Nutrition in the post-2015 Development Agenda

Remarks by Kul Chandra Gautam, University of Ottawa, RESULTS Canada National Conference, Ottawa, 2 December 2013

It is an honour to be at this historic University of Ottawa, a great centre of learning, that I understand hosts the largest school of development studies in Canada.

I thank RESULTS Canada and the Micronutrient Initiative for co-organizing this event along with the University of Ottawa.

I feel especially delighted to join my good friend Venkatesh Mannar, a great world leader of human nutrition, and President of the Micronutrient Initiative; and my old colleague from UNICEF Professor Luchlan Monroe.

I am not a nutritionist or public health specialist. So I feel a little awed and awkward to speak to this audience about nutrition on which I have no technical expertise.

My responsibilities while I was at UNICEF were those of a generalist development professional, a manager and a practitioner.

I did learn a little bit – but never quite mastered – the art of negotiations at the UN, from some great Canadian diplomats including Alan Rock, currently President of this great university, and his predecessors at the Canadian Mission to the UN, Ambassadors Stephen Lewis, Yves Fortier, Louise Frechette, Robert Fowler and a few others.

I salute the stellar record of Canadian diplomacy at the United Nations – from the exemplary leadership of Lester Pearson who won the Nobel Peace Prize in 1957, to Ambassador Alan Rock’s contribution, with the backing of Llyod Axworthy and Prime Minister Jean Chretien, to enshrine the concept of the “Responsibility to Protect” as a key role of the United Nations.

Many Canadians – and the rest of us – might not yet fully realize the far-reaching importance of this concept of the “Responsibility to Protect”.  But I assure you that future generations will appreciate it as a momentous contribution.

“The responsibility to protect” implies that the international community must intervene whenever a government is unable or unwilling to protect its citizens from massive violations of human rights – such as in situations of genocide and other crimes against humanity or on the face of cataclysmic natural disasters.

This is a very important counter-weight to the principle of national sovereignty which dictators sometimes use with impunity to oppress their own people.

Uncertainty about effective nutrition interventions

Before we turn to our subject of nutrition in the post-2015 global development agenda, let us quickly revisit where we have come from.

The serious consequences of malnutrition, and how it contributes to poor health; maternal, infant and child mortality; impairment of learning ability and diminished earning capacity, have been known for a long time.

We have also known for quite a while what needs to be done to tackle malnutrition and to unleash the positive benefits of good nutrition for human health and national development.

But nutritionists are a cantankerous lot. They argue and quarrel endlessly about the intricacies of all kinds of enzymes and nutrients, that some of us non-nutritionists have real difficulty understanding.

And so it is that nutrition is a subject that is over-studied and under acted upon.

In the past whenever planning commissions and finance ministries asked nutritionists what should be the key priorities for investment in nutrition, they often got conflicting answers.

Some said, invest in agriculture and food production, and nutrition will take care of itself.

Some said, more protein consumption was the right answer to malnutrition, and others cautioned not to neglect fibres and carbohydrates. Yet others said proper breastfeeding during infancy, and a balanced diet as we grow older, will do the trick.

Within the UN system, we got mixed messages – with FAO emphasizing agriculture and animal husbandry; WHO focused on control of infections and illnesses; and we at UNICEF were left bewildered as to what to do.

In the late 1980s, UNICEF came up with its own nutrition framework.

Some of you might recall it referred to the “Triple A approach” – comprising a cycle of assessment, analysis and action; that dealt with the immediate, underlying and basic causes of malnutrition; and recommended mutually reinforcing actions that dealt with control of infections, good child rearing and caring practices, and proper feeding and household food security as three key interventions.

This was considered a major conceptual breakthrough and became a fairly well accepted basis for nutrition programming in the 1990s.

Nutrition goals of Summit for Children

The 1990 World Summit for Children, co-chaired by Canadian Prime Minister Brian Mulroney, adopted a set of quite ambitious, time-bound and measurable goals for child survival, development and protection.

These included: reduction of severe and moderate malnutrition, low birth-weight, promotion of growth monitoring, breast-feeding and household food security.

Very importantly, the Summit for Children also endorsed a set of goals for tackling micronutrient malnutrition – specifically, the reduction of iron deficiency anemia, and virtual elimination of iodine and vitamin deficiencies.

To Canada’s great credit, it followed up with implementation of a number of these commitments quite faithfully. In the field of nutrition, the most important action by Canada was the setting up of the Micronutrient Initiative.

Of all the great summits of the 1990s, the commitments made at the Summit for Children were the most widely implemented and rigorously monitored.

And so it was that when the Millennium Summit was convened at the UN in the year 2000, the goals originally formulated at the Summit for Children became the most widely accepted basis for the Millennium Development Goals.

Many of the indicators to measure the child survival and development goals were developed under the guidance of a Canadian expert at UNICEF named Gareth Jones.

