International Development Committee
Oral evidence: UK aid for improving nutrition, HC 811
Tuesday 26 October 2021
Ordered by the House of Commons to be published on 26 October 2021.
Members present: Sarah Champion (Chair); Chris Law; Kate Osamor; Mr Virendra Sharma.
Questions 1 to 39
Witnesses
I: Professor Claire Heffernan, Director, London International Development Centre; and Dr Lawrence Haddad, Executive Director, Global Alliance for Improved Nutrition (GAIN).
II: Dr Agnes Kalibata, President, Alliance for a Green Revolution in Africa (AGRA); Dr Morseda Chowdhury, Director, Health, Nutrition and Population Programme (HNPP) Bangladesh, BRAC; and Grainne Moloney, Senior Nutritional Adviser, UNICEF.
Witnesses: Professor Claire Heffernan and Dr Lawrence Haddad.
Q1 Chair: I want to start this session of the International Development Select Committee looking into nutrition. This is something that the Committee has a long interest in, and rightly so, as malnutrition is a major cause of preventable deaths in the low and middle income countries. The World Health Organisation says it is the main cause of death and disease in the world.
To give some context with some stats, nearly 690 million people a year are hungry, that is 8.9% of population and that is an increase of 10 million in one year; 144 million children under the age of five were affected by stunting, being too short for their age in 2019 and three-quarters of these children live in southern Asia and sub-Saharan Africa. In 2019, close to 750 million people, nearly 10% of the global population, were exposed to severe levels of food insecurity. I think it is right that this Committee has this long interest in nutrition.
We are very lucky to have two panels today. On the first panel we have Professor Claire Heffernan and Dr Lawrence Haddad. Could I ask you both to introduce yourselves and the organisations you work for, starting with Claire?
Professor Heffernan: My name is Professor Claire Heffernan, I am the Director of the London International Development Centre. I am also the principal investigator of the UKRI GCRF Action Against Stunting Hub.
Dr Haddad: My name is Lawrence Haddad, I am the Executive Director of the Global Alliance for Improved Nutrition, which is a non-profit that brings food systems and nutrition together and works with the public sector and the private sector. I used to be the Chair of the Global Nutrition Report and I was the Director of IDS for 10 years.
Q2 Chair: Thank you both very much for joining us. My first question is to Professor Heffernan. Can you explain what the main impacts are of poor nutrition during childhood, particularly looking at the impact of stunting on a child’s development?
Professor Heffernan: Yes, stunting is a constellation of symptoms. It impacts children’s cognitive developments; the mass of the brains of children who are stunted is different. It impacts their educational attainment. They do less well in school. They do not tend to meet their development milestones on time and this stretches out over the life course. There is an intergenerational component; children who are stunted tend to be born to women who are stunted. As they grow up the children, as adults, earn about 20% less than their peers. We can talk about it being a short stature issue but it is a clinical constellation of signs that are related to child stunting.
Q3 Chair: If it was addressed early, say by the time the child was three the nutrition was increased, would the impact, particularly on the brain, be reversible or has the damage been done at that point?
Professor Heffernan: One of the things we are working on is looking at this cascade of good growth to poor growth and when is the best time to intervene. Most of the thinking is the best time to intervene is in the first 1,000 days. It is ensuring that when women are pregnant they get adequate nutrients and adequate micronutrients. That is one of the biggest factors in preventing low birth weight and then children who go on to stunting. We have a bit of a window in which we can address stunting and that is in the first two years. After that it is very difficult to reverse.
Q4 Chair: Are there any other impacts of poor nutrition in childhood?
Professor Heffernan: They have looked at poor nutrition in childhood and what happens looking at the macro level in macroeconomics and how that impacts a country’s GDP. It has an enormous impact. I think we have to start looking at this in a much wider context than we have done to date with specific micronutrient deficiencies or specific energy deficiencies. Child malnutrition has a huge impact; it plays out over the life course and has a huge impact on all of us ultimately.
Q5 Chair: It is not just food, it is the type of food?
Professor Heffernan: Absolutely. There is a whole variety of things and I am sure Lawrence can take us through the details of high nutrients. People cannot afford a high quality diet. This is another one of the parameters. We have food security parameters, we have a prevalence of undernutrition parameters that you mentioned, but we also have the cost of a healthy diet—80% of the people in Africa can’t afford the cost of a healthy diet.
This is not only a developing country issue, this also impacts people in the global north too, as does stunting. Some 2% of children in the UK are classified as stunted. This was a recent study by QMUL.
Chair: Thank you very much.
Q6 Mr Virendra Sharma: Dr Haddad, as the Chair said in her opening comments, the UN estimates that nearly 690 million people are hungry, an increase of 60 million over the past five years. What are the reasons for this increase?
Dr Haddad: I tend to use the FAO hunger numbers but they all come from the same source. They show that hunger has gone up by about 20% in the last year, which is the biggest increase I have seen ever and I have been doing this for quite a long time.
