As the COVID-19
pandemic generates waves of impact across the globe, “resilience” is bouncing
back into the development spotlight.
Whether linked to
health (e.g. AIDS, Ebola) or economic (food prices), climate or conflict shocks
and stresses, resilience has come to be seen as a useful organizing principle.
A conveniently fuzzy, all-embracing, cross-sectoral goal around which we can all
There are many
definitions out there. Most refer to the ability – in the face of a shock or
stress — to recover or bounce back to a past state. A type of buoyancy or toughness in the face of adversity — the capacity to weather the storm, to
cope. The Intergovernmental Panel on Climate
Change, for example, deﬁnes
resilience as the ‘ability of a system and its component parts to
anticipate, absorb, accommodate, or recover from the effects of a hazardous
event in a timely and efﬁcient manner’.
In the face of
COVID-19, at an individual level, resilience is ultimately the ability to
survive. For households, it’s the ability to withstand multiple social and
return of resilience, we see another emerging discourse that argues for the
need to jettison business-as-usual in a post-COVID world. We need to create a “new normal”. This sounds
very like transformation — quite different to coping.
So, can these two
goals – resilience and transformation – actually co-exist?
But first, even
before we ask questions about resilience, we need to consider resistance.
The front-line of resistance to a new virus like SARS-CoV-2 is an individual’s
immune system. We can go further back to ask why s/he was exposed to the virus
in the first place — was she working or living in an environment in which she
had more contact with potential carriers? Was she in control, could she reduce
the risk of exposure? If her ability to avoid exposure – her resistance — is
overwhelmed and she becomes infected, then we’re in the realm of resilience.
In 2003, in the
early years of RENEWAL, we conceptualized both resistance
and resilience in the context of AIDS epidemics to help understand the
different layers and waves of HIV risk and AIDS impacts. In the top left
quadrant (of the diagram below) we can see the different drivers of risk of
exposure to the virus, from macro to micro.
In the top right quadrant, we can see the waves of impact, from micro to
macro. The bottom half shows potential
responses – resistance to the left, resilience to the right.
As we learn more
about COVID-19, we can develop similar maps to help situate a comprehensive
response. Here’s a simplified illustrative
version, including potential key factors (some as yet unproven):
Much has been
written about resilience in recent years. In May 2014, IFPRI convened an
international conference “Building Resilience for Food and Nutrition Security”
in Addis Ababa, Ethiopia that led to a book
of key papers.
Where is agency?
One criticism of
resilience in the past has been its perceived inability to capture issues of
power, agency and social justice. It’s seen as an apolitical concept that is
not necessarily pro-poor. It is quite conceivable, for example, for a household
to demonstrate resilience (using a certain metric) but for this to entail major
costs. A household may remain “food-secure” in the face of climate shocks or
seasonal stresses, but there may be a big price to be paid (e.g. to the nutrition
and health of women working dawn til dusk transplanting rice, and/or to young
children who are not adequately cared for during peak labour demand).
Clearly there are
potential trade-offs. We need to ask questions about equity, about the cost
of resilience, and who pays? We need to consider scale (individual,
household, community etc) and timeline (e.g. does resilience endure?).
Pelling (2011), for example, argues that the notion
of resilience as “buffering” is too limited as it simply reinforces the status quo. Bene et al (2012) suggest a more organic way to bring
power and agency into resilience thinking is to incorporate them directly into
the conceptualization, as per their “3-D framework”.
limited notion of the capacity to cope by absorbing shocks (on the left), there
is the capacity to adapt, and even to transform. At a systemic level, this refers to a
fundamentally new food or health system.
Agency, power and
politics are thus captured in this framework. We can also see how the ability
to absorb a shock ensures stability, which in turn provides the potential for
incremental adjustments and even transformational change.
We could apply such
a framework to individuals, households and communities — and we could apply it
to health and food systems. Bringing in the related concept of vulnerability,
we can see how certain food systems — in which wild animals, domestic animals
and humans are in close proximity in wet markets — are vulnerable
to zoonotic emergence. The virus crossed species and now it’s crossing
entire systems. Emerging from a food system, it has gone on to overwhelm health
systems, and to undermine global economic systems in a way that’s not been seen
for more than a century.
economies will survive — in some form. In the aggregate, they are
resilient. But the COVID-19 pandemic is
exposing and amplifying many forms of inequity. We need to differentiate
actions and impacts within households and health or food systems and ask
questions about the cost of resilience, and who actually pays?