Even today, the Multiple Indicator Cluster Survey (MICS) originally devised by UNICEF and WHO is used to monitor most indicators of the MDGs.

So Canada can legitimately claim parenthood to quite a few of the MDGs, and their targets and indicators.

Nutrition in MDGs

With that rather long background, let us turn to how have we done in achieving the nutrition-related targets of the MDGs, and what might be the place of nutrition in the post-2015 global development agenda.

First, I must say nutrition was not given as much importance and visibility as it merits in the MDGs. Nutrition was subsumed under MDG 1 dealing with poverty and hunger, and MDGs 4 and 5 dealing with child and maternal health.

The progress made in reducing malnutrition in the past decade has generally not been satisfactory, with the notable exception of combating micro-nutrient malnutrition for which the government of Canada, the Micronutrient Initiative, and I might add, several Canadian academic research centres and the private sector, can take much justified credit.

The world still has nearly 100 million children who are under-weight, and 165 million children who are afflicted by stunting that seriously compromises their health and well-being.

In addition to under-nutrition, obesity is now becoming a major nutritional issue even in very poor countries, because of the spread of junk foods and unhealthy life-styles.

The life-saving and life-enhancing practice of breastfeeding is still not as widely practiced as desirable.

While the world has made great progress in reducing under-5 mortality, prospects for further progress are seriously compromised because of persistent malnutrition which today accounts for one-third of all under-five deaths.

So combating malnutrition remains one of the key unfinished business of the MDGs. This will have to figure much more prominently in the post-2015 global development agenda.

To combat malnutrition effectively, it is important for us to recognize that the major challenge is not a technical one, nor even a financial one, but a matter of right strategies and political priority.

We all know the old saying that “Man does not live by bread alone”, or as we would say with a bit more dietary and gender-sensitivity in Asia, “People do not live on rice alone”.

Of course, all human beings need food to survive, but food alone is not enough for people to thrive – and to live a healthy, productive and dignified life.

The challenge of hunger and malnutrition requires a multi-pronged approach, including: greater availability of food; enhanced livelihoods; education; clean water and sanitation; women’s empowerment; social protection; and a special focus on infant and child care.

But above all else, genuine food and nutrition security requires a strong political commitment that recognizes hunger and malnutrition as violation of people’s human rights, as well as serious impediments to national development.

Political commitment for hunger and malnutrition

The importance of political commitment was graphically highlighted by the Nobel Prize Laureate Amartya Sen who famously argued that the Great Bengal Famine of 1943 in which millions of Indians died, was not caused by the shortage of food, as the granaries of Kolkata were apparently quite full, but the British Raj of the time felt no political obligation to protect the starving masses from famine.

As we know, Amartya Sen also propounds a thesis that there is no large-scale famine in a functioning democracy.

Let us be clear though that while democracy may indeed help avert visible famines, as we have seen in India – the world’s largest democracy – and in other parts of the world, democracy is not an adequate anti-dote to combat malnutrition, which is often invisible to the naked eye, and therefore cannot be sensationalized in election campaigns.

Many types of hunger

Conventional wisdom would have it that hunger and malnutrition result from poor agriculture, lack of food or an unbalanced diet. But we know that hunger has many other dimensions.

There are at least four types of hunger:

The first hunger is the most obvious, caused by the lack of food. When we speak about millions of people going to bed hungry, or when we see the heart-wrenching pictures of emaciated children dying in famines, that is the common kind of hunger we refer to.

The second hunger, which we generally underestimate, is the “hidden hunger” for micronutrients – or tiny amounts of minerals and vitamins such as iodine, iron, vitamin A and zinc.

This type of hunger does not manifest itself in the form of a bloated belly or emaciated body. But it strikes at the core of people’s health and vitality. It seriously damages human brain, learning ability, human health, and productivity.

The third type of hunger is the need of children and women for adequate care, nurturing, and protection from infections, without which food alone cannot protect them from malnutrition.

The fourth hunger is for a safe and sanitary environment—including safe water, clean air, and sanitation – so essential for promoting health, growth and nutrition, as well as liberating women from the drudgery of these time-consuming chores.

To these, we might add the growing occurrence of obesity, largely caused by junk foods and unhealthy life-styles, which is becoming an alarming phenomenon alongside under-nutrition, even in very poor countries and communities.

Indeed, it has been noted that both under-nutrition and obesity are a reflection of the life-cycle consequences of inadequate foetal and infant growth, and the life-style related consequences of urbanization where the poorer people, including children, often eat cheap, processed foods which fill the belly and satisfy their taste buds, but harm their health.

Interestingly, some of the solutions to under-nutrition and over-nutrition are common. Optimum breastfeeding, for example, prevents both under-nutrition during childhood and protection from some obesity-related diseases in adulthood.

