It may not sound like a compelling topic - and it certainly hasn't grabbed headlines or dominated policy dialogues.
But if children fail to get adequate nutrients in their first 1,000 days, they - and their families and communities - will pay a lifelong price. New research suggests that tackling undernutrition would be among the most potent anti-poverty strategies, and discussion about how to address the under-recognized problem is underway.
More than 5,000 people are gathering in Barcelona, Spain, for next week's International Conference on Nutrition. The following week in New York, United Nations Secretary-General Ban ki-Moon will host a meeting on Sept. 23 to spotlight the Millennium Development Goals, a strategy agreed by the global community for ending extreme poverty by 2015. Two days later, the president of the 68th session of the UN General Assembly will host a presentation of the secretary-general's report on progress towards the MDGs. The same week, the Clinton Global Initiative and the Social Good Summit will discuss collaborations, commitments and innovative solutions to address social problems, and nutrition advocates will be there.
The Children's Investment Fund Foundation (CIFF) has played a key role in accelerating the momentum to end the crisis of undernutrition, especially in developing countries. The philanthropy joined the governments of Brazil and the United Kingdom to host the Nutrition for Growth summit in London in June. The convening of business leaders, scientists, governments and civil society leaders pledged up to U.S.$4.15 billion in new commitments to address under-nutrition between 2013 and 2020 and an additional $19 billion for investments in agriculture and other "nutrition sensitive programmes".
CIFF co-founder and board chair Jamie Cooper-Hohn wants you to know that all of this is a big deal. CIFF itself will invest U.S.$787 million (£2.7 billion) to tackle undernutrition, which underlies over three million deaths of young children each year and causes lifelong intellectual and physical damage to another 165 million - a process called 'stunting'. In her office in London, she sat down with AllAfrica co-founder and board chair Amadou Mahtar Ba. The two institutional leaders began by comparing notes on caring for young children, including Ba's twins and Cooper-Hohn's triplets, agreeing that becoming parents had made the welfare of the world's children a more personal issue for them. Text excerpts are below, and video clips of Cooper-Hohn are here:
At the London summit, there was high-level participation and financial commitments were made. But if effective programmes aren't implemented, it seems it won't be, really, a success. So what's next?
It was a great moment in reframing and placing nutrition much more centrally on the development agenda. In that regard, it was a success.
But as you say, if there isn't the proper follow-up, it won't come to much.
So, in terms of next steps, the first is to go to where the heart of the issue is, and that's mostly Africa and Southeast Asia, with a few laggards in Latin America and other countries. We can make the biggest difference by addressing undernutrition and working with those countries.
I've already had a very good series of follow-ups with President [Joyce] Banda, for example, in Malawi, to bundle and to plan for a set of interventions that most strategically build on the infrastructure that's already there. When do they reach pregnant women and children up to the age of two? And how can we bundle the smartest set of activities on top of that?
The first step is to make sure that this issue really does stay central to heads of state, to finance ministers, to health ministers, and get them working together. We want to move across the ministries of agriculture and all the ministries to find the most effective path forward. So the first step is to do that - and then to align the funding that's been pledged to complement where there are gaps and where countries couldn't do it alone or may need some time.
We ourselves often work by doing some of the wholesale infrastructure and big training across the board and then leave the country to continue - to make sure that programs are institutionalized, for example.
There'll be some matchmaking around that, and accountability. We'll need platforms to make sure that all the partners do fulfill the commitments that they made; that we're actually using the best evidence as it emerges and updating programs properly; and that we're driving down severe acute malnutrition and stunting as fast and efficiently as possible.
What is the place of civil society to all of this? How can they be brought into it?
We won't get there without this being an issue that we all prioritize and see as essential. Civil society has always played a key role in making sure that we don't lose focus and that we don't have a little peak of interest and then a diminishing return on issues.
So we are intending to set up a series of scorecards that would cross a range of maternal, child, newborn issues - Nigeria and Ethiopia have already taken the lead - and set up key indicators of where the evidence says that we can have the most impact and where there is an actionable response.
Nigeria and Ethiopia have already set nutrition indicators. Those will become public over time and become a great mechanism for monitoring - and all of us watching. There's also a lot of work for civil society to think about in terms of private sector and the workforce. For example, do we have appropriate provision for breastfeeding moms to be able to exclusively breastfeed in the first six months? It is a win-win in terms of workforce productivity to make sure that the communities where large companies are based take care of their workforce and take care of the community in terms of nutrition because it makes a big difference in the ultimate health of that community.
Which other countries are involved in the pilot phase and what have been the criteria in selecting those countries to be engaged in this process?
There are a number of countries that have in the realm of 40 percent stunting, so those are the ones that we need to engage. The ones who have made clear commitments include Nigeria, Ethiopia, Malawi, Zambia - they've been leaders. India has also recognized this to be a huge issue, but the Scaling Up Nutrition Network has identified and tried to bring into the tent all the countries impacted.
There are a lot of surprises. Kenya, which I at least think of as an emerging middle-income country, along with Nigeria, has 38 percent stunting; Nigeria over 40. So it's really key that we get these countries. They're all at different points in thinking about how to most strategically build on their existing infrastructure. We'll hope to move that a lot faster now that there's the commitment at the top from those countries.
With a lot of work going on by different countries and groups, is it all separate? Or can you all work together to be more effective?
As we were saying before, it's been a very under-prioritized issue, so there are absolutely organizations working on pieces of it. But have we thought really strategically about who is already reaching the key populations? Has it been internalized?