They were going up even before Covid. Covid is obviously a big accelerant, but they were going up before because of conflict, climate and now Covid. Five years ago they started rising. Climate has put a lot of pressure on farmers, conflict is putting pressure on people, people are weaponising food, but Covid has been the accelerant and that has driven everything up. That is because people are losing jobs, incomes are getting lost, food prices are going up as food systems are disrupted and health systems are disrupted so kids can’t get the other vital vaccinations they need and the other treatments they need. It is a triple whammy of lower income, food system disruption and health system disruption. That is driving everything up. We think conflict is responsible for about a third of all hunger but the other two-thirds are entirely developmental.
Q7 Chair: Professor Heffernan, how likely is it that we will reach sustainable development goal 2? That is the one to end hunger, achieve food security and improve nutrition and promote sustainable agriculture. We are meant to be meeting that by 2030. Are we on target for that? If not, what are the barriers?
Professor Heffernan: Everybody recognises that even before Covid we were not on target for SDG2. That is just a fact. With Covid the challenges get even worse. I am an optimist and I do not think it is impossible, but we have to completely change and transition from how we deliver aid and development now to what is required to meet the stunting goal. There are many challenges. Stunting is embedded in political, economic and social structures, as is malnutrition, and these have to change.
I am a cautious optimist and I think if we can get sufficient groundswell of transformation in how we look at these issues it is possible. At the moment, though, we are not on a pathway to meet that goal.
Q8 Chair: I love your optimism but tell me why we are not fully on track now. What are the barriers? What needs to be done?
Professor Heffernan: We will not fully know the impact of the Covid pandemic on child stunting until, I think, 2025 or even 2030 itself. Child stunting is a long-term condition. We have a much better take on child wasting but less on child stunting. The other problem that we have that makes meeting this goal difficult is a cut-off point for child stunting. Two standard deviations below the WHO mean of height for age is a cut-off. In reality we have many children who live below that cut-off but have many of the signs, symptoms and constellation of features of stunting. We have an additional population of children that we know very little about that are still impacted by malnutrition.
There are a number of barriers. The first barrier is understanding where these children are. A second barrier is that our approach to nutritional interventions tend to be very blanket: what works in one place will apply over here, we know that does not work. We need a different way to address malnutrition, which has very different drivers, forces, features in different geographies.
The other thing is that we need a much more joined-up approach. We have three summits. We have a food system summit, a climate summit and a nutrition for growth summit. We need the experts who are going off to the three summits all together to solve stunting and malnutrition. Those to me are the top three challenges.
Q9 Chair: Lawrence, do you share Claire’s optimism?
Dr Haddad: There are certainly countries that are on target to meet their stunting goals for 2025 as well as 2030 actually. They are quite big countries—Bangladesh, Vietnam, Ghana. The real problem with malnutrition is that it has lots of different sources. Lots of things can go wrong to tip a child into malnutrition. They do not get enough food, they do not get enough of the right kind of food, they do not get clean water, clean sanitation, they do not have enough of a care taker’s time and attention because feeding a young child is a very time-consuming activity. They do not get enough of the right healthcare. There are lots of different things that can go wrong. That means you need lots of different things to line up to fix stunting, to reduce stunting rapidly.
Ghana, Vietnam and Bangladesh have a nutrition strategy that says it is not just the health system’s responsibility, it is not just the food system’s responsibility, it is everyone’s. This is what despairs me about FCDO, which does not have a nutrition strategy at all. I think it is an essential prerequisite to making big impacts on nutrition.
Q10 Chair: Looking at other donors, are they putting the resources to the countries where they need to be to back up—it is all very well Ghana having a plan but, for example, does the FCDO recognise that plan and support that plan?
Dr Haddad: FCDO, when it was DfID—not because it was DfID just when it was called DfID—used to be the global leader in nutrition. It had a golden period of about 2009 through to 2015-16 when it was the premier convenor, the premier thought leader and the premier investor. I was running the Global Nutrition Report, which came out of the Nutrition for Growth 2013 summit that the UK hosted, and that report was there to track donors. Donors said this in 2013 but would they deliver?
The UK was supposed to deliver in 2020 and it delivered two or three years before then. Since then there is no compass on nutrition, there is no urgency on nutrition and you cannot build back better unless you take care of kids in the first 1,000 days of life, as Claire said. I like to think of a kid as a bud that is either attacked or not attacked by severe frost. If a bud is attacked by severe frost it can grow, of course it can flourish, but there is a scar that it carries with it for the rest of its life. It is like drying concrete. When concrete dries, if there is a disruption to that concrete that sticks with the kid.
If you do not fix it in the first two years, plus the pregnancy period, there can be some catch-up afterwards—it is hardly a contested scientific area, but it is not anywhere near enough. Sorry, I am very passionate about this topic. Until you have seen a kid who is really malnourished you just don’t get it.
Q11 Chair: You do not think the Department gets it at the moment?
Dr Haddad: No.
Q12 Chair: What needs to shift?
