Institute Notes: A Dialogue on Overcoming Hunger and Poverty

Obama's Initiatives on Hunger and Health: The Case for an Integrated Approach

The president is hip-deep in the process of reforming U.S. foreign aid, with multiple initiatives, ongoing studies, and congressional scrutiny. If Secretary Clinton’s speech at the Center for Global Development is any indication, the role of U.S. development assistance will be significantly elevated over the coming months and years.

Guiding principles abound for what reform should look like. One clear need is better coordination within aid programs and across development and diplomacy efforts. The State Department is tackling the question of how to coordinate development and diplomacy agendas, which will likely receive considerable attention in the upcoming Quadrennial Diplomacy and Development Review (QDDR). Unfortunately, a year into the new administration, the QDDR is still at least a month away.

In the meantime, the administration has launched two large initiatives that will create a blueprint for how aid efforts will work together internally. First, the Global Hunger and Food Security Initiative (GHFSI) is an outgrowth of the announcement made at last year’s G8 meeting to increase assistance for agriculture; the U.S. has committed $3 billion over the next three years. Since the announcement, an task force comprised of the National Security Council, State Department, USAID, the Department of Agriculture, the Treasury Department, and the Millennium Challenge Corporation have been working to clarify what a “whole-of-government” approach to development (and food security, in this instance) looks like in practice. The task force is expected to release a revised strategy document later this month.

The other major effort is the Global Health Initiative (GHI), an attempt to integrate U.S. global health efforts into a single coherent program of action. Currently, different funding streams, offices, and actors within the U.S. government tackle different aspects of global health, including the Office of the Global AIDS Coordinator, the Centers for Disease Control, and USAID. The GHI is intended to promote better coordination and cooperation among these groups and to create a more coherent approach to funding different health programs overall. The president plans to spend $63 billion on the GHI.

Where these two initiatives overlap is on the critical issue of nutrition.

New Hope for Malnourished Mothers and Children

The Administration continues to refine its Global Hunger and Food Security Initiative. The announcement at the G8 and subsequent emphasis on agriculture and food security is exciting and a welcome return to investing in areas that are critical to help people escape from poverty.

Bread for the World is urging the administration to include nutrition as a core area of emphasis in the new Initiative. The initial consultation document includes a substantial focus on nutrition, but as with all first drafts, it needs refinement. A recent briefing paper from the Institute, New Hope for Malnourished Mothers and Children, outlines further recommendations for the new initiative. Our recommendations include:

The Benefits of Clean Water

Two article caught my attention today reminding me of the importance of clean water. The first describes eight recent deaths in coastal Kenya caused by Acute Watery Diarrhea (AWD). My colleagues from PATH blogged about Diarrheal Disease last week. The deaths were attributed to "poor sanitation and lack of clean drinking water following heavy rain in most parts of the province which has destroyed sewage pipes and swept away pit latrine." The sharp increase in AWD shows just how fragile access to clean water is in Kenya and many other developing countries.

The second story describes how relief donations to internally displaced people in Pakistan include infant formula. While formula can be good for infants, when it is mixed with unclean water the consequences can be severe and even deadly. The inclusion of formula in the relief packages being provided to internally displaced persons has raised significant concerns among health professionals who worry that it sends the wrong message about appropriate feeding practices (running counter to efforts to encourage breastfeeding for example) and will also undoubtedly lead to more sick children as basic sanitation has been compromised or does not exist at all in the camps.

Both these stories highlight just how important clean water is to health and nutrition. Over at the One Campaign, signatures are being collected for Petition asking Congress to support the Senator Paul Simon Water for the World Act of 2009. The Bill authorizes funding to create sustainable access to clean water for millions of people around the world. It is one part of what is needed in order to create an integrated strategy for addressing the needs of poor and hungry children around the world.

Breaking the Cycle of Malnutrition and Diarrhea

A leader in efforts to address major challenges in global health, the NGO PATH recently launched a Call to Action on Diarrheal Disease, an effort which Bread for the World strongly supports. The Call to Action has caught the attention of other think tanks as well as demonstrated by this piece posted at the Center for Global Development. Janie Hayes from PATH and Altrena Mukuria from the Infant and Young Child Nutrition Project contributed the following to the Bread for the World Institute blog:

Last year on a June morning during a trip to Kenya’s Western Province, I sat with two mothers named Evalyne and Paula in a mud-wall home in the rural district of Bungoma. I was there to get their perspectives on the major health problems facing their children; when I posed the question, neither woman hesitated for a moment.

Malnutrition, Paula said. Diarrhea, Evalyne added, and her friend nodded in agreement.