If we miss the time between conception - and possibly pre-conception - and the age of two, we've missed the window [to prevent stunting] and, therefore, we have to take really concerted actions to pursue a bundle of activities that are smart.
For example, GAIN [the Global Alliance for Improved Nutrition] has done some really interesting work on fortification. A child probably wouldn't eat enough of a fortified product for it to be sufficient for them. A pregnant mom might. But we really have to look and say, "What does it take to get a child to grow three to five centimeters more?"
I think there are lots of entities who are well prepared because they're already working with that population or they may already be working on an aspect - diarrhea prevention and treatment, or hand-washing, or a vitamin distribution. What we need to do is put it together more efficiently into a package.
How much do you think the communities that you are targeting are really aware of these issues of malnutrition?
I don't think it has resonated especially - the difference between hunger and under-nutrition as an issue.
I think we're all done seeing the African child as the hungry bloated child. That just doesn't feel like where the African child is anymore and I think, rightly, there is resistance to that. Obviously, we do need to take care of those pockets where there's just severe acute malnutrition for whatever reason.
I think what we haven't done yet is get the messaging out on the variety of nutrients we need to get into babies in order to help them fight disease, in order to have their bodies and minds properly develop in the way that every parent wants their child to thrive. And that's going to be a conversation and work that's going to have to come from within countries, civil society, government leaders. But it is absolutely essential that we do get that message across, and that people are able to make the best choices for their children.
Do you think this initiative would help countries focus more on under-nutrition? Some countries already have the resources to do it. Did the summit help?
I think, in addition to the confusion about - or not distinguishing between - hunger and under-nutrition as an issue, we were thinking of nutrition purely as a health issue, rather than the economic issue that it is. What we've learned from Latin America is that you stagnate in your growth. As the vice president of Peru and the minister of industry so well articulated, for the longest time we fought poverty, assuming that would resolve malnutrition.
At some point the light went on, and we realized we needed to fight malnutrition and that would resolve poverty. In fact, that's exactly what we galvanized around and what has happened. It is very, very clear from a number of countries, and we see it now in India, that you can't sustain the trajectory of rapid economic growth that comes from minerals and other assets in a country if you have a large portion - which Ethiopia and Nigeria do - of your population stunted. Forty percent stunting translates into more than 11 percent GNP loss annually, so it's huge.
For an individual, being stunted is 20-45 percent less wages. People who are NOT stunted are a third more likely not to live in poverty and 28 percent more likely to work in skilled labor. The impacts, economically, are huge and that's why I think we can get a rallying across ministries and at the head of state level and keep this prioritized in the agenda.
You've said you favor evidence-based interventions. What does that mean in practice?
CIFF is interested in the entire cycle of making sure that a child survives - and making sure that they thrive. Our approach is to be very evidence-based. There is enormous and very high-quality evidence out of the development sector of what works and what doesn't work.
So what we have done is look for where are the biggest opportunities to have a profound and transformational impact on children that, for some reason, have not been properly situated on the agenda and, in fact, would be a better health investment or educational investment for both a child and for a country. Nutrition firmly fit into that.
The first area that we worked was around the issue of HIV/Aids. At the time CIFF was founded, five countries had speculated that they might not exist [as viable states] by 2015 - right around now - because they had so many teachers, so many health workers, so many leaders, so many parents who they anticipated would not survive Aids.
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Clearly, that hasn't happened. The world has responded, and we were really proud to be part of that, particularly making sure that children weren't left out of that response.
We also work on neonatal [newborn health]. About half the deaths right now happen in the first year of a child's life, and, within that, the first week. A lot of people anticipate that you need incubators and these very complicated interventions, but, in fact, most of it's about making sure the baby doesn't get hypothermia, that it doesn't have an infection, that it's breastfeeding properly. Those very easy, inexpensive interventions are very much part of changing the mortality rates in our journey to get the Millennium Development Goal met.
We also think that the attention to early learning and making sure that a child succeeds at the beginning of school is another area where there is incredibly strong evidence. You don't get just a little blip for the child, and then they fall behind again. If you get them to have a successful beginning to school; prepare them for what's going to happen in school and give them the basics; or make sure that if they fall behind that they get remedial education and can catch up - they then are much more successful academically over time.
We do feel that there are a very few areas where the evidence is extremely clear and, for some reason, there is relatively little resources or energy going into that. So those are the areas that we try to focus on.
We also work in the area of climate change. Again, our belief is that the world is inadequately prioritizing it, given how it will undo all of the progress we've made in terms of health gains, and economic gains across countries in Africa and Southeast Asia.
I think nutrition is a really exciting and important issue. I very much hope and am confident that we can really turn around the issue if we all act shoulder-to-shoulder and work where the evidence says we know we can make a difference.
To close, can you talk some about what made you take on this work on children's issues?
Well, we were talking before we formally started the interview, as both being parents of large families. That's where my heart and my soul are - in knowing that my happiness and my family's happiness are all about my own children's health and the degree to which they thrive. That's something I want for the world for everybody's children. That's certainly what gets me out of bed and what motivates me.
I'm also fascinated with how we approach development and, in my view, the gap that we've left in efficiencies and cost effectiveness and the drive for impact. As we often say, passion plus activities does not equal impact. What it takes to turn that around and make sure, now particularly, with more limited funds potentially being available in the development sphere, to undertaking everything we do smartly and well - I find very engaging.
