Nutrition is first and foremost a political challenge, says Gates nutrition lead

SAN FRANCISCO — Bill and Melinda Gates have spent a lot of time speaking with experts about stunting and its solutions. It is not the height of the child they are worried about, but rather what that number indicates, in terms of cognitive, emotional, and physical development, as they explain in a report released earlier this year.

Shawn Baker, director of the nutrition team at the Bill & Melinda Gates Foundation, leads their work on what has become a growing priority for the largest foundation in the world: ensuring that women and children get the nutrition they need.

Baker joined the foundation in 2013, and has led efforts to revise the program strategy as the Gates Foundation’s nutrition budget grew from $50 million to $125 million a year. Previously, he was vice president and regional director for Africa at Helen Keller International, which works on vision and nutrition, where his work included overseeing a tripling of country programs, shaping programs on vitamin A supplementation and food fortification, and building regional partnerships.

This week, he’s focusing on the Global Nutrition Summit in Milan, Italy, on Saturday. The event builds on the first major global pledging moment for the nutrition challenge, which took place in London in 2013, and resulted in commitments to expand the reach of nutrition interventions in the first 1,000 days between a woman’s pregnancy and her child’s second birthday. Almost half of under 5 mortality is driven by malnutrition, and the summit provides an opportunity to consider progress on what is often framed as an intractable problem, to check in on existing efforts, and to build new commitments, Baker told Devex.

“We’ve got enormous problems, we’ve got a number of solutions, but there’s a big gap between what we know [we need] to do and our financial ability to do it, and it requires both continued financial leadership but also political leadership,” he said.

More than most issues in public health, nutrition is first and foremost a political challenge, Baker said. He explained that the problem is relatively invisible because of the populations it affects, and that the solution requires multiple sectors working together.

“Unless you have high-level political leadership, it’s almost impossible to drive progress, and in those countries that have shown significant progress, that has been the secret sauce,” he said.

One example is Peru, a country that both Baker and the Gates report say demonstrates that stunting is a solvable problem. The prevalence of stunting among children under 5 declined from 39 percent in 1990 to 18 percent in 2016, largely due to the Child Malnutrition Initiative, a program implemented by CARE Peru with funding from the U.S. Agency for International Development. Two leaders from the program explained how they delivered a package of interventions, including nutrition, water and sanitation, and health investments rather than traditional feeding programs. The NGO has since worked with the government across three different administrations to make nutrition a national priority.

Baker also pointed to Brazil, a country that started by identifying the underlying causes of stunting, then working to address those issues by improving access to health services for pregnant women and investing in education for children and mothers. It also improved income distribution by launching an income transfer program, which provided families living below the poverty line with a monthly stipend to put them above the line.

And another example is Senegal, where the issue of malnutrition was elevated to the highest levels, and is overseen by the Nutrition Policy Coordination Unit in the Prime Minister’s Office. The government has shifted its approach to a community-based strategy, which the International Development Association of the World Bank Group — a supporter of the efforts in Senegal — summarized as “health education, breastfeeding promotion, infant and young child feeding counseling, monthly weighing sessions, micronutrient supplementation, conditional cash transfers, targeted food security support and more.” Stunting has fallen to 19 percent in Senegal, which Baker described as “dramatic” for West Africa, yet he expects political commitments to result in more examples like this in the years ahead.

“What I see now more than ever in the last couple of years is finance ministers and heads of state stepping up and being worried about nutrition,” Baker told Devex. “These are leaders who aspire to have emerging economies and they realize, ‘if half of my workforce is stunted during childhood, the idea of having an emerging economy in the future is pretty difficult to imagine.’”

Increasingly, leaders are making the connection between human capital and sustainable global development. Nutrition is a fundamental driver of human capital development, and malnutrition undermines that potential — a dynamic made worse by hunger and famine across the world, Baker said. But from the World Bank’s Human Capital Summit, to the high-level event in Milan this weekend, to the Scaling Up Nutrition gathering in Côte d’Ivoire next week, donors are coming together around the drive to reduce malnutrition.

Baker pointed to a comment made by Dr. Akinwumi Adesina, president of the African Development Bank, at the World Food Prize in Des Moines, Iowa, last year.

“We must now change how we look at the problem of malnutrition,” said Adesina. “The greatest contributor to economic growth is not physical infrastructure, but brainpower, what I refer to as ‘grey matter infrastructure.’ While it is obvious that a road or port can add to improved trade and economic growth, it is often not recognized that stunting shrinks the size of the brain and therefore compromises current and future economic growth of nations. Stunted children today leads to stunted economies tomorrow. It is that simple.”

World Bank president Jim Kim has also talked about how investments in grey matter infrastructure could be the most important infrastructure investments of all. The idea that boosting nutrition means boosting economies resonates with the people who hold the purse strings, said Baker. And yet he described the 1 percent of development assistance that goes into nutrition as “anemic” given the scale of the problem, and said he hopes to see more progress in the way of funding and policy from high-burden countries.

Prior to the 2013 Nutrition for Growth Summit, $400 million of development assistance went to nutrition each year. That number has risen to just shy of $1 billion. And new commitments to advance the global response to malnutrition will be announced this weekend in Milan.

Between high-profile events such as the annual Global Nutrition Summit, Baker and his team at the Gates Foundation are working to mobilize more money for nutrition, while also directly supporting partners working on the political prioritization of nutrition in their own countries. Grantees include the Graca Machel Trust, which works across the African continent on issues including women’s rights and children’s rights; the Scaling Up Nutrition movement, which unites a coalition of actors including 59 member countries working to end malnutrition by 2030; and a new initiative called African Leaders for Nutrition, which Baker said he hopes will get nutrition on the agenda at the annual African Union Summit.

The global development community must focus not only on reducing mortality, but also on improving well-being, Baker said, echoing the insight in the Bill and Melinda Gates report that, when it comes to stunting, limited physical growth is a proxy for poor cognitive and emotional development.

“If we don’t worry about the well-being of children, we’re actually trapping them in a vicious cycle of poverty, because all of the other investments in education, etc., are going to be suboptimal because we’ve deprived children of basic good development outcomes from the get go,” Baker told Devex.

Part of the reason that nutrition resonates so strongly with Bill and Melinda Gates, Baker said, is both because it is a necessary focus for a foundation working to ensure that children can not only survive but also thrive, and because it is a difficult problem to solve that requires different sectors to work together.

“When they see a gnarly problem, they get even more intrigued,” he said.

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