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.

28 October 2016

Have micronutrient powders been rolled out too fast? Yes and no.

Yesterday at the Micronutrient Forum in Mexico, there was a fascinating debate set up to answer the question: "have micronutrient powders been rolled out too quickly?".

Putting the case for "no, they have not" was Prof Stan Zlotkin and the case for "yes they have" was put forward by Dr. Omar Dary. Interestingly, both of them are on the GAIN Board!  Disclosure: GAIN works with partners to do work on scaling up micronutrient powders.

My former colleague Marie Ruel of IFPRI was the person tasked with penetrating the arguments and finding the areas of agreement and core differences.

The arguments seemed to boil down to why, when and how micronutrient powders are rolled out.

First, we need to demonstrate that there is a need to be met: is there widespread iron deficiency in infants and young children and might that deficiency be addressed through the better functioning of an existing program or interventions? Second, even if there is a deficiency and no way of meeting it with existing programs, does it make sense to address with micronutrient powders?  For example, can they be produced at the right quality at a low enough cost and is there a demand for such products? Finally, is the infant and young child nutrition infrastructure strong enough to support scale up and, indeed, will it be strengthened or undermined by such a scale up?  If the answer to these questions are in the affirmative then the scale up is probably going to make a positive contribution.

So the answer (at least this was my own takeaway) was, yes scale up if there is a need that cannot be met by existing interventions and if it is done thoughtfully in an evidence based way that supports health and food system infrastructure, but no, don't scale up where these kinds of conditions have not been met.

There should be more of these kinds of sessions in nutrition meetings: we faced a thorny issue head on, we showed that reasonable people can disagree without rancour, and we found some common ground in a serious but good natured way.  Lets keep it up!

What can we do to strengthen the enabling environment for micronutrient malnutrition?

This was the exam question I was set by the 2016 Micronutrient Forum organisers. My slides are found here and the stats below are referenced in them. The enabling environment is important. If strong, it makes it easier for people with power—at all levels, in all sectors—to make positive decisions for reducing micronutrient malnutrition. If the magnitude and distribution of the problem is unknown, the consequences unclear and the solutions unheard of, then not much is going to happen. Additionally if there is no pressure on the decision makers to act, this also makes decisive action less likely.

So, how good is the enabling environment for micronutrients?

Well, we have some data, but not nearly enough, on the state of micronutrient deficiency. To start with there is the “2 billion people who have a micronutrient deficiency” number, the origins of which are lost in the mists of time. Then we have the hidden hunger index which averages the prevalence of stunting, women’s anaemia and vitamin A deficiency. We also know that infants’ diets are appallingly monotonous – only about a quarter of them in 60 countries achieve even minimum diet diversity. Also for eight African countries we know that women’s diet diversity is shockingly low. We also know that progress in reducing micronutrient malnutrition is barely perceptible. At current rates of progress the WHA target for women’s anaemia will only be reached in 2084, not 2025.

So given this picture, how much talk, outrage or urgency is there about the need to do something about micronutrient malnutrition? It is difficult to measure outrage.  But I have two measures of “talk” for you, both from Google. The first is the Google Ngram reader which tracks the occurrence of words in the 5 million books that Google have digitized. According to this metric we reached “peak micronutrients” around 2002. The number of mentions has been declining since then. The second is the number of times “micronutrients” are mentioned in Google News, ever.  The number for obesity is 2 million. The number for acute malnutrition is 8,810. The number for micronutrients is 327.

OK, so maybe micronutrients have not really captured the public’s imagination, but are nutrition policymakers taking it seriously?  Is there any urgency? Less than you would think.  Only 33% of national nutrition plans contain targets for women’s anaemia reduction compared to 48% for stunting.  In addition, no one seems to be tracking the price of micronutrient rich foods. They are creeping up relative to staple prices. In South Asia, the purchase of 5 a day fruit and vegetables would take up to more than half of a household on $2 a day.

So, I would conclude, from this rather imperfect analysis that the enabling environment for accelerating reductions in micronutrient malnutrition is weak.  What needs to change?

