Interview with Meera Shekar on A Funding Call for Malnutrition

Yes, they could be of some benefit, but I think the question that is more important over here is what can you do that is the most cost effective, and from all the evidence that we have up to now it shows that you get the maximum bang for your investment if you invest in children either during pregnancy or during the first two years of life. If you invest later in life, the significant damage has already been done, and there is very little you could do to reverse the damage.

So, whatever you do for children after the age of two is really too little, too late, and also very expensive in terms of public subsidies.

Most children, all they need for the first six months of their lives is exclusive breast feeding, and I want to really focus on the exclusive part of it. The children don't even need water. This is not a commonly known fact, and many people do introduce other foods, and there are serious adverse impacts to introducing inappropriate food sources early in children's lives.

So, for the first six months all the child needs is breast milk alone. After six months of age, the child does need additional food. Many of those foods are foods that can be adapted from the existing family diet, so no special foods per se are necessary, although sometimes they ever available and can be used.

You asked whether the quality of diets of mothers has an impact on breast milk. The mother's body is physiologically such that it tries not to compromise the quality or the quantity of the breast milk. It tries--so to quite an extent, if a mother is deficient, the baby will not suffer. But if the mother is severely deficient, yes, it will have an impact on the quality of breast milk, as well as the quantity as well.

This situation is not unusual in Benin. It's a problem that is in many countries and many institutions as well, and the problem is that nutrition is a multi sectoral issue, so it is a--this is a big issue. There are several ways of trying to address this, and many countries have addressed it differently, depending on the country situation.

In some countries, they think that the best way to address nutrition is to think about it as multi sectoral, but to address it in a sectoral fashion. So, let the Ministry of Health continue to do what the Ministry of Health can do to improve nutrition and the Ministries of Agriculture and Education would do their piece and so on. Every Ministry would do their even piece. But it is not necessary to have multi sectoral programs. One way to think about it is to act sctorally. That's one way of dealing with the issue.

Some countries have done that, Madagascar, for example, where they have been trying to set up a more umbrella institution, like a national nutrition council, that will then coordinate across the ministries, but the important thing there is to make sure that the nutrition council that is set up actually has some authority to convene the various ministries. So many different models exist in different countries to address this problem, and we also hope to be studying this issue a little bit more carefully to see what institutional arrangements are best to implement nutrition programs.

Thank you, that is an excellent question, and that is exactly the thrust of this entire report: How do we prevent the negative effects of malnutrition? And as I said earlier in answer to one of the other questions, the best way of preventing malnutrition is to prevent the damage that happens between pregnancy and the age of two, but by focusing on intervention at that age group, whether it is reducing low birth weight or making sure children are exclusively breast fed, that they have access to good healthcare, and that they have good hygiene around them.

You're right in thinking that much of malnutrition is linked to poverty, but I would disagree that all malnutrition is related to poverty. I think we have enough evidence in, and if you read the report you will see that evidence shows that definitely malnutrition rates are higher in poorer countries. But, even in poor countries, to address that issue of the link between malnutrition and poverty, the Bank is definitely working on poverty reduction; that is the mantra of the Bank. But poverty reduction will take a long, long time, and if we wait for poverty reduction, it will be long beyond 2015 when we would be able to address malnutrition. So, what we try to make the case in this document is we want to do something beyond looking at income poverty and, in fact, malnutrition is what we call the nonincome face of poverty. It is a form of poverty itself.

So, we want to have direct programs to address malnutrition, in addition to poverty reduction programs as well. And if you see some of the data in the report that shows you that, in fact in a country like India, and I assume you are from India, Dr. Sarvalingam, that in a country like India, even among the richest Indians, 25 percent of the children are stunted. 64 percent are anemic.

So, malnutrition is certainly concentrated among the poor, but it is not limited to the poor alone.

Thank you. Actually, there are several questions on the same theme, so I'm going to try and answer several of those questions together.

Many of you suggest that improving food production or investing in agriculture or breeding livestock, fisheries, so on and so forth, will improve nutrition, and you're right in thinking that that is part of the solution, but I really want to emphasize that all of the evidence tells us that agriculture, rural development are extremely important, but it's not sufficient to improve nutrition outcomes. There are countries that have done well on agricultural production, but not necessarily improved nutrition outcome, and that's because nutrition is something that improves as a result of three sets of factors: access to food, access to healthcare and health services, and caring practices by the caregivers.

So, even if food is available at a country level, it may not be available at a household level, but that's where the breakdown often happens. If it is available in the household level, the intrahousehold food distribution can be such that the child who is the most vulnerable often gets the least amount of food. The pregnant woman often eats last in the household when she needs it most.

