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.

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.