First, we need to find ways to advocate more effectively for the reduction of micronutrient malnutrition.  The very word “micronutrients” gets us into technical waters very quickly, waters that journalists are mostly unwilling to navigate.  We need to get simple messages across: “low quality diets are a bigger risk factor that unsafe sex, drug, alcohol or tobacco use”; “from food quantity to food quality”; and we need to highlight the monotony of most people’s diets by hypothetically transposing that same monotony to the diets of the well off. We could learn a few things from the techniques that businesses use so effectively to shape and influence consumer choices.  Building alliances with global and national networks of celebrity chefs might be a useful approach: they have a reach we can only dream of. 

Second, we need to drastically ramp up accountability.  How are we doing on reducing micronutrient malnutrition rates? Are we improving target setting on these dimensions? What is happening to legislation on fortification and policies to improve diet quality? What is happening on coverage rates of direct micronutrient interventions?  What is happening to spending of governments, donors and businesses on enabling greater access to micronutrients and healthy foods? We have precious little data, but accountability tools need to be developed that highlight this data dearth and make suggestions for filling the gaps.  There are obvious opportunities for teaming up with the Global Nutrition Report team to deepen the accountability around micronutrients, perhaps in a complementary Global Micronutrient Report.

Finally, we need to come together.  As a relative newcomer to the micronutrient world, I am really struck by the tribalism that flares up more often than is productive. You know how it goes:  “diet diversity is the only sustainable approach”; “large scale food fortification violates people’s rights”; “home fortification and supplements are vertical interventions that undermine food systems and medicalize nutrition”; “biofortification is the Trojan horse for GMOs and give plant breeders even less incentives to invest in non-staples.”

I reject these divisions. We need all of these approaches—the mix will differ by context and must be determined by governments themselves. Together they intertwine to form powerful bonds that we can rely on to overcome micronutrient malnutrition. If we work together we can really make a massive dent in micronutrient malnutrition by 2030. We have to check our own self-interests and pet interventions at the doors of government offices and at the doors of the huts, shacks and isolated high rises of those actually living with micronutrient malnutrition. Those who experience the devastation of micronutrient malnutrition should not even have to wait until 2030, let alone until 2084.

27 October 2016

Rice Fortification: Hiding in plain sight. Time for leadership.

One of the sessions at the Micronutrient Forum in Mexico this week was on large scale rice fortification.

Very few countries mandate large scale rice fortification and yet at least 2 billion people consume rice on a regular basis in significant quantities, with a large overlap with the billions facing deficiencies of iron, folate and B vitamins.

Rice fortification, hiding in plain sight. So, it’s a no brainer, right?

Not quite. First, as one member of the audience said, we need to make sure that those who have these deficiencies actually consume enough rice for fortification to make a difference.

Assume that is the case, then we have to generate the demand for fortified rice (as one audience member said, via push marketing to rice millers and government and via pull marketing directed to consumers).  Then we need to bundle demand to make it worth it for the supply chains to respond. Public procurement via safety nets and humanitarian interventions (e.g. the WFP) seem to offer a lot of promise too. There are technical issues, but none of them seemed any more intractable than those found in wheat fortification which is much more widespread.

What seems to me to be lacking is ambition and leadership. The Food Fortification Initiative’s Executive Director, Scott Montgomery, said we are in a chicken and egg situation: how do we cover the upfront costs to kick start demand and supply creation?  This type of initiative is made for the Decade of Action for Nutrition.  In 10 years we would want to see a large percentage of the world’s rice consumption being fortified, addressing the needs of many of anaemic women and children, and men.

We need a plan, and a group of organisations to coalesce around that. WFP and GAIN are already discussing how to do this and there are others who need to join such as the Food Fortification Initiative, MI and DSM.  These organisations need to commit their resources to this effort before going to the donors for further investment.

Fortifying rice does not seem to be prohibitively risky. We should launch a relentless effort to get it going. Now. If we did not pursue this opportunity — in a careful but aggressive way — it would be irresponsible. GAIN is committed to playing its part to work with partners in supporting all major rice producing countries to fortify their rice by 2026 — for export and for their own population’s wellbeing.

22 October 2016

Geneva: global development’s best kept secret?

When I think of public policy centres of power in international development, I tend to think of Brussels, London, Nairobi, New York, Rome, Washington DC etc. 

