29 December 2016

Some Predictions for 2017

I gave my regular predictions blog a miss last year.  Given the wild and crazy ride that 2016 was, I suppose any predictions would have been futile.  

For example the night before the June Brexit vote I was in Berlin, and in a brief exchange with a senior politician I asked their opinion about the Brexit vote.  “No worries” said the experienced diplomat, the UK will stay in the EU!

So, despite the futility of making predictions (especially about the future J), here goes for 2017 (in no particular order).  

1.   The truth will matter more than ever.  Supposedly we are in a post truth, no fact, fake news world.  Now we know people make decisions on the basis of lots of things.   Cicero said that people make decisions based on reasoning, experience, necessity and instinct. How true.  At least reasoning and experience are based on research.  Researchers throughout the world have a greater than ever responsibility to speak truth to power and to do it actively rather than passively. 

2.   We will all have to come together to protect women’s health. The forces being lined up against women’s health are formidable.  Most obviously in the sexual and reproductive rights arena with some elements in the new US administration. These rights have to continually be fought for throughout the world.  Those of us in the nutrition community need to continually stress to decision makers the importance of girls staying in school, girls and women marrying when they are ready, giving birth when they consent and to have access to quality health services. All of these are vital to their own health and the health of their families—those that exist and those yet to be born.

3.   The development and humanitarian worlds will move towards each other. The new UN Secretary General, Antonio Guterres, will start on January 1, 2017.  He follows on from Ban Ki Moon.  Given Mr Guterres’ 10 year leadership of the UN High Commission for Refugees, he will undoubtedly bring a fresh perspective to development.  Can he begin to breakdown the barriers between humanitarian action and development action?  I hope so. We should give him all the help we can.

4.   Overseas Development Assistance (aid) flows will come under more stress.  Donors are under pressure from domestic constituencies who think their countries are overrun by immigrants, feel that services are stretched and who live the reality that real wages of low and middle income households have not yet risen to the 2007 levels.  The temptation for donors will be to “process strangle” the life out of those who compete to spend aid.  Spending money on what you said you would is important, but the most important thing is to have impact.  This will also reassure the doubters.  This means investing in “good enough” evaluations, often with a lag (even a few years after the intervention). Donors need to be more willing to do this.

5.   Human gene editing will lead to a reappraisal of GMOs. If human gene editing begins to show positive impacts on human health (in cancer, HIV, sickle cell disease), there will be a reappraisal of GMOs, at least in plants.  I’m not saying GMOs will become any less controversial, but positions—which have seemed ossified since 1999—could shift.  The reappraisal could lead to new possibilities for doing good things to reduce the use of energy, water, fertiliser, pesticide and herbicide or it could lead everyone to double down on entrenched positions.  We shall see.

6.   Social mobilisation for health will be led, increasingly, by those with the health condition.  As social media and internet penetration strengthens, the networks we already see emerging for people with diseases like Crohn’s may well happen with conditions more common in low and middle income countries. When will people experiencing undernutrition become a powerful political force?  Something may well surface this year.

7.   Big business will become emboldened by the new US Administration.  The talk of business deregulation has got some fearing the worst. They may be right, but this is a reason to intensify engagement with businesses rather than to shut them down.  In the absence of strong governmental regulation, civil society will need to fill the vacuum. Sometimes this will mean blocking action, but most often it should be advising, guiding, nudging, praising and, yes, shaming businesses when necessary.

8.   This could be a breakout year for vegetarian diets. See Impossible Burgers.  Does it count if vegetarian meat actually looks and tastes like real meat?  If it reduces land use, greenhouse gas emissions and boosts health, then, er, yes.  The main challenge will be to make the products safe and affordable. In other words, the “ifs” really matter.

9.   Texting will catch on for work purposes. Anthony Weiner jokes aside, I know of colleagues who use WhatsApp to communicate, eschewing email.  They feel it is more personal, more exclusive, more immediate, and more, well, social.  I’m not sure about this one, but I know that for many people work email is beginning to feel like home mail – only adverts and bills.


10.   2017 will defy predictions. It will defy mine, yours, and even Nassim Taleb’s (wait, he doesn’t make predictions—very smart).  With Mr Trump as POTUS and key elections coming up in Europe, Asia, Latin America and Africa, we are in for a rollercoaster year (let’s hope so, at least rollercoasters have some highs).  Again, evidence is going to be key—those of you who still believe in data (J) please remember to wield it.  I leave you with this: the year-ending edition of Time magazine asked populations in a number of countries “what percentage of the people in your country are Muslim?” In the US the answer was close to 20% (the real number is 1%) and in the UK the answer was 15% (the real number is 5%). The pattern was the same for every country asked—even India.  Good data still matter (although I wonder what the Time poll’s margin of error was? Sigh.)

