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Jayaseelan Naidoo Headshot

Banishing Malnutrition - The Struggle Continues

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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 the Global Alliance for Improved Nutrition (GAIN), as Chair of the Board. This is an organization that captured my attention almost a decade ago, and has kept me enthralled ever since.

An idea initiated by a few big thinkers after a thorough review of the data about why so many people across the globe were malnourished and often permanently mentally and physically handicapped for life, 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 recognized that most people, even poor people, engage with markets to get their food rather than health clinics; audacious because it recognized 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 two 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, opened the door for increased inclusion particularly from consumers and most notably women, and confronted the reality that to have a lasting impact would necessitate efforts being not just piloted, but taken to scale.

While this 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 and 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, access at least some portion of their food through markets or that preventing chronic malnutrition is both less expensive and more cost-effective than treating it. Essentially it is the market and private entrepreneurs from village to global level that primarily produce food. That with increasing migration that would see the bulk of our global population in city slums dependent on industrially produced foods and where household food security was 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 at causing close to 11 percent of the global disease burden and some 35 percent of all child deaths under five. Astounding that 3.5 million children a year were dying.That close to two million children are physically and mentally handicapped from diets largely insufficient in vitamins, minerals, fats and proteins resulting in national reductions in GDP estimated at 2-3 percent.

It had a difficult start, and the first years were not easy. Operational and governance issues, including a lack of infrastructure and an implementation model that was untested and thus unproven in the developing world made for some false starts, but by 2005 those problems were largely sorted out, and the programs began to take root.

GAIN had started with large-scale fortification programs, a wise decision given that food in the developed world had been successfully fortified since the 1920's 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 along with numerous other staple mainstays in the diets of the poor and eaten in regular quantities were fortified. GAIN's unique approach, to work with the public sector on the legislation and regulatory environments, the private sector on supply chain issues, demand creation and logistics, and NGO's to help with on the ground 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 realized that addressing the 1,000-day window critical for human development, from conception though the first two years, was another way to target preventing 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 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 six to 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 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 programs.

More recently, GAIN has begun to explore expanding nutrition programs further up the agricultural value chain, to enhance the inputs such as seeds and fertilizer, 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.

In short, GAIN aims to increase the efficiency and effectiveness of the entire food system to deliver information and nutritious foods to the poor at a price they can afford. They do this by educating and empowering consumers, developing new, affordable products and creating demand for and ensuring appropriate promotion of nutritious foods while also reinforcing healthy eating and feeding behaviours.

But is it working? GAIN's programs 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 US 32 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 percent 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 reorganization, prioritizing 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, recognizing the beauty of a good idea, well executed, but still with a long road to travel.

As Archimedes once said "Give me a lever long enough and... we can move the world."
Happy anniversary GAIN. You are an audacious idea that has been translated into a reality.

For further information: www.gainhealth.org