Dr Haddad: I read the ICAI reports a lot and I was refreshing my memory of the one it did last year on DfID and nutrition and they praised the DfID quite a bit for some things but it said it is a big mistake now to not have a strategy. This stuff will just fall through the cracks because no one really owns it. We always say in nutrition it is everybody’s business but nobody’s responsibility. That is what is going to happen. I am very worried about it.
It also needs to step up big on nutrition for growth. The Canadians, the Americans, the Germans, the Irish, the Gates Foundation, they will all step up, but the UK was traditionally the second or third biggest and it desperately needs to step up intellectually and with investment.
Chair: This Committee has been trying but has been unable for the last year to get that commitment out of the Department.
Dr Haddad: Thank you for trying.
Q13 Chris Law: We definitely will keep on trying and pressing home the urgent requirement to change. You mentioned the Covid-19 pandemic has increased the number of people going hungry by 20% in the last year. The rollout of the Covid vaccination has been very successful in western countries but very poor in the global setting elsewhere.
Can you tell me what the challenges have been in particular with the Covid-19 pandemic on improving nutritional levels? Are there particular communities that have faced extreme difficulties as a result in improving nutrition during the pandemic? What are your thoughts about how important it is to get this vaccination rolled out as quickly as possible globally?
Professor Heffernan: We know that Covid had very direct impacts. Food and nutritional programmes, basic healthcare and vaccinations were stopped. The UN estimated that just in the first lockdown in Asia in spring of 2020 up to 200,000 children were classified as excess deaths during this time because they did not receive these services. I think Covid has had a massive impact on highly vulnerable populations, but what is equally interesting is that these populations don’t bounce back.
There has been a variety of different research, particularly in India, that shows that six months after the lockdown households are still existing on one meal a day. You have this highly vulnerable population, very little resilience and this huge economic, social, health problem. You see they are sliding down the slope into extreme poverty. A health crisis has turned into a child nutritional crisis almost overnight.
The way that we need to get back to that and address it is to realise that going forward into these disruptions related to climate change and conflict and so on, we need to build more resilient systems that respond to the needs of the people that are—I hate to use this term—at the bottom of the pyramid. That is the group of people that we need to better serve in global development.
Dr Haddad: I agree with what Claire said. It is no surprise that the most vulnerable, the most marginal are the ones most affected by this massive stress test. Stress test is too trivial a term to call Covid but it has been a stress test on our health systems, our economic systems and our food systems.
The estimates from the group that I am a part of called Standing Together for Nutrition came out in Nature this summer. It is a collaboration between GAIN, John Hopkins and various universities. We estimate that the numbers of wasted children—these are children who are too thin and are much more vulnerable to mortality than other forms of malnutrition—went from 47 million in 2019 and will go, unless we do something, to 60 million by the end of 2022. That is a 13 million increase. For context, it took about 10 years to decrease that number by about half of 13 million. Covid has essentially turned the clock back on wasting numbers.
What to do about it? There is lots of things that can be done but there is no one thing that will solve it and this is the point that Claire and I are trying to make. There is a list of things that can be done and we need to have a strategy and it is not the same list in every context. For example, there are lots of social protection programmes, cash transfer programmes, and these sky rocketed during Covid, which is great. We need to protect, so they did in the UK and everywhere around the world, but they are not connected to the production and consumption of nutritious food. There is an opportunity to leverage those massive resources and steer them towards nutrition.
I am very worried about farmer planting. We have had food supply disruption, food getting from the farm to the markets. I am now worried about inputs getting to the farmers so they can grow the food. They may or may not make it to the farmers. I am an optimist but I am fearful of what is going to happen unless we do something different. Climate is just making it worse. The Nutrition for Growth Summit, the people who care about nutrition, all the political energy and the finances in climate and Covid right now—we need leadership and I can’t say it enough, this is where strategy comes in. Rather than say, “They should give us our money”, how can we go to them and say, “If you want to reduce greenhouse gas emissions, you should be paying attention to nutrition” because healthy diets tend to emit fewer greenhouse gases. If you want to deal with Covid and protect your population from Covid and you cannot get vaccination rates up above 4% in Africa, your next best of line of defence is improving nutrition because that strengthens the immune system. That does not stop Covid but it stops the comorbidities that make Covid very severe.
It is this kind of leap of imagination, policy work and strategising that needs to get resources into nutrition. ODA is £150 billion a year. You guys know this better than me. About £1 billion of that goes to direct nutrition intervention, so one out of 150. I think that number should be £2 billion, but the real play is to go after some of the other £148 billion, to make that relevant for nutrition, not because those other sectors are giving it to nutrition but because nutrition can help those other sectors achieve their goals.
Q14 Chris Law: Thank you, Lawrence and Claire. Those were both very comprehensive and insightful answers.
I will direct this question to Claire. Are we entering a perfect storm now? We have talked about Covid and the impact of climate but we also have to consider the cuts that the UK budget has made, reducing its GNI from 0.7% to 0.5%. What impact do you expect this reduction to have on the UK Government’s nutrition programming, given that we have already heard that it has slipped down the scale from where it used to be world leading? Have you witnessed any impact on the ground of this reduction already?
