07 June 2013

The New Lancet Series on Nutrition: Time to Step Up the Outrage

The new Lancet series on maternal and child nutrition was launched yesterday.

All papers can be found here

(Declaration of interest--I was one of the study team).

So, what's new?

1.  Undernutrition is the underlying cause of 45% of under 5 child deaths.
This is up from 35% from the last series in 2008, largely because the total number of deaths has gone down but the percent from undernutrition has not declined as fast. Put this with 11% GDP loss due to undernutrition from Steckel and Horton's latest estimates and the fact that less than 1% of ODA is allocated to nutrition. The mismatch is staggering.

Number one reason for outrage.

2. 27% of all births in low and middle income countries are small for gestational age (not pre-term).
They are born malnourished.

Most pregnant women living in poor contexts do not access nutrition services (if at all) until month 5 or 6 of pregnancy, which is late. This reinforces the need to make sure women are well nourished going into pregnancy--for themselves and for their children. It also focuses more policy attention on young girls, 10 million of whom are married before 18 years of age.

Number two reason for outrage.

3.  The numbers of under 5 year old children that are stunted stands at 165 million and with business as usual those numbers are projected to decline to 127 million by 2025.
The World Health Assembly Targets are 100 million stunted children by 2025. If we can get that close to the WHA targets through business as usual, surely the targets are too timid and are a weak accountability tool?

While the poverty world is aiming to end poverty (see the recent High Level Panel Report), the nutrition world is being complacent.

Number three reason for outrage

4.  Scaling up 10 nutrition specific interventions to 90% will reduce stunting prevalence by 20% and severe wasting by 60%.
This would comfortably exceed the WHA targets. The incremental costs of doing so is estimated to be $9.6 billion for the 34 highest burden countries.  More than half of this amount is accounted for by India and Indonesia which will rely heavily on domestic resources. Consumables (drugs, and other items for transport and administration) come to less than half of the $9.6bn, and all but the very poorest countries can be expected to cover personnel costs. So an extra $3-4 billion per year from external donors will make a substantial difference to maternal and child nutrition. The current spend is between $400m and $1bn.

Number four reason for outrage. Nutrition for Growth pledgers--surprise yourselves on Saturday.

5. For the first time nutrition sensitive programmes were analysed by the Lancet series.
These are programmes that address the underlying determinants of fetal and child nutrition and development--food security, caregiving, health services, social protection, safe and hygienic environment--but also incorporate specific nutrition goals and actions.

The message here is that these programmes are not "design-proof". In other words, if they are to have an impact on nutrition, surprise, design matters: they should target the first 1000 days, they should empower women, they should work in the poorest areas, they should be of the right duration and they should improve the quality of services as well as the demand for them. 

The presentation of this paper yielded an interesting discussion about the nature of evidence. The Lancet paper focused on micro-studies, looking for RCTs when available but not restricting themselves to such.  Nevertheless, two very senior and world class agricultural economics commentators pointed out that the medicalisation of evidence risks ignoring vast swathes of other types of rigorous evidence which make a strong plausible case that food and agricultural policies affect nutrition, even if they do not make it into the evidence pool of narrow systematic reviews.

The issue that came up in the discussion is: how do we incentivise these programmes to work for nutrition?  One answer is to embed nutrition specific interventions within these nutrition sensitive programmes because the latter can achieve scale and because synergies are likely to be generated between specific and sensitive.

But the incentive issue is more difficult when it comes to food systems--how do you incentivise the food system to support healthy growth (whether avoiding under or overnutrition). We are not devoting enough energy to this.

6. Malnutrition is Political.
The paper I was involved in with Stuart Gillespie (co-lead with me), Venkatesh Mannar, Purnima Menon and Nick Nisbett, deliberately chose to focus on the politics of malnutrition.  All development is political and so why would we expect nutrition to be any different?

In fact the returns to a political analysis for nutrition are likely to be high--many actors, with different agendas, different power levels, amid a sea of invisibility and asymmetric information--sounds like a definition of Politics 101.

We talk about the need to understand politics if we are to build and sustain commitment and then turn it into impact.  We focus on framing, evidence, governance, accountability, commitment, capacity and resource mobilisation. 

Malnutrition is more than a technical, health, policy, programme and economic issue, it is political.

Treating malnutrition as an apolitical issue is outrage number 5.

7. Private sector--deal with it.
We dealt with this in our Paper 4. The basic messages: (1) the private sector is already inextricably linked to undernutrition. The percent of foods and other nutrition relevant goods purchased in the market is rising inexorably, (2) there is lots of distrust of the private sector, especially the food industry. This is based on a troubling history of abuse and some continuing violations of the code of conduct for the marketing of breast milk substitutes. So the risks of getting it wrong are high. But the risks of foregoing the benefits of getting it right are also high, and (3) surely we can devise some governance structures that reward good behaviour and punish bad behaviour?

There are plenty of ideas: registers of interest, embedding adherence to the Code in job descriptions of senior executives, strengthening whistleblower protections. There are things governments need to do too: enshrine Codes in law, make cross-border trading of fortified foods simpler, enforce simple labelling.  Research funders and the research community need to be bolder in funding research to find out which business models work for nutrition and which do not. 

Children can't eat ideology. All sides need to engage. Failure to do so is my outrage number 6.

Finally I just want to thank Prof. Bob Black, the leader of the Lancet series. He is an incredible intellect, an incredible manager, and a very humble guy who has nothing to be humble about. It has been a real pleasure working with him and the team of coordinators to get this done in 6 months.

Expressing outrage is not just talking about it--it is doing stuff about it, stuff that often has a high personal cost. Bob has been an inspiration.


Unknown said...

Hi Lawrence. Great blog! I like the 'outrage' title! Greetings from Joburg. Stefan/GAIN

Miriam said...

again, excellent blog entry - thanks Lawrence!

Patti Rundall said...

Hi Lawrence.
thanks for the intervention - but just one thing that's really annoying..
It depends what you mean by engage. Those of us who monitor, double check, track and advocate the better regulations you talk about - do engage with all parties - constantly - yet we are accused as being too afraid to talk to companies. Its a nonsense. We just insist that they should do what they stick to the rules agreed by the World Health assembly (as they claim to do) and that they are
kept out of policy setting so that those who have a duty to protect health can get on with deciding whats best and safest for all. Its essential that we get the nutrition solutions right.
Not too much to ask surely. I have spent more time engaging and listening to what companies have to say on nutrition than most I imagine!
Patti Rundall

Lawrence Haddad said...

Hi Patti, thanks, as ever, for the comments. I know you and your colleagues do a lot of excellent "policing" work with the food industry and I think that is vital work. But what is missing is the search for new solutions, for different ways of working. This is everyone's responsibility, not just IBFAN's. I agree with you, the role of Industry should be determined on the front foot--the public sector needs to understand what, in a given context, it wants from the private sector. As I said in the meeting, I am worried about the 7-24 month age group who seem to be between a rock and a hard place: low incomes make it difficult to families to provide enough nutrients for infants in this age group, but few processed products are available to them for fear of doing even more damage. This is where the dialogue is most needed--with full transparency, monitoring and evaluation. Best, Lawrence

Lawrence Haddad said...

By the way, I have to thanks Shawn Baker of HKI for the inspiration behind the "outrage" theme...