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Inflamed — a review (…and a question)

Every now and again a book stops you in your tracks.  

Inflamed: Deep Medicine and the Anatomy of Injustice by Rupa Marya and Raj Patel is one such book.

Inflamed brilliantly links globalization with biology — and everything in between — highlighting the dynamic links between inflamed bodies, inflamed societies and an inflamed planet. Step by step, going back into deep history, the authors plot the causal origins of disease and ill-health “in the multifunctional spaces around and beyond the individual body – in histories, ecologies, narratives and dynamics of power.”

Inflammation is a process, triggered by the damage or threat of damage to cells, that mobilises resources to heal injured tissue. In a balanced system, once the damage has been repaired, inflammation subsides.  But if the damage returns, over and over again, the inflammatory response goes into overdrive and starts to create harm. The ultimate source of damage is not the pathogen that infects you – the true source can only be found in deeper and wider systems and processes that render an individual more likely to be exposed (to the pathogen) and, if exposed, more likely to fall sick or die as a result. Structural racism, violence, economic deprivation, pollution, contaminated water and poor diet all combine to generate chronic inflammation.

The authors remind us that ‘diagnosis’ comes from ‘dia’ (apart) and ‘gnosis’ (to know). A diagnosis is a story pulled apart.  Conventional diagnostic narratives are out of joint because the story begins in the middle with a symptom. Doctors then go back in time to try and uncover the immediate causes, before going forwards from the symptom to prescribe a treatment. But often this doesn’t work because the story doesn’t go far back enough in time, isn’t deep enough.

The colonial worldview – on which modern medicine is based – is ahistorical, emphasizing individual health and disconnecting illness from its social and historical contexts. Modern medicine patches up bodies broken by the same system that produces the medicine.  A similar thing could be said of the global food system, which we’ll come to….

As well as being comprehensively researched and written in a style that pulls you in for hours, Inflamed is an impassioned call for justice for people who have been, and continue to be, exploited, oppressed and marginalized.

The COVID pandemic has thrown intergenerational and colonial injustice into sharp relief. In May 2020, in the UK, nearly all of the medical staff who had died of COVID-19 were from black, Asian and minority ethnic communities. Throughout the pandemic, individuals from these communities were at greatest risk.  

Individuals who were hospitalized or died of COVID-19 were a) more likely to be more infected with SARS-COV-2 in the first place (being dependent on livelihoods that put their bodies at risk of exposure, without any safety nets), and b) more likely to fall sick, become hospitalized and die (because their bodies had suffered chronic inflammation due to poor living conditions, poor healthcare, unhealthy diets, chronic stress etc).

Marya and Patel use the concept of an ‘exposome’ – the sum of a lifetime’s exposure to non-genetic drivers of ill-health – to show how such individuals are far more prone to chronic inflammation and illness than others.

Colonialism isn’t a thing of the past – it’s happening today and threatening the lives of the 370 million Indigenous people living in over seventy countries, while many states continue with their ‘policy of amnesia’.  You may not be one of them, the authors argue, but you’re affected by them — their ideologies are alive and well…and they’re making you sick. Non-communicable diseases (NCDs) like heart disease, lung disease, obesity, depression, diabetes, Alzheimer’s, auto-immune diseases — are all diseases of colonization – they didn’t exist before.

“Le microbe n’est rien, le terrain est tout”

Eleven years ago, the philosopher, David Abram wrote “the body is itself a kind of place…a terrain through which things pass, and in which they sometimes settle and sediment”

One hundred and sixty years ago, Louis Pasteur wrote “the microbe is nothing, the terrain is everything”

I first came across this amazing quote, in 2000 when researching HIV, food and nutrition security.  Later, we brought the concept of enabling (or disabling) environments into the fourth paper of the Lancet Nutrition Series (2013) and subsequent papers and blogs – showing how these environments operate at all levels from the ‘milieu interieur’ of the human body to food and health environments to social, political, economic systems. I remember the analogy of an onion with its many layers from another ground-breaking book ‘Rakku’s Story’ that I read nearly forty years ago while working in a village in southern India. Like Marya and Patel – Sheila Zurbrigg locates the causes of the death of a child (Rakku) in multidimensional spaces and colonial histories.