Professor Heffernan: Thank you for asking about that. Absolutely. We were, at the hub, subjected to budget cuts, in which case what happens is our work stops in the field where we have trials going on and an observational cohort where we are following women. All of that work stops to deal with this budget crisis. I don’t understand why when our hub speaks to six of the seven FCDO priorities, and equally we are basic science research, we would have been impacted by these cuts but we absolutely were.
I think I can speak for the research sector. You funded global challenges. The Global Challenges Research Fund was incredibly successful. We need interdisciplinary teams to resolve and solve these challenges. By almost overnight taking all the money away from that, you are taking away thought leadership and putting the research community—I know that at least over 40 projects were cut across some of the institutions that are part of LIDC. We had projects cut that were creating filters to take away antibiotic pollution from the Nairobi River. All of these really intractable global challenges had funding cut, so how does the research community come back from that? It is very difficult. You lose research fellows and staff. People don’t want to work in the UK research environment because it is too unstable. Your funder may suddenly decide that you are not going to get money anymore.
How has that impacted on the ground? It has had a deep impact, certainly on the projects that I am aware of, by decreasing the number of people they can hire. There have been hiring freezes, money going back to the Government of the coffers, work has to be completely reorganised. It has been a very challenging time for the UK research community, working on ODA and global challenge research.
Q15 Chris Law: I really appreciate what you have said, Claire. Recently it was reported by a significantly large NGO that a million excess children deaths will happen as a result of these cuts. Is that an underestimate, given what we have been suggesting already?
Professor Heffernan: Absolutely not. When you reach into the NGO sector you see real impacts of feeding programmes, child school programmes, child health programmes being cut. I don’t think it is an underestimation at all. Research works on top of that to try to work out what is going on. We support these programmes but the actual deep on the ground cut for the NGO community—it is horrifying when you hear about what has been happening on the ground.
Q16 Chris Law: Thank you, Claire. I will put that question to you, Lawrence.
Dr Haddad: GAIN is an NGO that does programmes on the ground in nine countries. We aim to reach 6 million kids over the next five years and improve their diets. We don’t receive any funding from DfID at the moment but if someone cut our budget by one third, which is the cut that FCDO has put in place, we would not be able to get nutritious food to kids, we would not be able to get vitamin A capsules to kids and their mothers, we would not be able to get therapeutic foods, clean water, good sanitation. The price of nutritious foods would triple in the markets that we work in.
You heard from Claire that three-quarters of the population of Africa can’t afford a healthy diet. Only about half of them can afford a minimally nutritionally adequate diet and only about 20% of kids under the age of three get a minimally adequate diet. That number will go down because of the DfID cuts, the FCDO cuts. It has real consequences for the most vulnerable in society.
Chair: It is hard to move forward from that. The problem is that it is difficult to see the impact the real cuts are having on real people and that is something that we are constantly trying to get to the bottom of. I appreciate both of you sharing your experiences of that and trying to give us some proper understanding of what a line in a Treasury budget actually means. Thank you.
Q17 Mr Virendra Sharma: I can feel it when you talk. I come from the background and I have witnessed it. I am shocked that after leaving the country for so many years, as Claire said, in a country like India the children are still suffering and not getting adequate meals. That is shocking to me, but I hope we will all work together on that again. Evidence suggests that children from poorer households and marginalised communities are more likely to suffer from poor nutrition. How can governments ensure that nutrition interventions are reaching the most marginalised people, including people in fragile and conflict-affected states?
Dr Haddad: One of the former directors-general of FAO once told me that hungry malnourished people don’t have a union, they don’t have an association. A big part of this—and we know this from way back when—is about voice. The most marginalised need to have voice. How do we ensure they have voice in India? It is through village councils in India, so it is bottom up and it is top down. The Indian Government have a strategy for dealing with malnutrition. They have had a number of setbacks but before Covid they were making really good progress. The poorest are most at risk of malnutrition, that is for sure, but you would be surprised at how malnutrition reaches into the upper income groups even in a country like India. Stunting rates in the upper 20% of Indian population will be something like 15% or 20%. In the lowest income group it will be something like 50%. It is linked to income but it is loosely linked.
As I said, it is linked to this whole network of can the kids get the right care, the right water, the right food, the right healthcare? Money can help you buy some of those things but it can’t help you buy some of those things because they may not be available in the market. Having more money does not mean that you can get better healthcare necessarily.
Governments are putting in place these cash transfer programmes that reach the most marginal. India has a plethora of them and Bangladesh has a lot. The nine countries where we work all have them. The challenge is to get them to the last mile. They usually go pretty well to the penultimate 10% but not the final, the bottom 10%, so it is getting them to the bottom 10% and it is linking the money with services. Even if you get the money to those households, there are no services for them to buy, so it is building the services around them and getting the income to them.
That has to be a combination of the public sector and the private sector, because most people even in the poorest parts of poor countries buy their food. They grow some of it but they mostly buy their food. They are net purchasers and if you buy food you are interacting with the private sector. It is about using public sector funding to prop up income at the lowest and then using public sector income to catalyse and derisk private sector investment.
