“Orphan, invisible, unmeasured and voiceless” — these are the four words Shawn Baker employs to cryptically capture the root causes behind the neglect of nutrition in India and elsewhere. Having said that, the director of nutrition at the Bill and Melinda Gates Foundation (BMGF) is convinced that a sea change is underway in attitudes and outcomes on an issue that is critical to the social and economic development of the country.
Mr Baker, who was previously with Helen Keller International, has made health and nutrition the focus of a 30-year career in the social sector, the majority of it in Africa (Dakar in Senegal is home, he says). Mr Baker speaks to Christabelle Noronha about the blight of undernutrition and the urgency of dealing with what he deems “a clear and present danger that is undermining the health of our children, our communities and our nations”.
When I compare the situation in India with that in other countries where I have worked, it has an amazing set of assets. The overall policy framework is strong and aligned with global best practices. There is a tremendous frontline workforce and a rapidly expanding network of self-help groups that can support mothers and families in getting good nutrition.
There are public sector investments of upwards of $10 billion a year in programmes that are mandated to have nutritional impact. India no longer faces recurrent food shortages. After nearly a decade-long ‘data drought’, there is now almost a deluge of official data (and there’s the soon-to-be-released national micronutrient survey).
The fundamental missing ingredient thus far has been the political will to drive performance across various sectors and efforts that need to be coordinated effectively to produce results. This political will needs to be informed by smart information systems that focus on the ‘what’ that needs to be delivered and can inform course correction and improvement.
Simply put, health, food and social protection systems need to work in concert to achieve strong nutrition outcomes. India has enormous capacities and investments in these sectors; it now has to work on orchestration and accountability to get them to deliver on their mandate. The National Nutrition Mission provides a level of political prioritisation to nutrition that can lead such orchestration and accountability at every level.
I often summarise the root causes of the neglect of nutrition in four words: orphan, invisible, unmeasured and voiceless. Orphan because it is seldom clear which part of government is on the hook to deliver nutrition. Invisible because the public image of the problem is the severely emaciated child needing treatment, yet the magnitude of stunting, deficiencies in essential vitamins and minerals, and low birth weight are often not visible. Unmeasured because there seldom are robust data systems that assess status, quality of diets and coverage of essential interventions. And voiceless because those most at risk of undernutrition are those who have the least voice in political processes. I would posit that these root causes are universal; they are present in Africa, Asia and the Americas.
There are a lot of misperceptions about progress in Africa, and I have had the privilege of witnessing some dramatic changes. For example, there has been tremendous progress in large-scale food fortification since 2000, with all 15 countries in the Economic Community of West African States adopting common standards for salt, cereal flour and cooking oil.
Every time we fail to provide adequate nutrition, health and care during the 1,000-day window from conception through two years, we are depriving a child of future potential.”
However, Africa is facing some mega-trends that are deeply challenging. Rapid demographic growth means that, despite some progress in reducing stunting in percentage terms, it is the only region in the world where the absolute number of stunted children is projected to increase. There are growing security concerns in regions that have historically been very peaceful, cutting into government budgets in the social sectors, and decreasing governments’ and partners’ abilities to provide services to the most vulnerable. To these I would add rapid urbanisation and the impact of climate change, which undercuts progress in food security.
What encourages me, however, is the political awakening across the continent about the importance of nutrition to achieve Africa’s aspirations for economic development. As the president of the African Development Bank, Akin Adesina, says, “Stunted children today are stunted economies tomorrow.” He wants governments to invest in “grey matter infrastructure”.
When you are in a village in Bihar or in Niger and almost every child is stunted, that is just the norm. Parents, village leaders and decision makers don’t even see it. If you speak to mothers across Africa and India and ask about their experience during pregnancy, they will almost always talk about feeling weak in terms such as ‘lack of blood’, what we nutritionists and public health people would call anaemia. But it is so common that it is just assumed to be normal. I was struck by this while visiting maternity wards in Uttar Pradesh and looking at birth registers — almost every birth was recorded at 2.5kg or less. Low birth weight is so common it is normal.
