Well, that was intense, but fun. I'm talking about he the IDS Summer School on Transforming Nutrition. The 25 participants are shown above. About half from high burden countries and half from donors and agencies. We cycled through definitions, distribution, causes, consequence (all in Day 1), with interventions in Days 2 and 3 and building commitment and converting it into action on Days 3 and 4. There were also 4 country working groups who worked on an real issue facing the participants in Ethiopia, Tanzania, Burkina Faso and Kyrgyzstan presented on Day 5. We had some particularly interesting discussions on:
1. The differences between the SUN nutrition specific interventions (based on Lancet 2008) and the Lancet 2013 nutrition specific interventions. We noted that:
- Five interventions overlap completely (promotion of breastfeeding, complementary feeding, management of SAM, Vitamin A supplementation, salt iodisation).
- There are 6 in Lancet 2013 that are not in the SUN set (maternal balanced protein energy supplementation, maternal multiple micronutrient supplementation, Folic acid supplementation, management of MAM, preventative Zinc supplementation, Calcium supplementation). These reflect new evidence and new understandings about the importance of maternal nutrition.
- Finally, there were 6 "missing" interventions, i.e. in SUN 13 but not in Lancet 2013 (hand wash with soap, therapeutic zinc for diarrhoea management, Iron and Folic acid for pregnant women, multiple micronutrient powders for children, deworming and iron fortification of staple foods). Why are some of the interventions missing? Each missing intervention has a different reason for omission: hand washing with soap promotion and therapeutic zinc for diarrhoea management are still fully endorsed by the Lancet authors, but for categorisation reasons (they are about disease control) they were not listed in the Lancet 2013 list. Iron and Folic supplementation is now subsumed by maternal multiple micronutrient supplementation. Iron fortification of staples listed as beyond scope of review. Multiple micronutrient powders for children and deworming--increasingly mixed views on the nutrition benefits of these.
2. The absence of evidence is not evidence of absence
In other words, (1) a finding of no statistical evidence in a randomised controlled trial must be taken in the context that often these trials do not have large enough sample sizes to detect real differences. But also, maybe more importantly, (2) when a huge amount of non-experimental but highly plausible evidence suggests that one thing causes another it should not be ignored. This discussion came up in the context of nutrition sensitive programmes. Paper 3 in the Lancet by Ruel and Alderman is careful to make both of these points. Nevertheless the paper was politely criticised by Per Pinstrup Andersen in his commentary paper in the same volume for ignoring other types of evidence (e.g. econometric evidence) that suggest highly plausible effects of agricultural programmes and policy on nutrition status. What to do in the absence of definitive evidence that x causes y? Doing something has risks but doing nothing does too. The translation of evidence into action is still more of an art than a science.
Relatedly I just read an interesting paper by Andrea Cornwall at the University of Sussex on how RCTs are set up to capture impact by intervention design, but not (1) impact due to interaction with other interventions and (2) impact by emergence--unimagined outcomes which are not easily discerned, but which emerge due to interactions with other interventions or with historical and cultural processes. I suggest you write to Andrea for a copy (firstname.lastname@example.org).
3. The role of the private sector. We had a discussion that emphasised:
- the need to unpack what we mean by the private sector: national or international? small, medium or large? which sectors?
- the need to map this onto different stages in the lifecycle of nutrition: which age groups should be regulated more closely? which interventions are most susceptible to private sector influence? where can the biggest positive contributions be potentially made?
- the need to map different private sector roles: influence, delivery, innovation, finance
Only by doing this can we have a non-polarised discussion of the areas of private sector engagement that are likely to maximise the positive benefits and minimise the negative. Above all, the public nutrition sector needs to know where the bottlenecks are and which ones might be relaxed by private sector engagement.
4. The orphan to an orphan? Sanitation
We were enlivened by several interventions by Robert Chambers. Robert has just published a paper in Economic and Political Weekly on open defecation in India and together with the emerging interest in environmental enteropathy (focally transmitted diseases that do not necessarily manifest as diarrhoea) we had a lively discussion about whether sanitation is a potentially big and quick win for nutrition. A new systematic review is due out on this soon, I believe.
One of our participants was a Youth Ambassador for one of the major INGOs. He reminded us that we were not doing enough to include youth in this conversation about nutrition---the nature of the problem, how to build commitment to doing something about it, what to do about it, and how to sustain that energy. This has given us something important to think about.
we heard this week that one of the Summer School Convenors, Prof. Anna Lartey, has just been appointed as Director of Nutrition at FAO. This is a superb appointment by FAO--Anna is a smart researcher, a powerful speaker and an inspiring leader. We look forward to supporting her in this exciting new development.
We will run the course again next July. Watch out for the ads later this year.