13 December 2016

We Built This City: New WHO-Habitat Global Report on Urban Health

“By far the greatest and most admirable form of wisdom is that needed to plan and beautify cities and human communities.” Socrates

This is one of the key themes of the new WHO-Habitat Global Report on Urban Health: that promoting health in urban contexts goes way beyond the health sector. 

Yes health systems need strengthening, but the way we plan housing, transport, recreational spaces and water, sanitation and energy infrastructure are also vital--maybe more so.  And as the report points out, throughout history most of the worlds cities have not been planned with health in mind. 

I read the intro chapter, the chapter on nutrition and the chapter on governance. 

I thought the governance chapter was the most interesting. This chapter covers participation (important but not so easy to achieve in a sustainable manner), citizen empowerment through information sharing (currently working best in high income cities), intersectoral action (difficult, but maybe easier in "place-based" contexts), equity as a core value (is justice easier to build in cities where citizens are closer to their representative governments?) and public-private partnerships (on healthy infrastructure, on generating demand for healthier products, and as philanthropists).  Businesses are drawn to cities--can they be drawn to greater health generation as a part of the price of admission?

The chapter on nutrition focused on generating sustainable food systems (although the report does not tell us much about how to get sustainable food systems), urban agriculture (not clear why this approach is highlighted when many others are not), food deserts (which is mainly a US phenomenon), the cost of food (the focus in the report is on what the agriculture sector can do to reduce costs, but what about processors, storage facilities, distributors, marketers and retailers?) and local action (may seem like a drop in the ocean, but these can catch on if developed in the aspirational cities). 

My biggest criticism? There is not enough new data in the report (at least the chapters I read).  I was expecting lots of killer facts, but couldn't really find them.  Also while the presentation of the graphics is not business as usual, the graphs are really hard work to understand.  This feels like a bit of a missed opportunity to feed evidence based advocacy. 

Overall though, this is a solid and comprehensive report.  Socrates would have approved.  

27 November 2016

Fortification: It's a bit more complicated than "add, stir and distribute"

One of the great things about being at GAIN is that I have the chance to learn about lots of new things.

Surprisingly, one of the new things I am learning about is fortification.  Surprising to me, because if you are not an expert it is easy to think of fortification as "add fortificant,  stir and distribute".

A recent PLOS One paper (including two of my new GAIN colleagues) shows how misguided such simplistic thinking is.

The paper contains two pieces of analysis, both from the Indian state of Telangana (36 million people, containing the city of Hyderabad).  Both analyses are drawn from a survey of children 0-35 months of age residing in the catchment areas of all the ICDS centres in the state.   The survey found that 79% of all salt samples from the households of the selected children were adequately iodised.  BUT, the level of adequate iodisation varied significantly by District within the State and by iodised salt brand.  So even in one of the most easy to fortify substances, fortification is variable.  Work is needed just to maintain effective iodisation levels.

The second piece of analysis aims to examine the prospects for effective fortification of rice.  As I have written in an earlier gung-ho blog, I thought: rice fortification--its a no-brainer.  Well, its a little bit more complicated than that!

First, do the groups in the population that are micronutrient deficient actually consume rice?  Second, do they get rice from sources that can actually fortify rice?  Third, can the rice be fortified in a cost effective way?  Overall, the answers for Telangana are not encouraging.  First, no recent deficiency data exist for Telegana.  Second, if rice could be fortified it would make a big difference to the % of children and women meeting the RDA for various micronutrients (so this indicates the potential). But, third, a quarter of households consume rice they produced themselves and the households that do buy rice buy it from markets that are served by over 600 millers--a complex context for cost-effective fortification.

Of course the rice situation will likely change over time as more people buy rice from market sources and as rice milling and distribution becomes more concentrated, but for now the fortification of rice in Telegana does not look to be a promising solution to reducing micronutrient malnutrition in the state.  The authors examine if the government's Public Distribution System could be a viable delivery channel, but only 6% of households surveyed access rice from this source.  Still, 6% is not bad if the cost-effectiveness ratios look reasonable.

The rice fortification story just reinforces the need for policymakers in the State to look at their food systems to see what they can do to encourage the demand for and supply of affordable foods that are rich in nutrients.

Fortification: its not just "add, stir and distribute" -- but you already knew that!