So, addressing these intrahousehold allocation issues, addressing these issues of behavior and prioritization within the house are almost as important, if not more so, than aggregate-level food production alone.

And in addition to that you also need to address the health-care issue and the issues of caring behavior for young children.

So, yes, food production, increase in food production is definitely part of the solution but not THE solution that will improve nutrition.

Thank you for that very good question. There is a similar question from Elizabeth as well on the same issue, and a few other questions as well.

I think you touch on a very important issue: transparency, corruption, good management of aids funds are extremely important, whether we are dealing with malnutrition or whether we are dealing with other health issues or whether we are dealing with education--any of the these development issues, development aid can only be effective if it is effectively targeted to the problems that it is trying to address. The Bank recognizes this and continues to pay even more attention to issues of aid accountability, and we hope that over time that this issue will be addressed to a much larger extent than it has been addressed in the past.

Thank you, that's an excellent question. The Bank is working with private companies at many, many different levels, and in fact, more than the Bank on that particular issue, the agency that has done the most amount of work is UNICEF. And they have worked to ensure that there is an international code for marketing of breast milk substitutes, and the code is being implemented the world over.

NGOs have played a very strong role as well as in making sure that the private sector adheres to the code, and there is actually a very strong lobby of people who monitor this, and I think that is one of the success stories in nutrition.

But perhaps linked to that there is a question as well from Doctor Murtha asking whether the Bank is thinking about activities with multinational corporations, yet certainly not just the Bank, but the entire nutrition community is thinking about stronger public/private partnerships to improve nutrition.

And just to give you one example, there are huge amounts of processed foods that are available in the world. Many or most of them in developing countries are not fortified, and adding small amounts of micronutrients to foods is something companies can do at relatively low cost and very, very high benefit.

So, definitely the Bank is working with private sector groups to help make this happen. We are working with groups like the Micronutrient Initiative which is based in Canada. The Bank is the Trustee for and an important partner with the GAIN program (Global Alliance for improved Nutrition), and many other such partnerships as well, to bring in the private sector as much as possible.

Honduras is a country where, in fact, a very successful experiment with improving child health is being put into place, and you probably know more about that. It's called the AIN program, with supported primarily by the Government of Honduras, and U.S. Agency for International Development, and I haven't visited that project myself, but from all the reports from that project, it's one of the most successful programs in terms of engaging the communities in improving the growth of young children. You might want to look at the experience from that. It was also featured in the global Time-Life series some time back.

And similarly, in Mexico, there is a very successful program for--which is called Opportunidades. That program also highlighted both from a supply and demand perspective, both perspectives one needs to work to improve, to engage communities, and to improve nutrition. So, there are at least those two models I can think of right away, but there are many other paths of how we could improve nutrition that worked, particularly in a Latin American context.

Let me start by answering what I mean by mainstreaming into maternal child life programs. In one of the previous questions somebody asked about arrangements for children. It's hard at country levels for ministries to coordinate across ministries. So, one of the approaches we have taken is to continue to work with the Ministry of Health to mainstream nutrition into maternal and child health programs.

Similarly we intend to work with ministries of agriculture to bring in nutritional perspective into agricultural programs into community-driven development. One of you asked the question as well about mainstream programs into community development programs and so on and so forth.

Now, this particular grant that has been made is focusing on identifying which interventions are appropriate to be included in the work programs of the ministries of health, and that's what we call "mainstreaming." But in order to make that happen, we have allocated these funds to developing countries' institutions, the International Centre for Diarrhea, Disease, Research in Bangladesh, and the mandate is to pull together the evidence for nutrition at the global level as well as the country level, and once they have pulled together this evidence, they will then use this evidence as a platform for advocacy, and I really want to emphasize evidence-based advocacy, not just advocacy without evidence.

So that over time, more and more ministries of health in countries will be able to to have access to this evidence, and the experience from other countries on how nutrition interventions are being made a part of what is happening in the ministries of health. So, the ICDDRB, the International Centre for Diarrhea, Disease Research in Bangladesh will work with several country teams in South Asia, in Africa, and in Latin America and the Caribbean to help make this happen.

And, in fact, they are just starting work with the global group that is putting together the Lancet series on nutrition. One of the outputs from this work will be, to contribute towards the Lancet series, but we hope there will be other similar articles as well for global advocacy for nutrition.

Thank you. Excellent question. Actually, there are several questions within that question, so let me address them one by one.

First, you seem to take away the message we are talking about a global fund to tackle malnutrition, and that question has come up from a few others as well.

No, in fact, if you read the report, we basically say there is no need for a global foundation on malnutrition. We are saying some funds are needed for evidence based advocacy -- like for the IDCCRB to do advocacy to position nutrition at the country level, to build commitment at the country level as well as with donor partners.

