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It’s About Time: Intergenerational Equity and Nutrition

In his 2019 book “Upheaval: How Nations Cope with Crises and Change”, Jared Diamond starts by interrogating the word ‘crisis’.  Coming from the Greek noun ‘krisis’ and the verb ‘krino’ there are several meanings — to separate, decide, a turning point. Crises differ in terms of the way they emerge, their scale, duration, and impact. Some come as a shock, some are slow-burn — though in reality this distinction may be blurred once we look below the surface.

The COVID-19 pandemic is a sudden-onset crisis, while climate change is slow-burn (albeit linked to increasing shocks like floods and droughts). The biggest cause of global ill-health and premature mortality – malnutrition — is also slow-burn.  All three crises are massive in scale, they overlap and interact, and they share many drivers. In 2019, a Lancet Commission delivered an incisive analysis of the global syndemic of obesity, undernutrition, and climate change. This was a year before the pandemic. COVID-19 has since added another crisis into this toxic mix.

Crises heighten our awareness of time, and they generate new understandings or worldviews, often elevating neglected issues to centre-stage.

Equity is one such issue.

The COVID-19 pandemic not only exposes inequities of different forms, it amplifies them. We have seen this clearly in the experience of Black, Asian and Minority Ethnic (BAME) communities in the UK and elsewhere, who are disproportionately exposed to the virus, and more likely to become seriously ill or die. A similar situation plays out with regard to climate and malnutrition crises. Syndemics are fuelled by inequity.

Equity was the central theme of the 2020 Global Nutrition Report. The introductory chapter succinctly unpacked the concepts of inequity and inequality, highlighting the core ingredients of unfairness, injustice and social and political exclusion.

But we also need to take account of another dimension – time.  What we do (or don’t do) now — as individuals, organizations and governments – has immense implications for future generations.

This is the subject of a powerful new book by Roman Krznaric “The Good Ancestor: How to Think Long-term in a Short-term World”. While many activists are driving a decolonization agenda in global health, Krznaric argues that we have also colonized the future. Starting in the 18th century, Britain colonized Australia, considering it to be ‘terra nullius’ (‘nobody’s land) ignoring indigenous peoples’ claims.  We are now behaving in a similar way with time. Political and economic systems consider the future to be tempus nullius (‘nobody’s time’). Our time horizons have collapsed inwards, driven by short-term dopamine-triggered feedback loops.

Krznaric distinguishes between the marshmallow brain — routinely hijacked by the digital distraction industry that has weaponized smartphones and social media platforms to steal time – and the acorn brain, that thinks long-term, considering the intergenerational consequences of actions taken today.

His analysis of intergenerational injustice and the ‘dark art of discounting’ is compelling. As a method for weighing up the costs and benefits of investment decisions over different time spans, discounting has spread from finance into many spheres of development, including public health and climate-related policymaking.

Why, Krznaric asks, are the lives and well-being of future generations considered to be of ever-declining value?  Using a ‘progressive’ 1.4% discount rate, adults alive two generations from now would be assigned the value of half a human today – an ‘iconic expression of the colonization of the future’.  Why isn’t the welfare of a child born 100 years from now treated as equal to the welfare of a child born today?  Are we to accept that future generations will continue to be disenfranchised, like slaves and women in the past?  

Intergenerational inequity plays out in different ways.  Politically, it came to the fore, for example, in the 2016 Brexit referendum, when young people (overwhelmingly pro-Remain) accused the older generation (overwhelmingly pro-Leave) of stealing their futures.

So, what does this have to do with nutrition?

A lot. 

A growing body of research in the last few decades has shone a light on the way in which malnutrition persists through the life cycle – and even across generations.  Epigenetics is showing that what we do now has major implications for the health of future generations. A recent review states:

“Early insults during critical periods of brain development, both pre- and postnatal, can result in epigenetic changes that may impact health and behavioral outcomes over the lifespan and into future generations. There is ample evidence that these early stages of brain development are sensitive to various environmental insults, including malnutrition, childhood trauma and drug exposures. The notion that such changes, both physiological and behavioral, can also carry over into subsequent generations has long been recognized, especially in the context of experimental studies. However, epigenetic mechanisms capable of explaining such phenomena were not available until relatively recently.”

Nutritional disadvantage, driven by inequitable factors and processes, can last for many decades. 

Meanwhile, as we continue to learn more about long-term consequences, the ultra-processed food industry continues to exploit the short-term, addictive and impulsive traits of our marshmallow brains — one of the main reasons why obesity has rocketed in the last two decades. In evolutionary terms, we’re still very close to hunter-gatherers who were adapted to consuming food whenever and wherever they could.  What used to be a survival mechanism to bridge over times of scarcity, however, has become a maladaptation to the obesogenic environments we now live in.

What to do?

Following the Global Nutrition Report’s call, we need to develop and invigorate a pro-equity nutrition agenda that includes intergenerational justice. 

