Hunter-Adams, Jo (2017). 'Hunger and obesity: Can Capabilities provide insights for more healthy food systems?' Paper presented at the annual conference of the HDCA, Cape Town 2017.
Hunger and obesity are connected dimensions of food in South Africa and other low-and- middle-income countries (LMIC). Public health researchers and practitioners like myself come from a long tradition of health education and behaviour change: In the case of food, this often translates to finding better ways to guide people towards healthy diets. This is particularly true in cases where people are perceived to be eating too much. There are challenges to guiding people towards what they should eat, from being neo-colonial and paternalistic, to being ineffective or lacking a strong evidence base. Globally, both hunger and obesity are burdens ultimately borne disproportionately (though certainly not exclusively), by the poor, by non-whites, and by women. This uneven burden extends beyond prevalence of health-related non-communicable disease to unequal treatment access and even to moral condemnation related to body size. At times, the unintended consequence is that poor women of colour tend to be subject to public health nutrition interventions that risk reinforcing power imbalances, stigma, and unequal health outcomes.
In this paper I draw on findings from recent qualitative research in an informal settlement and township in Cape Town, where I explored food memories, changes in diet, and perceptions of food in relation to health. While I do not present capabilities as a unifying theory of everything food-related, I propose that a capabilities approach may provide helpful insights for interpreting relationships between food and health in South Africa and other similar contexts.
Choice, and lack thereof, plays an important role in framing public health debates on how best to improve diets. In many high-income countries, efforts to improve the food environment in “food deserts” revolve around teaching people urban farming, bringing subsidized farmers’ markets and fresh produce into the inner city, and sometimes even giving people money to spend at these places. That is, interventions focus on extending choice because obesity has been framed in terms of lack of access to fresh, healthy, affordable, food. Critics have noted the limitations of this approach, as even with barriers seemingly removed, the target audience does not seem to take up this new range of choices as readily as expected. At times, this lack of uptake even leads to reinforced social stigma or moral condemnation of the obese. These efforts, and their limitations, could offer insights as we approach the role of food choice in LMIC.
In contexts historically dominated by hunger, such as amongst people living in peri-urban settings in South Africa where I conducted my field research, food choice was less important than access to enough calories. Nevertheless, the recent expansion of choice—to include highly processed food—represented an important marker of improved socioeconomic circumstances. However, this expansion of choice was not necessarily enjoyed by participants; rather, participants felt guilty given that they knew these foods (typically highly processed, or high in fat or meat) were unhealthy and likely to cause disease. In addition to having access to a relatively recently expanded set of food choices, there were also foods that were less available in their current context. This represented a reduction in choice, where participants typically did not consume diets that they knew to be healthy because of cost, time, or social pressures. Applying a capabilities lens to this shift in choices will, in this paper, involve grappling with the role of policy in understanding and shaping choices to better fulfil capabilities.
Lack of choice continues to be a very important thread in understanding changing diets in South Africa, particularly as a new choice (to eat highly processed foods) actively reinforces the emerging lack of choice to have a healthy diet (given the ubiquity and affordability of highly processed foods). If choice in relation to food is intertwined with many other human capabilities, our understanding of the problem, and our efforts to bring change, might shift somewhat. From previous efforts in the U.S., where more wealthy individuals eat more healthy foods even when barriers to consuming healthy foods were reduced for poorer individuals, lack of other capabilities may be implicated (time, emotional support, etc). Where the poor are more vulnerable to obesity-related non-communicable disease, despite a lack of evidence that they have less healthy diets, it may be that intergenerational experiences of hunger, exposure to pesticides, lack of early detection of NCDs, or other disproportionate burdens of risk, are at play. While it is important to work at many levels (grassroots and policy) to change food systems, the capabilities approach offers important insights into why this may not always work as we hope. It also offers insights into how to partner with other sectors to understand and support efforts towards less paternalistic public health efforts.