In the UK, for
example, it is front-line health workers who — day after day, separated from
their own families for weeks on end — put their lives at risk to keep people
alive. The resilience of the health system (in this case, the NHS) derives from
the actions of these individuals. They are paying the price of resilience — not
the politicians who, for years, have argued against raising their wages, and
who dithered for weeks before responding to the pandemic.
In sum, resilience
can be a useful common goal across sectors and systems — so long as it is
treated comprehensively, and so long as it includes an analysis of equity. And
it is possible to strive for resilience and to pave the way for transformation
into a more sustainable, more equitable future. These two goals are not mutually
exclusive. But it will require actions that strengthen all three components of
resilience (absorptive, adaptive and transformative) together, at multiple
levels (individual, household, community).
And what can we learn from the response to the AIDS pandemic?
By Stuart Gillespie and Alan Whiteside
The COVID-19 pandemic is generating multiple waves of unprecedented global impacts. Epidemics in Europe and the United States are currently in their exponential growth phase, following declines in infection rates in China, South Korea, and Japan.
We have not yet seen major epidemics take off in South Asia, Latin
America and Africa south of the Sahara—where governments, health and food systems,
communities, and households have limited capacity to respond. But we do know
they will take off. Very soon.
In the first decade of this century, we learned a lot about how the
AIDS pandemic interacts with food and nutrition security—including how food
insecurity could heighten the risk of exposure to HIV in several ways. We learned
more about the upstream risks, including how undernutrition weakens the ability
to cope with HIV infection, leaving those with HIV less able to delay and
resist the worst effects of opportunistic infections that can kick in several
years after acquiring the virus. And we learned about the different types of downstream
impacts of HIV and AIDS on households and communities in hard-hit areas—and the
types of responses that mitigated these impacts.
AIDS epidemics are long-wave phenomena. In fact, there have been several
waves: The first wave of HIV infection in the 1980s was followed by increased
incidence of opportunistic infections and, several years later, by the third
wave of AIDS disease and death. Beyond this, depending on a host of variables,
there was a fourth wave encompassing a stream of economic and social impacts at
the household, community, and national levels. With regard to COVID-19, the
timeline is compressed significantly, with three waves—of infection, illness,
impact—the first two separated by just a week or two.
We are among the contributors to a considerable body of work on
the HIV and AIDS epidemics and food and nutrition. In our view, there is much
to learn from AIDS as we confront COVID-19—but there are also critical
differences. One is that, wherever they occur, COVID-19 epidemics are massive short-wave
shocks that will generate long-wave impacts. These impacts will manifest in
different ways in different contexts for many years to come. How we respond to
the first wave will determine the capacity of health and food systems to cope,
to keep people alive, and to buffer impacts on livelihoods and the food and
nutrition security of people who depend upon them.
In this post, we discuss some important questions about food and
nutrition, and about equity, as the pandemic begins to accelerate in lower
is at greatest risk?
We don’t know enough about what drives personal risk
of a severe infection, although age and certain preexisting conditions are key
factors in the north. Populations in the south are, on average,
significantly younger than those in Europe and North America, but it is the
elderly who are likely to be at highest risk.
do know a lot in general about nutritional status and immune health. Half a century
ago, the term “nutritionally
acquired immune deficiency syndrome” (NAIDS) was first used. Malnourished individuals are more likely to
have severe COVID-19 symptoms, possibly requiring hospitalization. These vulnerabilities
can be driven by undernutrition or by overweight and obesity. Intensive care data from the United Kingdom
suggest that obese adults are at higher risk of severe symptoms from the
disease. The immune systems of people with obesity are chronically activated to
respond to cellular damage caused by inflammation. Physically, obese adults also
have a harder time dealing with pneumonia, as excess weight can compromise the
ability of lungs to take in oxygen. Obese adults are more likely to have poor
cardiovascular health and less likely to be physically active—both factors
potentially compromising immune health. And there are other possible
interactions with non-communicable disease such as diabetes that are being
explored as more data become available. COVID-19 also has important implications for people currently living with HIV
and/or tuberculosis, including the critical need for testing and adherence to
do they live?
is a respiratory disease that spreads rapidly in overcrowded contexts where
many people are in frequent close contact, especially in insanitary conditions—for
example, an urban slum or a refugee camp. The
virus is 2-3 times more infectious than normal flu.
slum populations are more likely to be sedentary, and to be exposed to air
pollution that both adversely affects lung health and the ability to deal with
severe respiratory disease. Urban populations are also more likely (than rural)
to consume ultra-processed
foods which are widely available
and known to significantly increase the risk of obesity and other
We don’t know
much yet about the ability of the virus to thrive and spread in tropical environments.