One example—and then I will stop talking because I am going on—is using public funds to set up an impact investing fund that will invest in small and medium enterprises that are producing nutritious foods, not for export but for domestic consumption—nutritious foods: fruits, vegetables, pulses, eggs, dairy. These small and medium enterprises are the backbone of most food systems in Africa and south Asia but they are too big for micro finance and too small for formal finance. They are stuck in the middle. Here is an example where a government can put in 5 million and can leverage 95 million in private sector funding, but that is not easy for governments because it requires new institutional mechanisms. I am sorry for the long answer.
Chair: No, please, we are fascinated by this.
Professor Heffernan: I absolutely agree with that and one of the elements of our hub was to support SMEs with small amounts of money to scale up their activities around nutrition in the communities that they were working with, but unfortunately that was cut. I agree that we need new mechanisms of funding. We need to engage new partners. How do we ensure that these people are being helped and served? The Indian Government is quite a good example of a real dedication to reach the most marginalised whereas I think in other countries there is more of an issue with how to get these services to people who are really outwith. How do you reach people in informal settlements that have no kind of address? The NGO community has been quite successful at that but we do not do it at scale. We need government partners to do this at scale.
Q18 Chair: Lawrence, you spoke about the difficulty of getting to the final 10% of people with cash. Who are they and are there examples where countries have managed to reach everybody?
Dr Haddad: They are typically people who are destitute in urban centres. They could be landless labourers who probably work only 20 days a year. They are basically the poorest of the poor. They have very few economic assets, financial assets, social assets. They are not part of networks. They are kind of abandoned for one reason or another. Are there good examples? There are examples. It is not easy.
There are some good examples in Bangladesh. The Vulnerable Group Development programme is run through BRAC, the biggest NGO in the world, and it is very good at working with the extremely poor, but again you have to have the intent and—I come back to the word “strategy”—you have to have a strategy for reaching them. If you don’t have a strategy you will do okay with the people between maybe $3.20 a day and $2 a day, but below $2 a day you are really going to struggle. The work we do at GAIN is reaching people, improving their consumption of safe and nutritious food, through a combination of public sector and private sector and we really have to work hard to get to the people below $1.9, the extreme poverty level. It requires a deliberate strategy. It is not enough to say produce more food and build the demand for food; you need to do much more than that.
I don’t want to create an impression that this is all hopeless—it is not. We know what to do. We have a plethora of interventions about what to do. They are all evidence based. We even know how much they are going to cost, we know what impact they will have, we know the economic returns they will generate: 16:1 is the economic return, better than the Dow Jones Industrial Index over the last 80 years. It is just a question of prioritising.
The problem is that the material benefit to the politicians never really shows up because very young kids don’t vote and it usually takes a long time. As Claire was saying, you see the economic returns from investing in these kids in 20 years’ time. You see the existential benefits that they don’t die but again that is not something you can really parlay into politics. It requires an explicit determination on the part of politicians, domestic and international, to make a dent on this issue.
Chair: Thank you. I will hand over to my colleague Kate who is always trying to make a dent on this issue.
Dr Haddad: I know you do, yes. I remember.
Q19 Kate Osamor: Thank you, Lawrence. I just want to put on record that some politicians help people who can’t vote for them as well. I just thought I would let you know.
Thank you, Lawrence and Claire, for everything you have said thus far. Lawrence, earlier you spoke about the complex interconnected system that at times gets in the way—I will use that word—of people getting good nutrition. This is something that, of course, many countries are grappling with. I want to ask you about another thing that countries should be grappling with, which is climate change and how it is impacting on the global food system. Do you have thoughts on that?
Dr Haddad: Yes. A couple of my staff are at COP next week and we are on a number of panels. It is unusual for nutrition organisations to engage with this but I think there is a couple of things on the mitigation side and a couple of things on the adaptation side.
On the mitigation side, I think I mentioned earlier that it is important that food is part of this conversation. Food systems generate 30% of the greenhouse gas emissions that we worry about and so you can’t fix climate unless you fix food, but you can’t actually fix food unless you fix climate either. We are doing a lot of work.
There are three things you hear a lot about. One is people should become vegetarian. In high income countries there are probably lots of good reasons why people should eat less animal-source food, for their own health and it will help greenhouse gas emission reduction, but in the countries that Claire and I work in we want kids and malnourished people to consume more animal-source foods. If they are lucky they get three bowls a day of food staple gruel, basically, with very little else in it. We want them to have a little bit of some beans, some dried fish.
Why would that be of concern to the climate community? It is because this production and consumption is going to increase and if it is done in the wrong way it will generate massive increases in greenhouse gas emissions. We know that in low income countries the efficiency of producing animal-source foods with the amount of greenhouse gases that are produced is really bad. In North America and Europe herd sizes have been declining rapidly over the last 30 years and feeding more people but in Africa and south Asia herd sizes are two, three or four times as big but feeding the same number of people. There is a big reason for climate people to be working with nutrition people to say, “How can we make these animal-source food production systems more efficient?” There is a big reason for nutrition people to be engaging with climate people because as there is more CO2 in the air we know that the nutrient density of cereals goes down.
