made a number of suggestions. These included bringing together discursive and observational data to see how people “really lived”, conducting detailed oral history interviews and consulting archives to better understand the evolution of food access and dietary change, and looking for unseen or overlooked variables. With collaborators in Senegal, I discussed possibilities for developing new research questions and actively searching for new relations to investigate by embedded researchers in community contexts and setting up prospective, longitudinal studies. On reflection, these methods shared a number of characteristics with the interventions that Madame Niaye criticized. They were skeptical of community knowledge and looked for sources beyondwhat community members had to tell them. They were interested in prospecting back in time, or speculating forward, looking for unmarked or less visible sources of illness and food challenge.
Megan Vaughan has argued that the operationalization of metabolic thinking in public health interventions significantly belies the complexity of metabolism as a concept, stymying its analytical potential. If, so far, an increase in public health interest in metabolic syndrome across Africa has implied the deployment of tape measures, the escalation of “healthy eating” and lifestyle advice, and the expansion of authority given to nutritional expertise, we might still envisage a public health driven by a different or new kind of metabolic thinking; a set of concepts and methods that could draw on the capacities of metabolism to illuminate “complexity in the relationship between biology, environment and history.”[6]
While I agree with Vaughan’s analysis, I am still struck by the difficulties I had in locating and exploring these ideas in Dakar, as well as the emotional complexity of some of these conversations. When I suggested methods that focused on adding time depth, searching for causality in the risky encounters and exposures of everyday life, or conducting multidisciplinary prospecting in the “environment”, nothing I suggested here moved us beyond the logic of the protocol. What I took to be a more complete set of scientific explanations still seemed to abstract infant bodies from the social context in which they were nourished, still failed to propose a solution that respected women’s desires to heal bodies with “real food”, still did not imagine a meaningful set of political settlements for the production and provisioning of food, still gave no space and credence to the priorities of broader communities involved in raising the babies.
In Dakar, in other words, ‘metabolic thinking’ did little in practice to close the gap between scientific and everyday ways of knowing about the impact of eating on the body. Shifting between scales and integrating extensive timeframes often appeared to abstract issues from the social conditions that generated poor health and that required closer examination. A stated methodological and epistemological interest in bringing “hidden” causality to light echoed a familiar technocratic tendency in global nutrition, one that has often made hunger a question of nutritional deficiencies to be uncovered, and not the moral challenge rooted in social inequalities that exists in plain sight.[7] Methodologies that were designed with the intention of better understanding how the past weighed upon and shaped the present were often interpreted as designed by deny or obfuscate the existence, circulation and operation of hunger in the present. Metabolism is an extraordinarily productive concept regardless of how well it can be communicated, operationalized, or set to work. In conversations with public health workers in Dakar who recognized in ‘metabolic thinking’ forms of thought and modalities of intervention that were troublingly familiar, I confronted the potential limitations of metabolic thought. The rough diagnosis of tapes around arms cannot diagnose the source of the ‘multiple malnutritions’ and complex food challenges faced by people in Senegal. Researchers seeking to operationalize new forms of metabolic thinking, however, also risk failure and moral jeopardy. How far will metabolic thinking be able to account for the ways that Dakarois are repeatedly made responsible for their own survival under conditions of extreme precarity, or how it falls to households to ride out the region’s rolling food crises? In drawing on metabolic thinking to analyze bodies, biologies and environments in relation to one another, do we adequately understand those bodies as continually reproduced by historical processes and social norms? In the everyday pragmatics of public health, we may find friction that disrupts the integrative capacities, and the radical potential, of metabolic thinking.[8]
[1] See Branwyn Poleykett, “Collective eating and the management of chronic disease in Dakar: translating and enacting dietary advice,” Critical Public Health (March 2021)https://doi.org/10.1080/09581596.2021.1898545.
[2] Emilia Sanabria, “Circulating ignorance: Complexity and Agnogenesis in the Obesity ‘Epidemic’,” Cultural Anthropology 31 (February 2016): 131-158.
[3] Jennifer Tappan, The Riddle of Malnutrition: The long arc of biomedical and public health interventions in Uganda (Athens: Ohio University Press, 2017); and Megan Vaughan, “Conceptualising metabolic disorder in Southern Africa: Biology, history and global health,” Biosocieties 14 (June 2018): 123-142.
[4] Yan Slobodkin, “Famine and the science of food in the French empire, 1900-1939,” French Politics, Culture and Society 36 (March 2018): 52-75
[5] Harris Solomon, Metabolic Living: Food, fat and the absorption of illness in India (Durham NC: Duke University Press, 2016).
[6] Vaughan, “Conceptualising metabolic disorder”.
[7] Aya Hirata Kimura, Hidden Hunger: Gender and the politics of smarter foods (Ithaca: Cornell University Press, 2013).
