01 July 2017

GAIN: straightforward answers to some "awkward" questions

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!

1 comment:

Stacia Nordin said...

Thanks for putting this out here. On question one, I often answer this with "it depends on how fortification and supplementation is being done".

We should be working at reducing these treatments to the food system over time. Medicating the masses is necessary at the moment as things are so bad for so many people, but we should be working hard to work ourselves out of a job when it comes to the fortification sector. Fortification and supplementation should not be seen as a long term approach to nutrition, even if WHO and the Lancet and others say it is cost efficient in the short term - it is MUCH more cost efficient to solve the problem and not have to fortify.

We must work towards solving the problems and assuring that our environment is healthy for plants and trees to have the nutrients and health they need so that animals (including people) have the nutrients and health they need - including the right amount of water, sanitation and hygiene that each species needs to thrive.

I don't see enough fortification programmes educating people as to why fortification is in place and how we can fix our systems so that we can stop fortifying foods. I hope GAIN can be part of the solution and work on strengthening labelling and nutrition education programmes.