Ecological niche models—developed to project
monthly variation in climate suitability of COVID-19—suggest the virus may
prefer cool and dry conditions (similar to its predecessor SARS-CoV), though this
remains a hypothesis.
Given the links between COVID-19
epidemics and the livelihoods, food and nutrition security of the poor in
lower-income countries with relatively weak healthcare systems, we can expect the
disease will have serious impacts. As with the AIDS pandemic, the
conditions exist for vicious cycles of upstream risk and downstream effects,
particularly for the ultra-poor.
immediately, COVID-19 has already generated a massive global economic shock. In
general, economic downturns and recessions (whatever the cause) hit the poorest
households hardest via numerous pathways (higher food prices, less purchasing
power, reduced ability to stockpile, higher risk of losing jobs, lack of safety
nets, ability to access and afford treatment and care, etc.). Workers from poorer
households cannot afford to take time off work if they are feeling unwell. There
are multiplier effects—a recent multi-country study in Africa south of the Sahara and South/Southeast Asia found
that responses to health
shocks by people in poverty who
did not have health insurance or access to healthcare included distress sales
of assets and widespread exploitation by informal moneylenders. This was also a
response to AIDS shocks.
Second, COVID-19 is already having a
major impact on supply chains and logistics, both for producers and consumers—as evidenced
by closed borders, national lockdowns, and the reduction in air traffic. We
believe this will have many adverse effects on food and nutrition security,
especially in the global south.
Finally, a wave of deaths among grandparents and the elderly may
significantly impact the care of young children, especially among the poor
reliant on informal sector jobs. This in turn may raise their risk of becoming
Another overarching lesson from the AIDS crisis was
the need to engage actors from many disciplines in a comprehensive
multisectoral response that revolved around strengthening community and state
capacity to respond, both effectively and sustainably. The same will apply to COVID-19. A day is a long time in this pandemic,
as everything is moving so fast—but we have to apply these lessons now.
Turning to the health system and the immediate response, proven preventions
being deployed in the global north comprise social (or physical) distancing, testing,
tracking, and quarantines. As a March 26 Economisteditorial
observed: “Without a campaign of social distancing, between 25% and 80% of a
typical population will be infected. Of these, perhaps 4.4% will be seriously sick
and a third of those will need intensive care. For poor places, this implies
calamity.” On the same day, Imperial College, London published a paper on the
global impact of COVID-19 and strategies for mitigation and suppression, employing
modeling data from 202 countries. Doing nothing to
combat the virus would lead to around 40 million deaths this year, the report
said—a higher death toll than four decades of the AIDS pandemic. Social distancing
could halve this, but will require a monumental effort in urban contexts
in the global south. Health systems could be quickly
health system responses, there’s a critical need to develop and to strengthen
social protection systems. In the early 2000s, social protection systems were AIDS-proofed.
We now need COVID-proofing to protect the most vulnerable and to dampen viral transmission.
Finally, COVID-19 presents major issues for food systems. As with all responses, the state needs to play a leading role. But the crisis also raises questions about the role of the private sector in buffering food and nutrition impacts on poor households, especially in urban areas. Seven years ago, the eerily titled paper “Profit and Pandemics” spotlighted the products and practices of transnational food companies and the massive damage being wrought by ultra-processed foods in the global south. Since then, we’ve learned a lot more about the harm these foods cause to nutrition and health—harm that may translate into greater risk of severe COVID-19 disease for millions. Just as they were in the era of AIDS, human rights advocacy and activism will be key in turning back the COVID-19 epidemic, and to defining a new future that goes well beyond “business as usual.”
Stuart Gillespie is a Senior Research Fellow with the International Food Policy Research Institute, and founder of the Regional Network on AIDS, Livelihoods and Food Security (RENEWAL), 2001-2010.