Each chapter of Inflamed describes a system (circulatory, respiratory, immune, reproductive, digestive, nervous, endocrine), as Marya and Patel brilliantly highlight the way they generate inflammation, how they’re linked to themselves and ultimately to human health.

This book was written by a physician and a political economist.  Its focus is on health but it is wide-ranging analyses are directly relevant to all of us who work in the food system. The chapter on the digestive system highlights the importance and links between diversity of the gut microbiome and soil biodiversity – two enabling (or disabling) environments. Mediating both are food systems.

Which brings me to the question…

The global health ‘community’ seem to be way ahead of the food and nutrition ‘community’ when it comes to digging deeper to locate the drivers of ill-health and malnutrition that originate in wider structures, systems and colonial histories.

Decolonisation and the commercial and political determinants of ill-health are being discussed, researched and, in many cases, acted upon. And yet, the nutrition and food ‘community’ remains relatively silent on these issues. Some nutrition researchers and activists work on commerciogenic causes of malnutrition, but relatively few.  Issues of power and equity are similarly neglected.  And hardly anyone is working on historical perspectives, including the influence of structural racism and colonial legacies.

In a few weeks, there’s a major United Nations Food Systems Summit (UNFSS) in which the multinational food industry is actively involved — around the ‘table’ where ‘game changing solutions’ are being discussed and decided. It does not seem to matter that many of their core businesses are major drivers of malnutrition. These new colonials are happily engaged in shaping the future in ways which are more amenable to their interests and objectives. They will continue to ‘talk the talk’ about healthy diets, as evidence mounts about their failure to act. The fox is ensconced in the chicken coop and no-one in the UNFSS inner circle seems to think this is a problem (when was the last time the tobacco industry showed up at a World Health Assembly?)

UNFSS principles of engagement are cursorily listed but are weak and do not include the crucial ‘do no harm’ principle. Big multinationals just hide behind business associations (like WBCSD) who provide cover. Yes, protests have been aired, open letters signed and many have boycotted the summit altogether. And yet, summit leaders just carry on, sounding out their mantra that this is a “people’s summit”. Silence is the main response to criticism – as if there’s ‘nothing to see here’ and that somehow our normal expectation of critical engagement and debate among peers is to be suspended this time.

Why is this?

But the bigger question is — why aren’t we, in the food and nutrition policy community, more actively engaged in the decolonisation debate, and in research and action/activism around the commercial and power-related drivers of the problem we’re (supposed to be) focused on?

Echoing Marya and Patel’s call for a ‘deep medicine’ approach, isn’t it about time we engaged in some ‘deep nutrition’?

Stuart Gillespie, 26 August 2021

[‘Inflamed’ is published by Allen Lane and available at all good non-amazonian bookshops]

Beware the nutri-washers

The United Nations Food Systems Summit (UNFSS) has just wrapped up a three-day pre-summit – a hybrid conference involving participants in Rome and thousands more online.

The goal of the summit is to transform the global food system.

The UNFSS has been heavily criticized for months and many movements, organizations and individuals have boycotted it. A counter mobilization of hundreds of grassroots organizations has emerged. Several multi-signatory open letters and statements have elaborated on its shortcomings – including opaque governance, weak or absent principles of engagement with the private sector, an inability to address (or even acknowledge) conflicts of interest, the sidelining of existing UN institutions, the marginalisation of human rights (this is a United Nations conference remember!) and the silence of UNFSS leaders in the face of this criticism.

In this blog, I focus on one core concern – the Summit’s approach to engaging with multinationals whose products and practices have been shown to drive malnutrition (e.g. Nestle, PepsiCo, Coca Cola).

A few days ago, Carlos Monteiro and colleagues published A Call to the UN Food Systems Summit to reshape global food processing. Carlos is a legend in nutrition, with whom I was lucky to work thirty years ago when he contributed a case study on child stunting in Brazil to a UN Standing Committee on Nutrition initiative: How Nutrition Improves. As the Brazilian malnutrition challenge shifted from under to over, Carlos switched gears. He has since pioneered the NOVA classification and contributed to many studies that have shown how ultra-processed foods (UPFs) generate malnutrition, various non-communicable diseases and premature mortality. Scarcely a week goes by now without more studies emerging highlighting the damage UPFs cause. It’s not only papers — Dr Chris van Tulleken followed his groundbreaking BBC documentary with this podcast on UPFs.