The density of nutrients in cereals goes down the more CO2 there is, so we need to figure out on the adaptation side how to produce staple foods that have more nutrients in them; how can we make fruits, nuts, vegetables, eggs, dairy cheaper to offset the climate? We need a whole suite of climate resilient foods. The food system is a culprit for climate change but it is also a victim of climate change and we need to look at it in both those ways.
My dream is that next year at COP27 there will be dozens and dozens and dozens of nutrition side events. I would like to see food much more clearly embedded in the NDCs from COP26. It is not there yet because the Glasgow COP is not really about food but the African one next year in Rwanda will be about food.
Professor Heffernan: Lawrence, that is great because I completely agree with you on animal-source foods.
Dr Haddad: Sorry, Claire, I waffled on a long time then.
Professor Heffernan: You see a vast majority of livestock production of milk and meat comes from the global north and the vast majority of animals are in the global south, so you have a real disparity. You have countries that are importing milk and the cost of these imports for animal-source food is astronomical when you really look at it. You are starting to see local trade in milk products and what I think will happen in the next 10 years is simply a great shift of production in the north being sold to the global south as these livestock production systems become more and more unstable and unsuitable.
I can see that livestock and animal-source food will be rapidly out of reach of the core and it will become something that wealthy citizens in the global south are able to access. We have inequities and disparities in the global food systems that we know about now, so how do we address that?
This is what needs to happen at the summit and going forward into climate change and health. We can’t take health out of the picture either. It is a triumvirate of elements that impact people’s wellbeing and they are interlinked and synergistic challenges. We need to rethink and transition food systems into resilience and sustainability and at this point we have neither.
Dr Haddad: I completely agree with Claire. I would like to see FCDO at the forefront of helping countries in the global south develop animal-source food expansions that are not going to wreck the climate for everyone, including those countries. We are at an inflection point now. What happened in China 20 years ago with pork consumption doing this—many countries in Africa are close to take-off and take-off could be a catastrophe for the climate or it could be one of the saviours of the planet. I would like to see FCDO at the forefront of that. It plays to the strengths of COP and it plays to the not so distant strengths around nutrition.
Q20 Kate Osamor: Thank you. What commitments would you like to see come out of the Nutrition for Growth Summit in December?
Professor Heffernan: I would like to see a commitment to solving child stunting. That is what I want to see and solving child stunting is not implementation research, it is solutions-based research. Let’s start at the end. Let’s start where we want to be and get the global experts in the room that need to be there to solve this. That is what I would to like see; I want to see a solution.
We will get funding, there is funding and, as Lawrence said, there is this drive for synergies between the climate community and the nutrition community. We are starting to see that in the health community and we can see that there will be synergistic projects and programmes coming up, but I think we need to start talking about solutions. That is what I would like to see.
Dr Haddad: Kate, did you mean specifically the UK or in general?
Kate Osamor: Both.
Dr Haddad: In general, N4G 2013 was the high point for nutrition in the last 10 years. It has gone off the boil a little bit and here is a chance to reinject some energy and some dynamism into this space just when the world’s kids need it the most. I am giving all of of the donors, all of the governments, all of the organisations like mine—we are making commitments for N4G. We made commitments to the Food Systems Summit. Claire’s organisation will also make commitments.
We all need to make commitments, so it is about re-energising that space that has gone off the boil. I sent you a note, a one-pager. I don’t know if you managed to see it. I would like to see FCDO say, “We care about this topic. We have a strategy for this topic. We are going to make a commitment in N4G[1] that is the equivalent of the commitment we made in 2013”. I am not asking for the earth or a crazy request; it is what you did in 2013. A similar level to 2013 would be about £180 million a year, that is less than 2% of the £10 billion. I do not know what it is at the moment but it is a lot less than that.
I would like to see a really specific commitment; I do not want the UK to relinquish its role. This is a massive chance for the UK to show global leadership. You cannot build back better unless you build on the foundation of healthy brains and healthy immune systems. I would also like to see a special envoy appointed by the UK. We have a special envoy in the wonderful Nick Dyer but that is humanitarian and famine and we need someone in the development space.
Q21 Chris Law: To build on the point that we need a special envoy, do you agree that we need the Cabinet Secretary back at the table to talk specifically about the needs of development and humanitarian aid?
Dr Haddad: Absolutely. It is an issue for global Britain; there are so many indirect and direct benefits to the UK. To me it is a national security issue, Henry Kissinger said it well back in the 1960s that poverty overseas is a national security issue. There are so many reasons why it is the right and smart thing to do, otherwise those people’s voices will not be heard. There is a truism that if you are not at the table you will be on the menu and I think that is going to be the case here.
Kate Osamor: That was like the aid budget.
Dr Haddad: Exactly.
Q22 Chair: Lawrence, I am still slightly shocked by this. You said it is unusual for nutrition to engage with climate change?