Alan Whiteside is CIGI Chair in Global Health Policy, Wilfrid Laurier University and Balsillie School of International Affairs, Canada. In 1998 he founded the Health Economics and HIV/AIDS Research Division at the University of Natal, South Africa (HEARD).
The Lancet published a new series of papers on The Double Burden of Malnutrition—the combination of undernutrition (stunting, wasting, and micronutrient deficiencies) with overweight, obesity, and associated non-communicable diseases (NCDs). This term has been around for nearly three decades, but the rapid shifts in global and national food systems and their profound implications for the nutritional well-being of most people on the planet—and for the planet itself—justify the journal’s label, “a new nutrition reality.”
The series is relatively blind to the political and commercial drivers behind the double burden, and to the way in which different forms of inequity drive food system dysfunctionality.
The introductory commentary—“A New Nutrition Manifesto for a New Nutrition Reality”—does surface the political dimension well (e.g. “we must address the underlying drivers that incentivize endless market and consumption growth over human and planetary health”). But these issues and challenges are not systematically addressed in what follows.
In Dec. 2016, Ilona Kickbusch and colleagues published a Lancet commentary titled “Commercial Determinants of Health” arguing for a new framing of a “synergistic, multidisciplinary field that addresses the drivers and channels through which corporations propagate the non-communicable diseases pandemic.”
A whole slew of papers has emerged in the last few years on the commercial determinants of health (including NCDs), but nutrition tends to be treated relatively apolitically, while simplistic statements about the private sector abound. And yet, now more than ever—given this “new reality” and given the momentum building towards the Tokyo Nutrition for Growth Summit in 2020—we need a much stronger focus on the commercial determinants of malnutrition.
There is a risk that the recommendations for commitments being developed by the Tokyo 2020 working groups fail to adequately take into account commercial drivers—the way in which the products and practices of many transnational food companies continue to drive the problem, as their corporate social responsibility people argue for a seat at the table. Again, the commentary captures this well.
….we must recognise the damage and mistrust that result from incompatible partnerships with stakeholders whose behaviour runs counter to human or planetary health. The food industry has an important role in implementing and delivering change. However, companies cannot be allowed to influence and interfere in public policy making or bias the science that underpins this process. While constructive dialogue is necessary, a default seat at the table for private-sector representatives should not be assumed and policy development processes need to be firewalled from vested interests:
As an aside here, if we are serious about human and planetary health, why is “growth” still the main focus of the Tokyo event? As Johanna Ralston asked at the London launch of the Lancet series—why not “Nutrition for Sustainable Development”?
Interestingly, the political dimension became quite prominent in the discussion at the London launch when a question was raised about an international code or framework convention on ultra-processed foods. Similarly, the excellent Lancet Commission report on The Global Syndemic of Obesity, Undernutrition, and Climate Change (released in Jan. 2019 and discussed here) made a call for such a framework convention. The report included a strong analysis of the political and corporate drivers of the syndemic—perhaps the links between this series and that earlier work could have been strengthened.
Relatedly, we need to raise the profile of human rights. In October, 180 health and nutrition experts from 38 countries signed this open letter to the UN High Commissioner for Human Rights and the Director-General of the World Health Organization calling on them to initiate an inclusive process to develop guidelines on human rights, healthy diets and sustainable food systems. The successful application of rights-based thinking and action in addressing the HIV pandemic was cited.
Nine of the 10 double duty actions recommended by the double burden series relate to redesigning and scaling up priority interventions and programs in health, social protection, education, and agri-food systems. The 10th focuses on implementation of policies to improve food environments. But before we get to policy implementation, we need to look upstream to understand how political attention and policy traction is achieved (or not) in countries where the double burden is prominent.
“… how can enabling environments and processes be cultivated, sustained and ultimately translated into results on the ground”? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How to ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, water and sanitation systems and programmes are proactively reoriented to support nutrition goals?
This requires a focus on the political economy of the double burden, and on the dynamics and pathways of (policy) change—another research priority to add to the list in the third paper. A recent initiative—Stories of Challenge—aims to shed light on some of these issues and questions in the coming months, and it is hoped this will be a prominent theme of the forthcoming World Public Health Nutrition Association conference in Brisbane in April 2020.