Even when we speak about linkages between undernutrition and under-five mortality, it can be overly nuanced. For example, the statement “undernutrition is the attributable cause of 45% of under-five deaths” isn’t clear for all our audiences. Instead, let us say simply: “If these children had been adequately nourished they would be alive today.” We have to break this vicious cycle of invisibility and demonstrate to decision makers that malnutrition is a clear and present danger that is undermining the health of our children, our communities and our nations.
Every time we fail to provide adequate nutrition, health and care during the 1,000-day window from conception through two years, we are depriving a child of future potential. More optimistically, if we ensure adequate nutrition, health and care during this critical period, we have locked in potential that is irreversible and set this child up to be more resistant to disease, better equipped to learn, and more able to earn a living.
There has long been a myth in development circles that only overall economic development can solve malnutrition, particularly stunting. But the evidence shows that there are a number of countries that are performing far better in reducing stunting than their economic development would indicate, among them Brazil, Peru, Nepal and Senegal. Sadly, there are also a number of countries that have far greater stunting rates than you would expect from their economic status.
I have spoken a lot about what I see as the ingredients, or assets, that are in place. I will also give you a few examples of opportunities that are currently being missed. India has made major strides in ensuring skilled attendance at birth, with the latest estimate at over 85%. But one of the essential actions for newborns and mothers is breastfeeding within an hour of birth, and the rate for this is just 42%. That’s an ‘opportunity gap’ of 43%.
[Foundations] can take on longer-term and riskier bets that are much more difficult for governments to fund.”
There are similar missed opportunities in other sectors and these can be converted into impact. One is empowering angawadi (child-care centre) workers to visit all households with pregnant and lactating women and provide just-in-time counselling on maternal nutrition and feeding infants and young children, making sure that all public distribution rations are fortified with essential vitamins and minerals, and providing appropriate nutrition advice through self-help groups.
I think the single biggest contribution we can make is to ensure that nutrition has a voice at the table — a consistent and long-term voice. Governments have so many competing priorities and these priorities often change with election cycles. Those who suffer the most from malnutrition are the least likely to have a voice at the table.
I think the big advantage that foundations have over other donors is their flexibility to adapt their approach to what best meets the needs of the context and the moment. We can also take on longer-term and riskier bets that are much more difficult for governments to fund.
One of the most rewarding parts of my job is the opportunity to learn about the amazing diversity of opportunities and challenges in India. The Tata Trusts have been a huge part of that learning. At the most basic level, when the most trusted name in India and the most visible foundation in the world both say that nutrition is vital, it gets attention. Collaborating with the Tata Trusts is one of our ‘make-or-break’ partnerships to advance nutrition in India, and it is a pleasure and a privilege to work with them.
I should probably reveal that I am actually a repurposed marine biologist, which is what I studied for as an undergraduate at university. I had a hankering to serve as a Peace Corps Volunteer and I thought it would be a two-year hiatus on my way to becoming the next Jacques Cousteau.
Because of a youthful act of rebellion I had forced my middle school to provide a French language instructor. When I applied for the Peace Corps that vestigial knowledge of French got me posted in a Francophone country, teaching biology and chemistry to school students. During the summer recess, I worked with the district hospital and local missionaries to set up what were then called ‘well baby clinics’.
That was my pathway to falling in love with nutrition and to falling in love with Africa. My children are all from Burkina Faso and this makes global nutrition deeply personal for me. I see every day how much of a difference good nutrition and care makes in their lives, and I wish all children could have these same basic entitlements.
I am an obsessive reader, I love watching birds, am an opera fanatic and also love to run. You have picked up on the biggest challenge, which is finding time for these pursuits. Reading is probably the easiest because the amount of time I spend on airplanes and in airports fits well with my most inseparable companion, my Kindle, which is always fully loaded.