Overcoming these different types of hungers, requires a holistic, life-cycle approach to ensure that all children get a healthy start in life; that all families have essential household food security; that primary health care and basic education are universally available in all communities; and that we promote good nutrition and healthy lifestyles among adolescents and adults

Canada’s leadership in nutrition

Among major donors, Canada has been an enlightened leader in giving high priority to nutrition. Canada’s decision to invest in micronutrient interventions has been very wise, pragmatic and has produced great results.

Canada has invested billions of dollars for food security and nutrition in response to the L’Aquila and Muskoka G-8 Summits. But I believe Canada has gotten the biggest bang for its bucks through its support for the Micronutrient Initiative.

I do not have the exact facts and figures, but I would guess that Canada’s investment of less than a billion dollars over two decades through MI, has probably reached cumulatively over 2 billion people, and provided them with life-saving and life-enhancing vitamin A supplements, iodised salt, iron-folate and zinc tablets, and other micronutrient powders.

Millions of lives have been saved, the health of millions has improved, and millions of children have been protected from brain damage, resulting in better learning, and eventually better earning by a whole generation of children who otherwise would have been condemned to death and disability.

The MI’s job is still not done, and it is in the cusp of yet another great breakthrough – that of double-fortification of salt – with iron in addition to iodine – that could truly liberate millions of poor women and children from the world’s most prevalent form of malnutrition – iron deficiency anemia.

I would hope that in the spirit of Prime Minister Harper’s Muskoka Summit commitment, Canada will make a renewed commitment to support MI, including a bold new initiative of double fortification of salt.

When I say, a bold new commitment, you might wonder if I am talking about billions of dollars. No, I am not even talking about a hundred of million of dollars.

Perhaps a modest, additional $50 million dollars for MI could help it to initiate a whole new breakthrough in tackling one of the most stubborn problems of malnutrition that victimizes millions of poor women and children in Asia and Africa.

Venkatesh Mannar, is the world’s top expert on DFS. He can speak more authoritatively about it, but I would urge us all to launch a massive campaign to mobilize the required resources for this new breakthrough in improving human nutrition.

Nutrition is Multi-sectoral

We all say that nutrition requires a multi-sectoral approach, which it does. But therein lies a big problem. When something is multi-sectoral, it becomes nobody’s priority.

Most sectoral ministries of governments understandably champion their own sectors. And multi-sectoral programmes become secondary and discretionary for which one can always pass the buck to another ministry.

With a few notable exceptions, there are very few Planning Commissions and Finance Ministries, or heads of government and provincial chiefs who play an enlightened leadership role in support of programmes that maybe very important, but for which there is no lobbying by powerful constituencies.

Let me conclude my remarks on a happy note. There has been a significant change in the last decade – and a growing consensus nationally and internationally – on what needs to be done to improve nutrition; why it deserves a high priority; and some very strong evidence-based cases for investing in nutrition.

About a decade ago, the World Bank issued a seminal report on “Repositioning Nutrition as Central to Development”, drawing on evidence from many country studies that demonstrated very high cost-effectiveness of many nutrition interventions.

Starting in 2008, the British medical journal, The Lancet, has published a series of articles, drawing on lessons learned from many projects around the world, and made the case that there is a ‘Golden 1000 days’ “window of opportunity” from pregnancy to two years of age, during which a set of specific nutrition interventions can have the greatest impact in reducing malnutrition, morbidity and mortality in children.

Around the same time, a group of leading economists, including several Nobel Laureates, came up with what is known as the “Copenhagen Consensus” that showed that investment in nutrition, such as on micronutrients and some community-based nutrition interventions has far higher rates of economic return and social impact than investment in any other sector.

Scaling Up Nutrition

All of this culminated into a bold proposal for “Scaling Up Nutrition” – The SUN Initiative – around which there is now an emerging global consensus among governments, UN agencies, multilateral and bilateral organizations, academics and NGOs that are key players in promoting nutrition.

The SUN Initiative recommends two complimentary approaches to reducing under-nutrition – a set of about a dozen specific and evidence-based direct interventions to prevent and treat under-nutrition, and a broader multi-sectoral approach to deal with the underlying causes of malnutrition.

The SUN approach got a major boost earlier this year on the eve of the G-8 Summit in London when a commitment of nearly $4 billion was announced for a “Nutrition for Growth” initiative.

I really hope that the strategies and actions proposed in the SUN initiative will find a prominent place as we prepare for the post-2015 global development agenda.

In nutrition, we do not need to rediscover the wheel again. Much thoughtful work has already been done. It is time now to implement what we know works well, and produces good results.

Nutrition is one field in which Canada can, and I hope will, take the lead – and the rest of us will follow – so that by 2030 we can say with confidence and pride that we helped break the back of malnutrition that has enslaved humanity for millennia.

Thank you.