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.