Many of us hoped that the Summit would take the challenge of ultra-processed foods head-on — if not now, then when?

So, what’s happening?

Well, not much. It’s not as if the glass is half-full, or half-empty – the problem is the glass is cracked and the water’s leaking out. We really need a new glass.

Jeff Sachs made this point in this barnstorming speech the other day — “we have a system but we need a different system” – reminding us that we turned food systems over to the private sector a hundred years ago.

Private sector involvement in the Summit is managed by the Private Sector Guiding Group (PSGG) run by World Business Council for Sustainable Development.  The WBCSD is an association that prides itself on its open membership – a group that includes tobacco giant Philip Morris among its members. It invited two of these companies – Nestle and PepsiCo to speak the other day in a 50-minute session on “private sector priorities for the UNFSS”. I naively tuned in thinking there would be a discussion of private sector priorities for the UNFSS.  There wasn’t. Instead there were 10 presentations by individual companies and organizations on their own priorities.  Better to email promotional flyers next time.

Yesterday, WBCSD ran another session in which a speaker from EUFIC suggested that ultra-processing of food was an ambiguous and hotly debated notion. EUFIC count Coca Cola, Cargill and Bunge among their Board members.

Way back in the mists of time, I raised a question in a UNFSS pre-consultation about the involvement of malnutrition-causing behemoths in a global conference aimed at reducing malnutrition. I’ve worked on principles of engagement while at IFPRI (including IFPRI’s own), and I wanted to hear about the Summit’s principles of engagement. I was told that no single company is in a position of influence in steering the UNFSS process and outcomes. On asking why PepsiCo was invited to speak at these consultations, I was blocked on twitter by a UNFSS leader who then accused me of spreading malicious lies (not sure how a question can be a lie, but anyway…). Many other commentators with similar questions have had similar responses.

The fact is that the Summit principles remain as they were at the start. There is no “do no harm” principle.  Instead we get vague exhortations to “recognize complexity” and — irony of ironies — to “build trust”.

Looking back, a day after the pre-summit, and two months before the main Summit, the only reasonable conclusion is that the UNFSS is operating under a similar set of engagement principles as the organization who runs its Private Sector Guiding Group (PSGG) – WBCSD — and therefore anyone can join up.

This dovetails with the inclusion rhetoric – that this is a “people’s summit” open to all.  Power asymmetries don’t exist in this world — all voices are equal, everyone’s welcome to the party….all we need to do is keep talking to each other.

Over two years ago, Nick Nisbett and I wrote about principles of engagement and the need for clarity on red lines.  We were concerned about companies doing “minor goods” with their left hand, while continuing to do “major bads” with their right hand.  Minor goods include small-scale boutique corporate social responsibility initiatives and projects.  Major bads are the core business practices that generate huge profits from selling junk food and drinks.

Anand Giridharadas wrote about this too here cautioning us to be wary of side salads!

José Graziano da Silva – former FAO Director General and architect of Fome Zero, launched 20 years ago — tweeted his concern yesterday about sugary drinks companies being part of Zero Hunger, Nourish the Future Pledge.  

In this session, I asked whether there was a “do no harm” principle for the Pledge. The response (min 33.50) was “yes, there will be”. I guess this means that PepsiCo are not perceived as being harmful to nutrition, or they will be relegated once the principle shows up.

This is not trivial. It opens up a whole new can of worms that could be described as ‘nutri-washing’ – when companies play off one form of malnutrition for another. 

Companies whose ultra-processed foods, drinks and marketing practices generate obesogenic environments now have a new ‘get out of jail’ card to play. 

They can now gain kudos, profile and acceptability by pledging to fight hunger and undernutrition while continuing to drive overweight and obesity.

Big step backwards.

Of course, there’s a different way. Why not employ clear principles, including “do no harm”, from the start? Why not determine eligibility to pledge by using independent benchmarking and monitoring tools — such as the new FACT transparency index developed by Feed the Truth?

Meanwhile, in all this corporate carousing, the most successful public-private partnership of all time – taxation — has been relatively sidelined. Jeff Sachs again: “To private sector leaders — behave, pay your taxes, follow the rules — that’s what you should do”.