 A couple of years earlier, Evalyne’s son Abel Juma died from diarrhea. Paula’s nephew was recently admitted to the hospital with diarrhea and nearly died from dehydration. Like most in the area, Evalyne and Paula each live on less than $1 a day, and I was curious about their diets, so I asked about what they could afford to feed their children each day. Evalyne rattled off the list of what her five- and two-year-old children eat, which varies little each day: some beans and rice, a bit of porridge, and tea.

In poor communities, like Evalyne and Paula’s, around the world, the relationship between malnutrition and diarrhea frequently leads to a vicious cycle—one that too often results in death or long-term physical or developmental delays in young children. Being malnourished makes a child more susceptible to diarrhea, causing more frequent and more severe diarrheal episodes. And when a child suffers a bout of diarrhea, the illness saps nutrients that young bodies desperately need. When it doesn’t kill, this cycle causes stunting and cognitive impairment. Diarrheal disease today is the second leading cause of child death, and undernutrition is an underlying cause of more than a third of child deaths from diarrhea and other childhood illnesses.

Giving a (Loud) Voice to Nutrition

I somehow missed Nick Kristof's excellent piece last week on the toll malnutrition takes on infants and young children. From severe acute malnutrition (à la the typical image of starving babies) to the "hidden hunger" of micronutrient deficiencies that affect 2 billion or more people around the world, Kristof's piece draws important attention to this issue.

One of the concerns raised in the piece is about the long-term consequences of child malnutrition in terms of both physical and cognitive development. The evidence of the impact of malnutrition on early child development is consistent and overwhelming. Connected to the individual health outcomes associated with malnutrition (including 3.5 million deaths of children under-five years of age) are the long-term economic consequences. These have been documented in a number of places, paper 2 of a 5 paper series published in 2008 in The Lancet as but one example of many. As the authors of The Lancet paper note,

Poverty is both a cause and an outcome of poor human development, and investments in child nutrition are being promoted as a strategy for economic development. Better child nutrition improves cognition and schooling, as discussed. It can also affect adult earnings through reduced lean body mass (including shorter height) and decreased productivity in jobs requiring manual labour. In the Guatemala trial, the nutrition intervention led to increased body size and improved work capacity.

These indicators of physical and intellectual human capital, in turn, have been associated with increased earnings. Adult height is positively associated with income, even in urban settings and even after adjustment for education... Exposure to improved nutrition before, but not after, 3 years of age was associated with higher hourly wages in Guatemalan men. For exposure from 0 to 2 years, the increase was US$0·67 per h (95% CI 0·16—1·17), which equates to a 46% increase in average wages. (internal citations omitted, emphasis added)

A momentous week for vitamins indeed!

This week marked big news in the fight against micronutrient deficiencies. Experts and practitioners from around the world gathered in Beijing under the auspices of the Micronutrient Forum being held in Beijing, China. The event was used as the platform for the release of a new report, Investing in the Future: A United Call to Action on Vitamin and Mineral Deficiencies. Congratulations are in order for the groups - Micronutrient Initiative, GAIN, UNICEF, The World Bank, USAID, the Flour Fortification Initiative - which sponsored and wrote the report.

As the report makes clear, around the world hundreds of millions of young children do not get the vitamins and minerals, vitamin A, iron, zinc, iodine and folic acid, especially. Without these key nutrients children will suffer a lifetime of debilitating cognitive and physical disabilities. For women too, lack of proper nutrition including iron can wreak havoc. Each year 135,000 women who suffer from iron deficient enemia die from complications during child birth.

Beyond making a strong case for why micronutrients are critical for child growth and development and maternal health, the report includes examples of succsesful programs and partnerships that are helping to improve access to these nutrients. Finally, the report also includes country level estimates showing the size of vitamin deficiencies. This is a much needed addition to the information and literature available on the size and scope of malnutrition.

As if one major report highlighting micronutrient deficiencies were not enough, Nicholas Kristof took up the problem of vitamin A deficiency (and the accompanying problem of night blindness) in an Op-Ed published on Thursday

Creating Political Will to Address Malnutrition

In a recent blog post, Ruth Levine at the Center for Global Development points out that malnutrition is an important issue that has not received the kind of attention and coordinated response that other health initiatives have (think HIV/AIDS).She makes a convincing case that better coordination is a crucial component of a global response.

To underline the problem and point out why a solution is so imperative, it  worth adding that malnutrition has dramatic impacts on long-term health and development. This is true for individual children who, when malnourished, suffer stunted growth and cognitive and motor impairment that can harm their ability to learn and work. It's also true of countries, particularly those with high-burdens of child malnutrition (there are 36 countries where stunting rates top 20 percent, 21 of which are in sub-Saharan Africa). When large segments of the population have suffered malnutrition in their childhoods, the result is a less capable, less productive work force (cf. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults).

We know what the problem is (and how it impacts development) and we also know many of the appropriate solutions. What we lack, as Dr. Levine point out, is political will.