I don’t think about Geneva as much as I should.  Until now. GAIN is headquartered in Geneva and I am spending more time in the city.  Last week I met with the Director General of the UN Office of Geneva.  The preparation for the meeting made me realise just how many stellar organisations there are working on development and humanitarian issues: The Global Fund, GAVI, ILO, IRC, SUN, UNAIDS, UNHCR, UNHRC, UNCTAD, UNRISD, WHO, WTO and, of course, GAIN. The list goes on — and these are just the HQ organisations, for example UNEP has a regional centre of 400 people in Geneva working on environmental issues! 

So why didn’t Geneva quickly spring to my mind as a development powerhouse?  No doubt, partly due to my own need to get out more.  Perhaps it is also due to my limited knowledge of the humanitarian space where the city is so strong.  But I think partly it is due to the fact that Geneva has not really sold itself well as a development and humanitarian ecosystem.  That is changing. The UN Office of Geneva is trying to create a whole that is greater than the sum of the parts. It is doing this in several ways, including by changing perceptions about the city (e.g. I am told that 10% of Geneva residents work for these types of organisations and many more people depend on them economically), encouraging substantive issue and networking events (see below) and by engaging the media in ways that tell everyday stories about the UN (e.g. “how does the UN affect you?”). 

GAIN is already playing its part.  We are members of the Perception Change Project which aims to engage Geneva's youth on global issues.  

Most immediately we are hosting an event on November 10 in Geneva on issues around urban food and nutrition security.  (Details to come on GAIN’s website) I have written on this issue before, but it feels like its time has now arrived.  Why? First because urbanisation is clearly driving poor diets throughout the world—high levels of consumption of ultra processed foods that have high concentrations of sugar, fat and salt and not too much else. Second, the citizens of cities are close to governments and can make their presence felt—city governments have to pay attention.  Third, city governments have a fair bit of leeway to actually change the food environment their residents face: for example they control land use through planning permits, they can incentivise via the granting or withholding of licences to retailers and their residents represent a concentrated mass of potential consumers for businesses—so businesses have to pay attention to city regulations if they want access to the market.

19 October 2016

Ghana is rewriting norms on nutrition in Africa. Other countries can too.

OK so it is not the snappiest of titles for a report series, but the AnnualTrends and Outlook Report from ReSAKSS has become a widely respected annual stock take on agriculture in Africa.  So it is highly significant that it is titled “Achieving a Nutrition Revolution for Africa.”  Why significant? Because this series is produced by, and for, an agricultural policy analysis audience.  The report has been going for 10 years and this is the first time they have focused on nutrition. This is the true test of whether nutrition is moving up the agenda —when flagship publications from related sectors choose to highlight nutrition. 

The 2016 ReSAKKS Annual Conference drew about 150 people, from all over Africa, to Accra. The Government of Ghana, the African Union Commission, USAID and IFPRI were co-hosts and it was excellent to move nutrition outside the echo chamber. We heard about nutrition training for 15,000 agricultural extension workers in Rwanda, about the need to revamp agricultural economics policy curricula starting with South Africa’s, about strategies to engage seed companies around more nutritious seeds and what might incentivise them (in the absence of immediate commercial return), about the need to invest in the productivity of non-staple crops, and about the economic productivity returns to adults of improved nutrition.

I gave a keynote on where Africa is on meeting various targets.

Key points:
  • few countries have SMART targets for women’s anemia, low birth weight and under 5 overweight;
  •  9 countries are on track to meet the WHA stunting target, and another 30 or so are making progress towards it, although not rapid enough;
  •   only 4 countries are on track to meet the, admittedly stringent, Malabo CAADP targets of 10% stunting by 2025;
  • government spending on nutrition actions, broadly defined, is low at about 1% of total government expenditure.
I also presented the 2016 Global Nutrition Report at a side event and was a discussant on a biofortification session.  On biofortification, I stressed that the programmes seems to be at the end of the beginning and now scaling is the imperative.  But it was not clear to me how this would be achieved:  how to create profit incentives for seed companies to pick this up and how to create demand among consumers for the crops.  The presentations said that this is what the biofortification programs were going to do, but not how.

I finished my various presentations with the Ghana data: stunting has almost halved in 11 years: 36% to 19%.  This is especially remarkable because it was achieved without much fanfare.  And this is an important lesson: commitment does not confine itself to glitzy proclamations, even if they are SMART.  Commitment is manifest in many people from many sectors doing their jobs well and finding ways to bend existing resources ever so slightly towards nutrition goals.  Increased accountability is important to help keep those in power focused on the prize and to give the rest of us hope that our own work will count. 

