I am often asked, “So what do you do now?” It is usually a serious question at airports by customs officials; on aeroplanes, where much of my time is spent; or in the streets and supermarkets where I shop. There is always a curiosity. “Why have you left government? Why don’t you go back to politics?”
While I may not be in a formal position in any political party or in government, I find myself increasing my political and social activism. I do that because I believe that all our challenges are political. It is the lack of political will that drives the greatest human development challenges of the 21st century. In the absence of inspiring leadership globally, we have no choice but to stop being subjects and becoming active citizens who demand accountability and efficiency from our leaders.
One of the organisations I chair is the Global Alliance for Improved Nutrition, GAIN. It’s not every day that I take the opportunity to assess a decade’s worth of work. Yet this year, I was placed in just such a position as I presided over the 10 year anniversary of GAIN. This is an organisation that captured my attention almost a decade ago, and has kept me enthralled ever since.
GAIN was initiated by a few big thinkers after a thorough review of the data on why so many people across the globe were malnourished and, as a result, often permanently mentally and physically handicapped. GAIN was, in the words of Josette Sheeran, former head of the World Food Program who spoke at the launch, an “audacious idea” designed to rethink the solution set.
It was audacious because it turned the conventional wisdom about addressing malnutrition from one focused on treatment to one focused on prevention; from a medical model to one that recognised that most people, even poor people engage with markets to get their food rather than health clinics; audacious because it recognised that if malnutrition was to be addressed, it would need to leverage the skills and abilities of both the public and private sectors across a variety of disciplines, in order to reach the roughly 2 billion people on the planet who do not get enough of the nutrients they need to grow and thrive.
In short, it challenged the status quo, opening the door for increased inclusion, particularly from consumers (most notably, women) and confronting the reality that to have a lasting impact, efforts needed to go beyond the pilot phase and be taken to scale.
Food security has always focused on the issue of price volatility. We have to go beyond the challenges of increasing food production to meet future demand, and much rather address the nutritional quality of the food that the poor consume. We need to ensure that the developing world can deliver life-sustaining nutrients for the millions of pregnant, lactating women, infants and young children who have greater nutritional requirements than the general population.
Malnutrition leads to impaired cognitive development in children, which weakens their development path and leads to irreversible changes. Its impact includes growth faltering (stunting or low height for age) and lower learning abilities. Malnourished young children are also more at risk for chronic diseases such as diabetes, obesity, hypertension, and cardiovascular disease in adulthood. Moreover, these overall effects cause a decline in human capital which we cannot afford during economic crises.
While GAIN’s approach may seem intuitive, at the time there was little political will to change the business model to address malnutrition. Ever-tight financial and human resources were targeted toward recuperating children on death’s door. The nutrition community was fractured and had little data to back its cause to change the paradigm; preventing the problem seemed overwhelming. Moreover, the health community held a myopic view that this was a problem to be solved by medical means.
It also did not take into account that the majority of the poor, even those at the base of the pyramid, accessed at least some portion of their food through markets, or that preventing chronic malnutrition would be both less expensive and more cost-effective than treating it, since it is the market and private entrepreneurs from village to global level that primarily produce food. There was also no acknowledgement that with increasing migration, the bulk of our global population in city slums would begin depending on industrially produced foods, making household food security a great risk.
And so, in 2002, at the Special Session of the UN General Assembly on Children, GAIN was launched with the commitment to saving lives and improving health in developing countries through the elimination of nutritional deficiencies. Malnutrition was estimated to cause close to 11% of the global disease burden and some 35% of all child deaths under the age of five. Astoundingly, 3,5 million children a year were dying and a further two million children were physically and mentally handicapped from diets largely insufficient in vitamins, minerals, fats and proteins, which resulted in national reductions in GDP estimated at 2-3%.
GAIN started with large-scale fortification programmes – a wise decision, given that food in the developed world had been successfully fortified since the 1920s, and so they knew that at least in some settings, this could be achieved quite effectively.
Soy sauce in China, maize meal and wheat flour in South Africa, fish sauce in Vietnam, and numerous other staple mainstays in the diets of the poor were fortified. GAIN’s unique approach, namely to work with the public sector on the legislation and regulatory environments; the private sector on supply chain issues, demand creation and logistics; and NGOs to help with ground-level implementation, began to prove that large-scale fortification could indeed work in the developing world.
Then in 2008, in response to the newly published Lancet Series on Maternal and Child Undernutrition, GAIN realised that addressing the 1,000 day window critical for human development, from conception to the age of two years, was another way to prevent malnutrition rather than treating it. It entailed some similar techniques to large-scale fortification, but with a twist, because with the exception of promotion of early initiation and exclusive breastfeeding for the first six months and continued breastfeeding through 24 months, little was being done to enhance the nutrition of pregnant and lactating women, and children aged 6-24 months.
GAIN began working with the community, including researchers, food scientists and policy makers, to develop and promote the use of home fortificants – small sachets of essential nutrients that can be added to food already being eaten by young children aged 6 – 24 months and pregnant and lactating women, to provide added nutritional value to the diets to those whose nutritional requirements could not be met through their diet, even those that included fortified foods, alone.
GAIN didn’t stop there. They developed a global vitamin and mineral premix procurement system to address supply chain issues for vitamins and mineral used to fortify food – increasing the quality and reducing shipping times and stock-out for the those products. They pioneered an “Access to Nutrition Index”, designed to rate food and beverage companies’ performance in providing nutritious products to consumers.
This will challenge companies to improve their nutrition practices and, in so doing, increase consumers’ access to more nutritious products and ultimately contribute to addressing malnutrition. The index will allow food and beverage companies to benchmark their performance on nutrition against their peers, and provide stakeholders, from investors to consumers and policymakers, with information that they can use to inform their decisions and their programmes.
More recently, GAIN has begun to explore expanding nutrition programmes further up the agricultural value chain, to enhance the inputs of assets such as seeds and fertiliser, improve storage and milling practices, reduce waste and make use of suitable by-products to improve the nutritional quality of agricultural products – again working with agri-business, government officials and civil society to leverage their strengths.
But is it working? GAIN’s programmes are now reaching over 600 million people, about half of whom are women and children, in over 30 countries around the globe. Some 67% of the beneficiaries are in Africa, and the average cost per beneficiary reached is just 32 US cents per year. Program evaluations in peer-reviewed journals indicate that GAIN’s programs have significantly reduced the prevalence of micronutrient deficiencies in a number of countries.
In China, South Africa and Kenya, for example, micronutrient deficiencies dropped between 11 and 30% among those who consumed GAIN’s fortified products, including a 30% drop in neural tube defects here in South Africa after the introduction of folic acid fortification of wheat flour and maize meal. During GAIN’s ten years of existence, it has also raised $322 million in new financial commitments from its partners and leveraged many times more from its private sector and government partners.
And GAIN is learning. After a review of the most recent data on trends in nutrition, GAIN completed reorganisation, prioritising country action in key high burden countries like Bangladesh, Ethiopia, India, Kenya, and Nigeria, hiring local experts to help run the programs, and assessing the model to ensure that it’s relevant to local culture and values. They’ve also beefed up their advocacy efforts, and are working to build constituencies around the world to be champions for nutrition, and convince policy makers to act.
Can we rest now? Do we have all the answers? No. But for a moment, as a political activist and one-time policy maker, I can say that it is great to reflect on the past 10 years, recognising the beauty of a good idea well executed, and looking with excitement at the long road ahead.
As Archimedes once said, “Give me a lever long enough, and we can move the world.” DM
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