The UNFSS may, or may not, take on board some of these concerns proactively and transparently – there’s still time.  But whatever happens the level and type of discourse has changed this year.

In the midst of a pandemic that has highlighted the imperative for transparency, leadership and trust – big issues affecting people and planet, hitherto shrouded or back-burnered, have been surfaced and debated.

That has to be a step forward.

Rebuilding trust in food systems and nutrition (part 2)

At the turn of the year the UN Food Systems Summit leadership had been talking a lot about the need for trust to make progress on food systems. I agreed, and wrote this blog: rebuilding trust in nutrition.

Six months later, in the UNFSS Science Days session today the issue of trust came up again in questions to the panel.

The panel responded as if the issue was a mistrust of science.

I’m not sure why this was side-stepped, but the big issue – and the focus of the questions – related to the science-policy interface. More broadly, it relates to the issue of governance of food systems – present and future – and more immediately, governance of the UNFSS process itself.

IPES-Food recently brought out this briefing note and this podcast was released today. The brief questions the Scientific Group of the UN Food Systems Summit, suggesting it “falls short in several respects: it is nontransparent; is imbalanced in its composition and biased in its perspectives and sources of knowledge; is unreflexive about the relationships between food systems and society; and is pursuing a business-oriented ‘technology and innovation’ agenda.” This led to an open letter “no new science-policy interface for food systems” with multiple signatories.

Then there’s the open letter from the Ad-Hoc Committee on UN Food System Summit (UNFSS) Governance to the UN Secretary General and UNFSS leaders. This letter was written following several meetings, a review of publicly available UNFSS documents, expert input, a crowdsourcing survey and an Independent Dialogue in mid-June.

The conclusion? Though this is a UN summit, the UNFSS decision-making process has yet to implement adequate transparency and accountability principles in line with best practice followed in other UN processes. The crowdsourcing exercise raised issues around conflict of interest, weak principles of engagement and the widespread perception of a lack of trust. Again, multiple signatories.

Many of us who seek to amplify these concerns on social media are either met with silence or we are blocked by UNFSS leadership — as has happened to me twice now.

The UNFSS for months has positioned itself as a ‘people’s summit’. It has prided itself on gazillions of hours of consultation time – and yet so much decision-making remains unexplained and opaque. We don’t know how the hundreds of ‘game-changing solutions’ were whittled down to 50 odd solution clusters, and we don’t know how these clusters map conceptually and operationally to the bigger picture in terms of the summit’s vision and goals. Many have asked to see details of the decisionmaking and selection process and criteria made available online.

Trust is downstream from transparency. To earn it, any public process would need to broadly adhere to the seven (Nolan) principles of selflessness, integrity, objectivity, accountability, openness, honesty and leadership.

Earlier this week, Duncan Green published this excellent blog on building and maintaining trust at the interface of policy and research, with this useful chart of 14 trust-building strategies, along with a stepwise process for repairing damaged trust.

Chart, radar chart Description automatically generated

Fourteen strategies identified through a case study of ICES for building trust at the interface of environmental science and policy, as published in Cvitanovic et al (2021).

Trust is researchable, and much work has been done on trust theory and its various applications e.g. in natural resource management.

If a lack of trust is seen as such a big challenge, why doesn’t the UNFSS systematically investigate what is needed to build trust and maintain it? Why not commission an independent social network analysis of actors, processes and outcomes?

Why continue to decry the lack of trust – or any major obstacle or constraint – while doing so little to address it?

Digging deeper

Over the last year, the resurgence of the Black Lives Matter movement has been paralleled by an accelerating movement to decolonise development. Among the many papers and blogs, this Lancet Perspectives article is one of the best. Seye Abimbola and Madhu Pai not only highlight the colonialist roots of global health, they go on to envision a decolonised future where equity, justice, humility and respect replace supremacy.

Supremacy goes well beyond ‘pale, male and stale’.  It manifests in what does (or does not) happen between countries, and groups and individuals within those countries.

In research, it governs who sets the research question, who pays for the work, who decides on methods, who does the work, whose names are on the paper, who publishes it, who reads it and who decides on the next study to be done – or the next research program to be set up and funded.  In a word, everything.