But in order to actually scale up the nutrition interventions, we are not aiming for a global fund. We think that, as several of you have suggested, a better way is to have nutrition funded through existing aid that is flowing to the countries through exixting channels. There should be more money, but not necessarily through a global fund kind of vertical initiative. I hope that is clear.

The second question is: Overall how much money is needed? As you will see in the report, we haven't given a firm number as yet. That's because we don't have a firm number. We are working on that, and we hope to have a better estimate very soon.

The other question you ask: Is it cost effective to put money into this? Of course, this is one of the most cost-effective developments in the world today. You might be familiar with the work done by the Copenhagan Consensus last year, and if you look at the list, and that Copenhagen Consensus was a consensus last year, which included a number of Nobel laureated, and concluded that from among a lengthy list of development best-buys, returns to investing in nutrition interventions (including micronutrients) are very high. So it's not just nutrition people saying this is a good thing...these are some of the best thinkers in the world who say it is good investment.

That's one of the reason, and there are many other reasons why we believe this is a very cost-effective investment for countries.

Thank you, this is an excellent question. All the evidence tells us that if we want to improve nutrition, and I think you heard me say this several times now, you need to intervene early. So, school feeding programs, whether it is school lunch or midday meal programs, are good interventions for keeping girls in school or for reducing school dropouts among poor children. They are not necessarily the best way to improve nutrition. The objective of school lunch programs is an educational objective. It will not have an impact on nutrition.

Dinar, you put your finger on something that is an emerging problem all over the world, particularly in developed countries, but even more so in developing countries as well. And, in fact, there is a meeting next week of the UN Standing Committee on Nutrition in Geneva, and that meeting will focus specifically on the double burden of malnutrition.

So, perhaps if you can access information that is available online and to the agenda and the output from that meeting, that will give you some of the answers.

But perhaps one answer I want to mention specifically is that in countries like Indonesia, the double burden is very closely linked to the undernutrition that happens in the first few years of life, and more and more evidence is becoming available now. Perhaps you have seen the work of Professor David Barker of the U.K., that children who are undernourished, underweight, or born with low birth weight in the first months or years of life are the same children who, when they grow up and become adults, are much more prone to cardiovascular heart disease, obesity, diabetes, and so on and so forth.

So, it is really ironic that in the same countries that are undernourished today, 20 or 30 years later they will be overweight, much more prone to cardiovascular diseases, diabetes, and so on and so forth.

So, this is something we want to be able to address, but you need to again address it very early in life.

That is an excellent, excellent question, and it's something that has intrigued, the nutrition community for a very long time, and sometime ago there was a report published called the Enigma of Malnutrition in Southeast Asia.

First, most people don't want to believe it. They think the data are wrong when we say South Asia has high rates, but over time, everybody has come to accept that that is, in fact, the case. South Asia does have double the rates, or many countries in South Asia do have double the rates of malnutrition as compared to Africa. The reasons are not crystal clear, but the evidence suggests that perhaps things like women's empowerment and women's decision-making roles may be extremely important in the high levels of undernutrition. If you see in South Asia, many children--and I'm giving you a rough estimate of approximately 30 percent of children in India and other countries are born with low birth weight, and these low birth weight children never catch up with normal birth weight children.

So, the problem happens very early during pregnancy, which is very different from what happens in Africa. Low birth weight rates are not as high in Africa, but they are very high in South Asia.

And that is very closely linked to what happens during pregnancy, and women's access to food, women's decision-making powers, and so on and so forth. And perhaps the other issue that is linked to the high undernutrition rates in South Asia, is that of poor water and sanitation which is closely linked to malnutrition.

Thank you, Glenda, excellent question. I think there are two or three things that we would like to see happen in the next few months. First is that we need to be sure that we have a consistent message that goes out to the leaders in developing countries. A message that is technically correct on how we can improve nutrition.

Second, we want to make sure that the same message goes out to donor partners as well. If we invest in something and the solution we are investing in is the wrong solution, that would not have the impact we are looking for.

A third thing we want to make sure is that there is strong leadership, a strong partnership at both the country level and the global level, as well as with the NGOs, and. And there is a similar question from another colleague as well as to what we can do about the issue. What we could all do collective is to have a consistent message that is technically correct, get some funds together from several partners to be able to support the scaling up of these consistent messages, so we could have large scale programs in countries. The solution doesn't lie in having little programs. That is a good way to start to define what works, but the ultimate solution lies in scaling up what works. And what we have tried to highlight in the report are some of the strategies that have worked in different countries in circumstance, and then to make a call that these now need to be scaled up at a national level in many countries, especially the high burden countries.