Dr Haddad: Yes, they are different communities.
Chair: While you have been speaking, I have been thinking that is the same with health in this country in that nutrition is very much seen as an add-on or a separate discipline, whereas tackling obesity, for example, has a huge strain on the NHS so good healthy food helps everyone. Why is there that gap when it comes to development? You are working with the farmers and the producers so why is there that disconnect between the two disciplines?
Dr Haddad: For a long time—Claire knows this as well—all we cared about was the quantity of food produced and people thought hunger and malnutrition were the same things. Then in the 1970s we saw in India again—but we could have seen it anywhere—the places that produce the most food have the highest levels of malnutrition. People quickly began to realise it is not about producing the quantity of food, it is about being able to afford the right kind of food plus all the other things, the water, health, sanitation.
Nutrition is this orphan issue that is in the middle of everything, but because it is in the middle of everything it is like mercury: it falls through the cracks. That is why you need to have a plan to draw on the best of all the sectors to say in climate, school meals, the health system for obesity, the transport industry and in the markets we are going to bring all of these talents and resources together. We cannot just rely on the health system; it is overwhelmed. They cannot do it so you need a plan to bring all of these pieces together.
I have talked about new money but the main story is about aligning money, aligning everything up. The countries that have done really well—and there are some states in India that have done brilliantly. Maharashtra is a massive state of 80 million people and it has done brilliantly and has halved its stunting rate in a 13-year period because it has aligned all the resources. In agriculture, they have subsidised the production of things that matter for stunting. They have not increased the subsidies; they have switched them. In their procurement programmes they have bought foods that matter for their safety net programme. Instead of just staples, there are pulses as well because pulses are really good. In schools they have taught nutrition. They have oriented all of the massive resource flows towards nutrition but there is no ministry of nutrition anywhere so there is no one who has the responsibility to do this.
Every country that has been successful has appointed somebody to look at the broad set of resources that are available and to ask how these resources can be shifted by 1% or 2% in this direction to have a really massive impact on nutrition.
Q23 Chair: You mentioned the private sector. One of my concerns is the big multinationals with their food production and also their marketing budgets. I think it is very rare to go anywhere, however remote, and not see an advert for Coca-Cola for example, or cereals or whatever it is. Is it about the countries having the confidence to be growing the right food for their own people rather than just the short termism of the export market?
Dr Haddad: I think a lot of countries do not realise that poor quality diet is responsible for most of their health burden and it is the same in the UK.
Chair: Very much so.
Dr Haddad: If you look at the top 10 risk factors for the burden of disease, which is mortality plus morbidity, five or six of the 10 will be related to diet. The policymakers just do not get that their health system is being wrecked by their food system. That is part of it.
The private sector is very heterogenous. You have the big corporations—there is food and non-food, then you have the big corporations, the multinationals, the big nationals, the medium and the small. Most people in south Asia and sub-Saharan Africa depend on small and medium enterprises for their food and advertising can be pernicious, and sometimes the multinationals behave very badly. They need to be called out on it; the products they produce are not healthy enough, but really the concern is with the small to medium enterprises. If you are producing, processing, selling, distributing vegetables you need support from your government not just for export, which is important, but for domestic consumption. Too few governments do that and that is a policy issue. Again, FCDO could really help support governments to do that.
Professor Heffernan: I absolutely agree with Lawrence, but I see this problem in a slightly different lens. One of the problems that we have is expertise, and developing nutritional experts, climate change experts. We develop cadres of expertise that often cannot talk to one another and often they are not going to be able to move into a solution space together to solve the problem. These are complex, wicked problems. I think we have a capacity issue and the research community needs to train, build and strengthen capacity and introduce similarity in understanding complex problems, and we do not have that. I can see that at the PhD level and as students come up through the ranks. I think that is one thing we can address.
I absolutely agree with Lawrence that we need better ways to engage all the stakeholders including the commercial companies, who need to be shamed into doing better. We need to understand what they do to enable people to buy these products that we are not doing in the healthy food space. It is one of the things we are looking at in the hub; you can market Coca-Cola very effectively but you cannot market good healthy green vegetables.
What are these trigger points that we need to get much more savvy on and fight fire with fire at the community level concerning healthy foods and diets? There is a lot of research work that needs to be done and we need to be much more joined up in how we approach this.
Dr Haddad: I completely agree on the research side of things. I am an economist. I have studied nutrition but I am not a nutritionist, but you need different disciplines to come together to resolve this issue. One of the big gaps we find in the research space—I do not know if you find this, Claire—is that GAIN, as an implementing organisation, does not know about the trade-offs between climate, nutrition, resilience, economic livelihoods, and environment. We do not know enough about those trade-offs. All the evidence we have comes from Europe and North America, and not enough from south Asia or sub-Saharan Africa. There is a big research agenda right there.
Chair: Very interesting.
Q24 Kate Osamor: Lawrence, could you tell us a little about the coalition that you are a member of, Standing Together for Nutrition?