Much of the impetus on decolonisation in recent years has come from global health thinkers and doers like Abimbola and Pai, as the reading list below shows. But of course it transcends any one discipline. Last week, Arvind Subramanian and Devesh Kapur wrote about absent voices in development economics. They cited Kazuo Ishiguro’s 2017 Nobel
lecture
in which he urged the broadening of “our common literary world  to include many more voices from beyond our comfort zones of the elite first-world cultures.”

Malaria Commission of the League of Nations, Geneva. Photograph by Poesch photographic agency, 1928. Credit: Wellcome CollectionAttribution 4.0 International (CC BY 4.0)

The decolonisation movement has shone a light on questions of agency, power, human rights, equity and justice in the midst of a pandemic which has also brought these issues to the fore. Not only has COVID-19 exposed different forms of inequity, it has amplified them. People who are poor, marginalized and exploited are more likely to be dependent on fragile livelihoods that cannot be outsourced to Zoom meetings. It has led to the loss of livelihoods and lives.

The word ‘crisis’ comes from the Greek noun ‘krisis’ which means ‘to separate, decide….a
turning point’

A year ago, Erica Nelson, Nick Nisbett and I decided to look into this potential ‘turning point’ in the light of past histories of global nutrition. Like global health, global nutrition has roots in colonialism and supremacy. We like to repeat the mantra that nutrition is both a marker (of deprivation) and a maker (of development) but we are far less likely to hark back to a history when nutrition was a discipline that propped up colonialismracism, inequality and injustice.

Nutrition has always operated at the interface of health and food systems which have deep roots in colonialism. For global nutrition to move forward, it needs to confront its shady past – the overt and disguised racism, the systems of food apartheid and the massive power imbalances within health and food systems. Vaccine nationalism, global food trade terms are just two examples — there are many more.

Credit: Martin Karumwa

Twenty years ago, just after I joined IFPRI, I worked on ‘strengthening capacity for nutrition’. At that time the finger of blame for the failure of large-scale nutrition programs often pointed to insufficient/unsustainable capacities within communities and organizations responsible for implementing them.

But many of us then failed to take the next step. Inadequate capacity is not just the cause of failure, it’s the symptom of a larger failure that has its roots in colonisation and intergenerational injustice. The proper response to capacity gaps or weaknesses is not simply to initiate a capacity development program – it is to dig deeper, to respect, protect and fulfil the human right to food and health, and to work towards intergenerational equity and justice.

A recent article in the New Humanitarian shows how much work remains to be done. The EU’s commissioner for crisis management recently stated: “What is actually the biggest barrier to localisation is the capacity of local actors. Most often, the local organisations lack the capacity to fulfill all the criteria with regard to accountability, transparency, sound financial management…”

Just as ‘community-based’ does not equate with ‘community-driven’, localisation — defined and driven by global northern organisations — is far from decolonisation.

For those of us in the global north, decolonisation requires us to get out of the way – or ‘lean out’. It requires us to become better allies and enablers, not leaders.

Coming back to the notion of a turning point, 2021 has been declared a Year
of Action for Nutrition
— a year when there is not one but two major summits – the UN Food Systems Summit and the Nutrition for Growth summit.

The UNFSS promotes itself as a ‘people’s summit’ where everyone is welcome at the table. Current past UN human rights commissioners have written: “Coming to the table to discuss ‘solutions’ is not as simple as it sounds. What if the table is already set, the seating plan non-negotiable, the menu highly limited?” In their Lancet article, Abimbola and Pai also remind us, in a broader context, that “what is on the table is as important as who is
around the table.” 

In a seminar last week, the UN Secretary General’s Special Envoy, Agnes Kalibata provided assurances that human rights will be foundational to UNFSS processes, and that corporate capture is not an issue.

The big question remains – how will such an open-door policy address the huge power asymmetries between actors that underpin and enable dysfunctional food systems? If human rights are foundational to the Summit process and deliberations, then issues of power, agency and justice must be ‘on the table’ too. As far as I can see, there has been little open public discussion of these issues. Without this, the notion of transformation based on ‘game changers’ is meaningless.