Security is a start point. How can anyone ‘think long’ or plan for the future if they cannot even nourish their families today? Food, health and nutrition security are foundational pillars for building a future – at all levels.

Second, nutrition researchers and activists need to become politically adept in analysing and challenging political and governance systems that colonise the future. For too long, the nutrition community considered politics and political economy as beyond their remit. We have a special challenge given that the full benefits of addressing malnutrition will take many more years than a politician’s term in office.

Third, institutional mechanisms that ‘look long’ and consider interests of future generations need cultivating – especially youth movements, such as the Scaling Up Nutrition (SUN) Youth Leaders for Nutrition. A Lancet Planetary Health commentary, released alongside International Youth Day last week, argues: ‘It is time to democratise [planetary health], balance the asymmetrical power structures, and leverage fearless voices challenging the status quo’. The authors outline a pragmatic roadmap based on three pillars: governance structures enabling young people’s participation, funding that supports inclusion and compensation of young people from all backgrounds, and capacity building for young people. 

Another example of long-termism, as highlighted in the Lancet syndemic commission report, is the Iroquois concept of ‘seven generation stewardship’. This urges the current generation to live and work for the benefit of the seventh generation into the future. To this end, the Commission proposed the establishment of a ‘Seven Generations Fund for Traditional Peoples’ Science’. 

Nutrition advocacy that emphasizes the foundational aspects of nutrition, and its central role within holistic strategies for achieving the Sustainable Development Goals will be more important than ever. In this context, #BuildBackBetter has become a bit of a cliché in 2020. Many also question use of the word ‘back’.  Why go back to economic systems that target short-term gains, and profit over people? Why not go forward? 

The SDGs rightly focus on sustainability and on equity – leaving no-one behind. In this context, the title of the postponed ‘Nutrition for Growth’ summit is looking ever more dated. Yes, we know that $1 invested in nutrition generates $16 in returns. The economic investment case needed to be made a decade ago, and it’s been made. Now we need to make the case in terms of nutrition’s pivotal role as a driver of sustainable and equitable development. ‘For Growth’ is just not a compelling rationale any more. The world has changed.

Finally, we face a challenge of public perception that can perhaps be best illustrated by a mythical fable about frogs and hot water (don’t try this at home!). If you drop a frog into boiling water it hops straight out. If you drop a frog into tepid water and heat it to boiling, it will not react until it’s too late. The COVID-19 pandemic is a rapid-onset global emergency that has generated an unprecedented sense of crisis and a large-scale response. The climate and nutrition crises, on the other hand, are slow-burn crises that proceed incrementally, month by month.  They kill many more people than COVID-19 but they do not generate a sense of crisis that leads to action on the scale and intensity required. It’s reflected also in the terminology – the notion of climate ‘change’ is a little like referring to an earthquake as a ‘land movement’!

So, the overarching challenge is to generate a sense of urgency that leads to concerted large-scale action. One opportunity lies in showing the connections (through data and research) within the syndemic. During the southern African HIV epidemic in the 2000s, a similar approach was taken with nutrition, following research that showing that antiretroviral therapy did not work well unless people were adequately nourished. A recent example comes from the UK where evidence of the higher risks of COVID-related hospitalization and death of people who were obese led quickly to a strategy (flawed, but a start) to address obesity.

At long last, equity – including transgenerational justice – is central to the nutrition agenda.

There’s much work to be done.

It’s about time.

COVID-19: Resilience or Transformation?

COVID-19: Resilience or Transformation?

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 align.

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 economic impacts.

Alongside the 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.

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Source: Loevinsohn and Gillespie (2003)

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):

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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”.

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Beyond the 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.

Societies and 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).

How will COVID-19 affect food and nutrition security in the global south?

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 income countries.

Who 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.

We 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 treatment protocols.

Where do they live?

COVID-19 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.

Urban 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 non-communicable diseases.

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.

Expected impacts

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.

Most 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 common 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 malnourished.

How to respond?

UNAIDS have just released a new publication, Rights in the Time of COVID-19: Lessons from HIV for an effective, community-led response. It has seven key takeaways: 1) engage communities, 2) combat stigma, 3) test, test, test, 4) help people protect themselves, 5) clarify evidence-based restrictions, 6) country cooperation, and 7) the crucial need to support and protect health workers. 

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 Economist editorial 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 overwhelmed.

Beyond 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).

First published by IFPRI

Focus on political and commercial drivers

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 four papers in the series—on dynamics, etiological pathways and consequences, double-duty actions and economic effects of the double burden—are all excellent.

But there’s something missing.

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.

Over six years ago, the Lancet Maternal and Child Nutrition 2013 series included a paper on the politics of reducing malnutrition. While we focused more on undernutrition in this paper, the questions raised are relevant to the double burden:

“… 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.

Previously published on ifpri





Principles, practice, and the private sector’s role in malnutrition: Time to review red lines?

Principles, practice, and the private sector’s role in malnutrition: Time to review red lines?

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 how.

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 non-engagement.

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.

Stuart Gillespie and Nicholas Nisbett