19 November 2016

Evidence in nutrition: have we set the bar too high?


I’m going to be honest here, I don’t know the answer to this question, but I think it is a question worth asking:  is our quest for evidence enabling or inhibiting us when it comes to acting to end malnutrition?

I raise this now because over the past few weeks I have met senior people in various development organisations who think the quest for evidence about nutrition interventions may have gone too far.  

The arguments they put forward include:

* Randomised controlled trials are not the only credible source of evidence and in many cases are not the most appropriate.  Think of the recent BMJ evaluation of the soda tax in Mexico—this was done with good old-fashioned economic modelling.

* Does an intervention really have to show positive impacts in multiple geographies before we are convinced? Are we trying to find design-proof interventions?

* If the intervention we are implementing in the absence of cast iron evidence could do harm, then caution is of course warranted, but in the absence of the potential of harm, are the downsides of taking calculated gambles on interventions really that large?

* Do the tools we consider to be gold standard lead us away from exploring certain approaches?  Are we only exploring what is amenable to randomisation and not what is meaningful?

This is a familiar debate in development but not one I have heard voiced in nutrition.  Make no mistake about it: the Lancet series of 2008 was a massively positive game changer—a set of proven interventions (“proven” being largely determined by randomised baseline and endline kinds of evaluations) that policymakers could latch onto in their search for a response to the food price crisis of 2007-8. 

Nevertheless, I do have some sympathy for the above views.  I am a staunch advocate of rigorous evaluations, but this does not mean RCTs only (and I have been involved in the design of at least 2 RCTs).  Moreover only certain interventions--new ones, ones never tried in a certain context before—need the highest level of rigour.  “Rigorous enough” should be the guiding concept.  We are trying to figure this out for GAIN too—when do we go deep in our evaluations and when is something less heavy “rigorous enough”?

But does the quest for purity on evidence really matter?  Does it really stop action?  I feel like it might be—particularly in stopping creative thinking and experimentation on how to reduce adolescent malnutrition.  A recent meta review cycles through the current options: micronutrient supplementation, delaying age of first birth, increasing birth spacing, and the education of adolescents around healthy diets. OK, but we could have written this list 20 years ago—where is the creativity in this space?  

Evidence is the ideal driver of action, but if it is the only driver then we are stuck in its absence.  We can’t be hamstrung by the lack of evidence—we must be driven by it.  Driven to imagine, innovate, design, pilot and evaluate.  Lives depend on it.

12 November 2016

The world is urbanising. So is malnutrition. Time to think differently.

This past week GAIN organised an event, in partnership with the Scaling Up Nutrition Movement (SUN) and the Global Health Centre at the Graduate Institute in Geneva, on urbanisation and nutrition.  

Both of these issues have been the subject of major international conferences in  recent years.  The second International Conference on Nutrition less than 2 years ago was a major rallying call for food systems to do more for nutrition, 20 years after the first conference in the early 1990s.  Similarly last month’s Habitat III conference on cities was the first in 20 years.   While there have been some voices calling for these two issues to come together, this has not really happened, although things now seem to be changing.

Why has it taken so long?  For a long time the centre of gravity for poverty and deprivation in many low income countries resided in rural areas. In the 1960s and 1970s Michael Lipton was writing about urban bias—policymakers focusing on their potentially troublesome urban neighbours but ignoring the more deprived but “out of sight out of mind” rural counterparts.  As late as the 1990s we could see the massive resource mismatches in Mexico, with most anti poverty resources going to urban areas while most poverty was in the rural areas-this was a big spur to the redesign of Mexico’s social policy programs.

But this picture is changing.  Poverty is slowly becoming urbanised, and, probably, undernutrition is too.  I say probably because we don’t know definitively.  We can track nutrition indicators over time but the designation of households as urban or rural also changes over time.  A simple analysis I did with Natasha Ledlie of IFPRI and Tom Pullum of ICFI for the WHO-Habitat 2015 Global Report on Urban Health showed that in 9 out of 17 countries in the Figure below the urban share of stunting is growing, in 7 it is decreasing and in 1 it is constant.  


But the big game changer is the growth of adult overweight, obesity and diet related non communicable diseases such as type 2 diabetes.  These are increasing faster in urban areas--in part due to the spectacular rise of the consumption of highly processed foods in towns and cities. A recent study showed that in 6 Southern and Eastern African countries, the consumption of highly processed foods among the lowest income groups in urban areas is almost as high as the consumption of these foods in the highest income groups in rural areas. 