The framing of malnutrition as a global problem that affects
us all is long overdue. This view demands more systemic approaches, engaging
the whole of society, that align with the universality of the UN Sustainable
Development Goals. This framing also highlights certain challenges, some of
which nutrition actors are not currently addressing well.
Food environments and food systems intersect with health and
environmental systems in complex ways that may be harmful to nutrition. Private sector
organizations—especially large transnational corporations—are major actors in
these systems. Their products and practices may help address this nutrition
problem, or they may drive, exacerbate, or deliberately confound it.
Governments and public agencies therefore need to ask themselves questions
about whether to engage with certain companies, for what purpose, when, and
Until now, there has been a tendency to frame this issue as
“either/or” in terms of whether to engage with the private sector, or
not. This is far too simplistic. There’s a lot of space in between these
extremes where negotiations can take place and collaborations can be developed.
While stated engagement principles do exist, there are few
examples of clear, practical guidelines, and even fewer examples of how they
have been applied in real-world contexts. Principles tend to become
individualized and atomized rather than widely agreed-upon norms. We argue that
these issues need to be surfaced and debated openly, as part of a
consensus-building process that leads to practical guidance, including where
and how to draw red lines.
As nutrition researchers and advocates, we often have cause
to think about our engagement with the private sector—particularly in terms of
from whom we take money, or with whom we share an alliance or even a platform.
Debates rage on, with positions ranging from full engagement to strict
The private sector does not exist on a different planet; it
is all around us, encompassing a huge range of actors from small farmers and
shopkeepers to huge corporations, all of whom have a job of delivery within the
food system. Of course, we need to engage with the private sector. This fact
does not—as many pro-engagement advocates imply—mean that non-engagement with
particular companies is a ridiculous position. In other spheres of development,
e.g. public health, climate change, and green investment more generally, there
are a number of clear cases of “no-go companies”—tobacco, climate
disinvestment, child labor, alcohol, gambling.
When does working with a particular private sector actor
become unpalatable for malnutrition researchers and advocates? We all have our
own examples, but it has been interesting to see how relative this is.
Companies that we find unpalatable, e.g. serial Breast-milk Substitute Code offenders,
and large unreformed transnationals that derive the greatest share of their
profits from products and practices associated with obesity, are in
relationships with other organizations that we respect in the nutrition world.
This has led us to examine our own reasoning, bias, and
subjective assumptions about partners with whom we will and won’t work. We
wonder whether ours and others’ reasoning about the seeming illogic of
combining, for example, public health approaches with sugar-sweetened beverage
distribution (which we see as similar to combining public health with tobacco
retail) could be better channeled into the development of a clear set of
practical processes and indicators.
Indices like the Access to Nutrition Index (ATNI) could
help. The methodology involves an assessment of corporate and product profiles.
The former assesses companies’ performance against “international
guidelines, norms and accepted good practices, except when such guidance was
not available” (which again highlights the gap we face). Product profiles
assess the “healthiness” of products that generate the greatest
revenue for the company. Since its inception, companies that perform highly
(scoring 6-7 or above out of 10) only do so in relative terms. Many score below
3 out of 10. Companies tend to score better on stated commitment and governance
than on product healthiness. Implementation lags behind commitments, and ATNI
has been criticized for
focusing too much on the latter. Nestlé is an interesting case: a company that
has done a lot to reform and consistently ranks highly on the ATNI and yet
doesn’t seem to manage a year without Code violations.
We argue that companies need to show pro-nutrition actions (not
just words) over a reasonable length of time before discussions on engagement
or partnerships start. To this end, we would need consensus on what this would
look like, including what metrics, indicators and targets are sufficient to
demonstrate institutional commitment to better nutrition.
A traffic light rating system could work. At present, most
companies assessed by ATNI would be red or amber. Such a system (which would
need to be grounded in a consensus on appropriate metrics) could improve
clarity, and better incentivize the reds and the ambers to reform.
We recognize the complexities and the fact that things are
changing, day by day. It is not, for example, as simple as considering whether
to engage with any one organization. Some of the larger organizations have
linked corporate social responsibility units and linked foundations which may
be supporting pro-nutrition activities that in themselves are positive for
nutrition. And yet, their core business practices encompass products and/or
practices that continue to damage nutrition—at a much larger scale. There is
also the distinct possibility that ignoring the “major bad” to focus
on the “minor good” lets the companies off the hook, and even
disincentivizes reform of their harmful core business practices. This suggests
we need to go beyond judging the merits of any one project or any one type of
engagement, to also look at the bigger picture of what the company is doing.