Ghana is rewriting nutrition norms in Africa.  Other countries can too.

 Editors of the report, Namukolo Covic and Ousmane Badiane from IFPRI and Sheryl Hendriks from the University of Pretoria.

15 October 2016

Lessons from biofortification’s success at the 2016 World Food Prize Symposium

This week I was in Iowa at the World Food Prize Symposium.  It is a three-day event of about 1,500 people, mostly food and agriculture policymakers, but many researchers too.  I gave three talks.  First, presenting the new Global Panel report on Food Systems and Diets.  Second, I was on a panel discussing metrics on food and nutrition.  For this I drew on the Global Nutrition Report experiences.  The third presentation was at a reception for the 2016 World Food Prize winners: Howdy Bouis, Jan Low, Maria Andrade and Robert Mwanga for their work on biofortification—breeding for higher concentrations of micronutrients in staple crops — without compromising yields. 

I focused the last presentation on what we can learn from the biofortification experience.  I argued for three lessons.

First: donors—keep investing in innovation.  Innovation takes time.  Over a 20 year period the biofortification team had to find the varieties of staples such as rice, sweet potato and pearl millet that showed sufficiently high levels of micronutrients; maintain or improve their yield so farmers would grow them; show that consumers would eat them; make sure the micronutrients were bioavailable when the food was consumed; show it had an impact on micronutrient status — all the while making sure a market existed for such foods.  It was a long and uncertain journey.  The original donors who supported this in the 1990s — DANIDA, Canada, DFID, USAID and the Bill and Melinda Gates Foundation — deserve an enormous amount of credit for taking the risk. Keep it up.

Second: the biofortification programme was convinced that agriculture could do much more for nutrition than it had done in the past.  They were right. The rest of us need to take note. Clearly the CGIAR — the network of international agricultural research centres that gave us biofortification— needs to come up with a second nutrition act.  They should ask themselves, where would the CGIAR be on nutrition without biofortification? When will there be another program like it?  The biofortification journey is far from complete, but what is the next innovation rolling off the production line? The CGIAR desperately needs to diversify into allocating more R&D funding to crops other than staples.  If they don’t they will be fighting a 20th century battle in a 21st century world.  Talk about “green revolution”, well vegetables, fruits and pulses have green leaves too!  For health and nutrition reasons we need fruits, vegetables, pulses, fish and poultry to become the “new staples” but this will not happen unless more agricultural R&D dollars are invested in them.  At the moment, the spend on them is minimal.

Third, the biofortification programme took science to scale.  The scientists weren’t content with developing the improved varieties; they wanted to get them into the markets and into the mouths of consumers who are malnourished.  They weren’t content with upstream work, they wanted to see children grow—just like the founder of the Green Revolution, the late Norman Borlaug did. To do it, they had to venture into the food system: into value chains with seed distributors, storage facilities, processors and marketers and into the food environment where consumers come face to face with options. This is where most of the action is (I think) when it comes to finding win-win policy solutions that improve the nutritional content of food and diets while maintaining commercial return. 

GAIN already works strongly in this food system space and I think this will intensify in the coming years.  It is hard to work in this space—it involves analysing systemically, building alliances with unusual suspects, and creating incentives for scaling. 

But when the going gets tough we will be sure to draw inspiration from the pioneers of biofortification.  Their innovation, their insistence that agriculture can (and should) do more for nutrition and their journey from agriculture into the rest of the food system in search of impact will be touchstones we can all draw on as we aim to end malnutrition by 2030.

Endnote:  I saw presentations by Jim Kim and Akin Adesina, Presidents of the World Bank and African Development Bank respectively on “grey matter infrastructure”.  I had read their views before but nothing beats an in the flesh presentation and they were great: genuine, committed and eloquent.  It is terrific that they have both secured new five year terms. 

Like Jim Kim (health) and Akin Adesina (agriculture) none of the four new World Food Prize Laureates are nutritionists. We need more non-nutritionists (as well as nutritionists) to become nutrition champions.  Only in this way can it be seen for what it is: a driver and a barometer of the quality of development.