This morning I had my first “awkward” media
interview as Executive Director of GAIN, challenging some fundamentals about
how we work and who we are. Here are some of them:
Doesn’t
fortification prevent spending on other types of nutrition interventions that
change the underlying determinants of malnutrition?
What
about the negative effects of fortification, such as diarrhea?
Why
do you have funders like the Bill and Melinda Gates Foundation on your Board?
By
having businesses on your Board isn’t there a conflict of interest? Won’t
your strategic direction reflect their interests?
How
can you work with companies that promote high sugar, salt and transfat foods?
I must admit I was not always brilliant at
answering these questions on air, because I was led to believe this was a
different type of interview.
Live and learn.
Nevertheless I need to get used to answering
these questions, and so here are my (slightly) more considered answers.
First, on fortification.
Doesn’t
fortification prevent spending on other types of nutrition interventions that
change the underlying determinants of malnutrition?
Fortification is one of the most effective interventions to improve certain
nutrition outcomes particularly deficiencies which weaken immune systems, inhibit
normal brain development or are essential in pregnancy (iron) or prevent
specific diseases such as goitre and neural tube defects, and with high benefit
cost ratios (Copenhagen Consensus, Lancet 2008 and 2013). Does it take
away from efforts to address the underlying determinants? No, if only
because the underlying determinants are related to things like female
disempowerment, high fertility rates, poor water and sanitation, high poverty
rates, large inequalities, poor governance and conflict—and solutions to these
are found in the remaining 99.5% of government and donor budgets that are not
spent on direct nutrition interventions in totality (of which fortification is a
very small component). And these interventions are all supported by WHO.
What
about the negative effects of fortification such as diarrhoea? This question was referring to a study in Pakistan on micronutrient
powders, reported in the Lancet 2013 (Soofi et al.). A key quote from
that study is “In our study the difference between micronutrient powder (MNP)
groups and the control group in incidence for bloody diarrhoea was around 0·08
per child year which corresponds to about one additional episode of bloody diarrhoea
per year for every 12–13 children treated.” (p.9). The positive effects
of the powders, from the same study, included halving the rates of iron
deficiency anaemia from 57% for children at 18 months to 23-27% at the same
age. Bloody diarrhoea of course needs to be taken very seriously.
Future evaluations need to and will test MNPs for diarrhoea episodes so
we can get a better idea of the conditions under which this may occur and the
frequency and severity of occurrence. As the 2013 paper notes, we need careful risk benefit assessments of MNPs. Of course, every public policy intervention needs this. Presently, however, WHO clearly recommends this intervention “In populations
where the prevalence of anaemia in children under 2 years of age or under 5
years of age is 20% or higher, point-of-use fortification of complementary
foods with iron-containing micronutrient powders in infants and young
children aged 6–23 months is recommended, to improve iron status and reduce
anaemia.” Incidentally, the senior author on the aforementioned Lancet 2013
Pakistan paper, Dr. Zulfiqar Bhutta, is a longstanding member of GAIN’s
Partnership Council.
Now, to the even bigger questions. In development,
who can be partners and sit at the table? Is business or are business people
inherently anti-nutrition?
What
about businesses on your Board—isn’t there a conflict of interest? We strive for a balance of public and private sector backgrounds on our
Board. We believe diversity of viewpoints and experiences is key. My
experience from being on and working with Boards over the past 20 years is that
pretty much everyone sitting on any Board has a vested interest of some
sort. An NGO that favours a certain intervention or approach will
consciously or unconsciously insert those views into discussions.
Similarly, academic researchers who have certain ways of looking at the world
will do the same. It is inevitable—our views are shaped by our
experiences and values. The key is to declare any vested, conflicted or
competing interest, make sure there is a variety of viewpoints at the table and
to have transparent mechanisms to manage the risks. So it is really
valuable to have people with business experience on our Board---if we want to
engage businesses to become a bigger part of the solution we have to know more
about how they think and operate. And we require all interests and
potential conflicts – from every member – to be declared and recorded at each
meeting.
What
about working with companies that are promoting high sugar, salt and transfat
foods? For me this is perhaps the most difficult
question. Where the company is doing something good for nutrition in one
domain but also promoting the sale of foods dense with these ingredients you
can do one of three things: engage uncritically, engage critically, or not
engage. Not engaging seems like capitulation. But engaging uncritically
also seems like capitulation of a different sort. We try to engage
critically. Whether that is working with a company to highlight the damage it
may be causing, or to change the product formulation (and we have had some
success in medium sized firms in Africa), or to improve labeling, we try.
And we will strive to do even better in this area: just as we will with
governments and NGOs that do good and bad things for nutrition.
Finally let me say we are really proud of our
association with the Bill and Melinda Gates Foundation. They support
thousands of independent organisations in development and as the Global
Nutrition Report data shows, they are the fifth largest funders of direct
nutrition interventions (behind the US, Canada, EU and the UK). But why
do we have funders on our Board? It is common to have funders on the
Boards of organisations like GAVI and the Global Fund and this is the spirit in
which GAIN was founded 15 years ago. However, we are moving to a more
standard international NGO model where funders are not on our Board. In our case
they will sit on our Partnership Council (along with NGOs, independent
researchers, UN, businesses and governments) - which is an advisory body.
So why am I sharing this with you folks?
We at GAIN want our work to be of the highest quality and transparency.
The challenge of working effectively with businesses is the struggle that many
of us in nutrition are facing -- or will be facing in the future. Since
it is business that delivers the vast majority of all foods consumed, not to
involve them seems illogical. We want to share our thinking behind the
struggles and to promote dialogue.
Remember the African proverb: if you want to
change someone’s head, it is best if they are in the room!