A traffic light system also aligns with the reality that nothing is static. The situation is dynamic; companies are changing. The question for wider discussion becomes one of how to judge whether and when a company’s net impacts are sufficiently “pro-nutrition” to become eligible for potential collaboration. This again will require a discussion of metrics, thresholds, and red lines. These are issues and challenges that should not be over-simplified, fudged, or hidden—especially at this time. Many in the nutrition community are gearing up for a major nutrition summit, linked to the Tokyo 2020 Olympics, in which pledges and commitments will be made to address malnutrition in all its forms. The arena for nutrition action now—compared to the last Nutrition for Growth event in 2013—is a lot wider and there are many more (actual and potential) actors. Principles and practical guidance are needed more than ever. On this basis, we want to start a new kind of conversation and would welcome views.
Obesity is increasing in most countries, in both urban and rural settings, across socio-economic levels, among children and adults. Consequences include a heightened risk of noncommunicable diseases, including type 2 diabetes, hypertension, dyslipidemia, and various cancers. This alarming global trend coincides with limited and patchy progress in driving down rates of undernutrition, as shown by the Joint Child Malnutrition Estimates, 2019, from UNICEF, WHO, and the World Bank Group.
The concept of a “double burden of malnutrition” — first posited in 1992 at the first International Conference on Nutrition — relates to the co-existence of undernutrition and overweight/obesity. Initially, the reference was to national burdens, before it became clear that the dual burden also existed within communities, households, and even within individuals (who may be overweight following growth stunting in childhood). As we learn more about the etiology and epidemiology of the double burden, we come to realize these are not separate conditions. They overlap and interact in space and time, and they have shared drivers that derive from dysfunctional agri-food and health systems, and the environments within which they operate. Accordingly, it is more appropriate to frame the problem as “malnutrition in all its forms.” Among others, the Global Nutrition Report championed this focus while the 2019 Lancet Commission on the Global Syndemic of Obesity, Undernutrition, and Climate Change recognized these interactions and the urgency of transformational change, discussed in this recent A4NH blog post.
In recent years, IFPRI and several major programs it leads — Transform Nutrition, POSHAN, and A4NH — have assembled a rich body of work on the drivers of relative success in reducing undernutrition in different countries. The “Stories of Change” initiative included in-depth case studies from Senegal, Ethiopia, Zambia, India, Bangladesh, and Nepal, with more in the pipeline from Rwanda, Tanzania, Vietnam, Ghana, Nigeria, Burkina Faso, and several Indian states. These case studies used mixed methods to investigate drivers of change, and to glean the perceptions of key actors, from community to national levels. The emerging stories were fed back to participants in national consultations (to be critiqued, endorsed, and sharpened) before the studies were finalized and ultimately published in different forms (journal articles, briefs, audio-visuals, etc.).
Four years later, considering the framing of “malnutrition in all its forms,” we recognize a need to balance this work with a new focus on how countries are addressing the challenge of overweight and obesity. Here, there is much less of a history to mine for data, evidence, experiences, and stories. This is why A4NH’s Flagship research Program SPEAR is now embarking on a new wave of case studies, called “Stories of Challenge,” to investigate how political commitment and policy traction are being generated in real time to deal with overweight and obesity. Four case studies will be developed by teams including local researchers in South Africa, Ghana, Vietnam, and Indonesia, with a mini-case study on Brighton, UK. These will be linked with other work, including a qualitative evidence synthesis of drivers of obesogenic behaviors, a review of approaches adopted to set priorities for nutrition, and a narrative synthesis of integrated approaches to promoting nutrition and physical activity.
Like its predecessor, “Stories of Challenge” will seek to foster learning across contexts – in this case, lessons on how individuals and organizations are striving to turn obesogenic into enabling environments, how they pre-empt or tackle obstacles, and how they are seizing opportunities to support a new raft of nutrition-relevant actions. More than ever, we need to understand how different actors, including the public and private sectors, civil society, academia, and the public at large, can come together to forge alliances — built on evidence, experience, trust and transparency — to drive and sustain change.
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