Not all highly processed foods are bad for health, but many are: think of sugary drinks, high fat, salt and sugar snacks and fast food made with processed meat products. These foods are more available in urban areas due to fast food outlets, small and large supermarket chains and because adults have less time for food preparation—often they have to travel long distances to work, they have no cooking facilities if in slums and women work outside the home--these outlets are the most convenient, and often the cheapest. 

So what are the solutions?  We certainly don’t need to completely reinvent the wheel—many interventions and approaches that work in rural areas will work in urban spaces (e.g. food fortification).  But the opportunity to work with “new policymakers” in the urban space--food buyers for supermarket chains, mayors and municipal leaders, and collectives of opinion formers and activists who are powered by social media—may well create new policy and program intervention opportunities. We need to find these. 

To do this, we need to change our perspectives.  Cities are places full of young people.  Cities can be drivers of growth and good nutrition for their residents and for the rural areas they are linked to.  But those of us over 40 probably need to reorientate our thinking.  We were brought up learning about--and experiencing-- rural development.  But rural contexts are different: less market based, with more social capital and more security but with less political power.  

We need to engage the new policymakers in our alliances against malnutrition: they are the "unusual suspect"s we need to unlock the seemingly intractable nutrition problems.  

For example, how can we incentivise supermarkets to source not only more ethically produced foods but also more healthily processed foods (we have FairTrade, what about HealthyTrade)?  How can we get mayors to care about human infrastructure as much as they care about building physical infrastructure?  How can we get social media leaders to get their followers interested in food systems as well as political systems?  How can we get the strong tech innovation hubs in cities to focus on disrupting food systems as well as disrupting car transport systems?

Malnutrition in all its forms is driven by confluences of powerful forces: poverty, inequality, urbanisation and globalisation to name a few.  To combat them we need powerful alliances of actors to come together to act.  Urban spaces provide many new challenges, but also many new opportunities.  We need to open our eyes and take them. 

30 October 2016

To blog or not to blog?

I'm often to be found encouraging my colleagues and friends to blog about their work.

I blog for many reasons (beyond the ego driven nature of it all).  I find it helps me get more familiar on an issue and it helps me organise and clarify my thoughts on it. It also forces me to read key documents.  It helps me write more succinctly and to the point.  It helps to share information and views (admittedly mine).  It also helps promote transparency.

I write about this now now because I just passed a million page views on the Development Horizons blog.  The blog has been running since 2009 and I have posted about 600 blogs during those 7 years.  That's about 1,600 page views per blog.  

For context my Google Scholar citation count is about 18,000 over about 120 articles over 30 years.  If we assume one citation for 10 article reads (and I have no idea if this ratio approximates reality, but it seems plausible) then that is 180,000 reads.

Apples and oranges, I know, but it is interesting that blogs are so widely read (not surprising when you think about it--they are short, free and one click away).

Are there risks? Yes, blogs can oversimplify, have no peer review process and are often data and link free.  They can be sheer vanity projects.   Still, these risks can be managed.  And finally, remember that content is king (or queen): if the blog is boring and uninformative no-one will read it.

So colleagues (and I use that term in the widest sense) I encourage you to blog now, blog often and blog responsibly!  (And if you can't do that, at least keep reading my blog!)

Nigeria: Can it be a driver of nutrition progress?

One of the great sessions at the recently completed Micronutrient Forum was on the implementation of Nigeria's National Strategic Plan of Action for Nutrition (2014-2019).

The national strategic plan of action focuses on direct nutrition interventions.

It is exemplary in that it has (1) SMART targets for the reduction of stunting, wasting, exclusive breastfeeding and complementary feeding, (2) is costed, (3) identifies current resource allocations and needed resource mobilisation, (4) identifies platforms for delivery and (5) tells policymakers what their investments will buy in terms of lives and DALYs saved.

The plan has buy in from the Ministry of Health, State Nutrition Offices, UNICEF, the World Bank, GAIN and others, so it reflects a collaborative consensus building process.

What needs to happen now?  Well, with the World Bank looking poised to increase funding to nutrition, the Government must now step up to allocate more of its own resources to increasing the coverage of effective and proven nutrition interventions.

I would have liked to see the opportunities within Nigeria to link with other sectors such as the food system, education, and water and sanitation (the plan is health sector focused), but perhaps they are in other documents.  Still, it would have been good to see how this fit in with the others.

If Nigeria can get stunting rates down to 28% by 2019, the whole of Africa will move forward.  If Ghana can do it, then so can Nigeria.  The world is watching.