In our brief review of global nutrition histories, we concluded that it is not enough to listen to different perspectives, we have to learn from them, and act differently as a result. To dig deeper, well below the surface to better understand the ‘causes of the causes’ so we’re better able to address them.  

And for this to happen, we need humility (not hubris), we need creativity and honesty and — if we are to work together– we need trust.

Here are a few other key readings on decolonisation:

The foreign gaze: authorship in academic global health

The problem of ‘trickle-down science’ from the Global North to the Global South

Foreign Aid Is Having a Reckoning, New York Times, 13 February 2021

Dreams Of A Beloved Public Health: Confronting White Supremacy In Our Field

Governance in Conflict Network: (Silent) Voices blog

Parasitic and parachute research in global health

Closing the door on parachutes and parasites

Global health: who tells the story?

Global health needs to be global and diverse

Decolonising Global (Public) Health: from Western universalism to Global pluriversalities

Is global health neo-colonialist?

Does global health still have a colonial mindset?

Decolonizing global health: if not now, when?

*

Rebuilding trust in nutrition (part 1)

For some reason – unlike our health counterparts — nutrition professionals tend to shy away from research and action on the commercial determinants of (mal)nutrition.  They don’t want to be involved in polarizing discussions on the role of the private sector in nutrition.

A big part of the problem is the way the narrative is shaped.  We constantly hear clichés like “the private sector should be part of the solution”, or simplistic questions like “how do we work with the private sector?”.  A good start is probably to ban the phrase “private sector”. It’s just not helpful. There are many forms of private business, including many small companies who are trying to improve access and affordability to healthy diets. We need to do better in differentiating those whose products and practices harm nutrition from those who (actually or potentially) support good nutrition.  The former include the ultra-processed food and beverage industry which controls much of the global food system. They want to be loved by the nutrition community, so they target influential individuals, organizations and conferences and woo them in various ways. Adapted from Big Tobacco, this corporate playbook has been described and used many times. Being seen to be part of the nutrition community is huge as it confers tacit approval of actions – a soft-power ‘get out of jail card’ that reduces the pressure to change damaging products and practices.  And these tactics clearly work.

The nutrition community has made progress in differentiating good and bad corporate behaviors and even ranking them.  Much of this however draws on statements of intent, rather than action on the ground.  There are different sets of principles that define good (pro-nutrition) behaviour. But what’s missing is clarity and consensus on what this looks like in practice, where the red lines are, and the implications of crossing them.

This is not trivial.  We currently have a divide between some who believe that it’s perfectly fine to ‘talk to anyone’ and others (myself included) who believe that actions need to precede words. The ‘talk-first’ group think they can persuade malnourishing companies to change their ways – as if they were somehow still not clear on what to do.  The ‘walk-first’ group believe it’s perfectly clear to everyone what’s needed, it just needs to be done – or at least, there needs to be clear, tangible, independently verifiable progress first. This needs to be large-scale – it’s just not good enough to have a few showy small-scale CSR projects dotted around, here and there.  Boutique projects and the media froth they generate are distractions at best. At worst, they’re dangerous side salads that confer legitimacy on core business practices that may run in a very different direction.

Malnutrition is a large-scale problem, it needs large companies to act at large-scale, in the long term, to be seen to be serious.

This year we have not one but two big talking events – the UN Food Systems Summit (UNFSS) and the Nutrition for Growth Summit. The rules for engagement in these summits are not entirely clear. I have been told there are guidelines but they’re not visible on the web. There is a Private Sector Guiding Group for the UNFSS but again – it’s not clear who is in this group, or whether it’s open to anyone.

In the various consultations in different Action Tracks for the Summit there has been a lot of discussion about the importance of enabling environments, trust and responsibility. On 23 November, the UN Special Envoy, Agnes Kalibata stated: “One of the most broken pieces of our food system is our trust in each other. There isn`t a high level of trust in the system right now, and that is preventing us moving forward.”

She’s right — it’s crystal clear that many stakeholders see trust as a big issue.

The UNFSS has put out a call for game-changing solutions. One that would go a long way to rebuild trust would be an unequivocal position on the part of the UNFSS regarding the role of the ultra-processed food industry in the challenge of addressing malnutrition. In general terms, and specifically with regard to the Summit process.

If not now, then when?

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.