Dr Haddad: We were inspired by the scientists who came together to develop a vaccine really quickly and share data. A group of us said, “What is happening? We need one set of estimates that the UN can use and that the UK Government can use”. We pulled together researchers from Hopkins, the World Bank, IFPRI, which is a food policy research institute, GAIN, Micronutrient Forum and a bunch of others.
One group had a model on child deaths, another group had a model on food prices, another on how much it costs. We put them all together and the first paper was published in The Lancet in July of last year, the second one was in Nature this year. It is ongoing and is a small group of enthusiasts but I think that the estimates they have are the best estimates out there. I am happy to share the reports.
Q25 Chair: What is the group called?
Dr Haddad: Standing Together for Nutrition.
Chair: If you could share the reports and we will get a link.
Dr Haddad: I will. They are massively short, two reports.
Chair: They are more likely to be read, thank you very much.
Lawrence and Claire, thank you so much for your contribution. You have shocked and depressed. I am really trying to find your optimism, both of you, but we have to do something and we have to maintain the hope that we can make the change that we need to see. Thank you very much for your contributions today.
Dr Haddad: Thank you. It is not a gift, it is not a hopeless thing, we know what to do. Thank you for your efforts; I know Claire will thank you—what you do is really important. This is my seventh or eighth appearance before this Committee since 2008 and you play such an important role. You may not hear that from outsiders but we look to you and what you do is very important, so thank you.
Witnesses: Dr Agnes Kalibata, Dr Morseda Chowdhury and Grainne Moloney.
Q26 Chair: We will start with panel 2 of the International Development Committee’s inquiry into nutrition. We are very fortunate to be joined by three women. We have Dr Kalibata, Dr Chowdhury and Grainne Moloney. Please introduce yourself and your organisation in that order, and then I will hand over to my colleagues. We will direct questions to each of you but raise your hand if you want to come in and we will bring you in afterwards.
Dr Kalibata: My name is Agnes Kalibata. I am the President of the Alliance for a Green Revolution in Africa. It is one of the organisations that works with the FCDO. I am also the current special envoy for the Nutrition for Growth Summit and I am happy to be here to have a conversation with you.
Dr Chowdhury: Thank you for giving me the opportunity to appear in front of the Committee. This is my first time and I am very honoured and humbled to be here. My name is Morseda Chowdhury and I am the Director of the health programme and BRAC is a social development organisation. It was established in 1972 and was started to provide relief for war-ravaged returning refugees just after the liberation war of Bangladesh.
At that time BRAC was really a rehabilitation assistance committee. Soon after, BRAC set a longer-term sustainable development mission and changed its name to Bangladesh Rural Advancement Committee, but now BRAC stands for BRAC. This indigenous NGO has gone global in 2000 and expanded its footprint in 11 more countries. BRAC has explicitly a “learning by doing” philosophy and is driven by the motive “leaving no one behind”.
The major area of work is social development, social enterprise, investment and university. For social development, our focus is explicitly on elimination of existing poverty, climate change, gender equality, universal healthcare, nutrition, education, and so on.
Grainne Moloney: Thank you so much, Chair. I am delighted to be speaking today. My name is Grainne Moloney and I am a senior nutrition adviser with UNICEF in our headquarters in New York. I lead our work on early childhood nutrition, so nutrition from zero to five years of age. I have been in this position for the last year and prior to that I spent 20 years mostly in sub-Saharan Africa working on public health nutrition policy and programming and many contacts in partnership with DfID and FCDO. I am delighted to be here.
Q27 Kate Osamor: I have a question for Grainne. In UNICEF’s recent report, Fed to Fail? you said that children’s diets have seen little to no progress over the past 10 years. What are the main reasons for this lack of progress?
Grainne Moloney: That is a great question. We released our report, Fed to Fail? regarding the crisis of nutrition in early childhood just before the Food Systems Summit to draw attention to the particular challenges of complementary feeding, the age group six to 23 months. We are not talking about breastfeeding; we are talking about the complementary foods in addition to breast milk and other livestock milk.
Our report is based on 90% of all under-twos in the world, so it is very comprehensive. We have a global database looking at data from 135 countries. The reason why this age group is so important—and building off the earlier panellists—is that the needs are huge. The body weight of babies under the age of two quadruples and their height increases by 75% yet they have little tummies and they can only eat very small amounts of food, so every bite counts.
Our research pulled together analysis from several different sources and came up with 80 findings. The first one is that children six to 23 months are not fed enough of the right foods at the right time. For example, about 27% of infants in this age group are not provided with any solids; they are still on milk. Our youngest children in the six to 11 months old age group have very low diversity in their diet. Less than half are meeting the nutrients they need in their diet. That is the first point, that children are not fed enough of the right foods at the right time.
The second point, as you mentioned, which is quite depressing is that children’s diets have seen little or no improvement. We show that where our minimum dietary diversity data went from 21% in 2010 to only 24%. It is mostly in sub-Saharan Africa and south Asia where we see the least progress. We have some success stories, particularly in the Latin American and Caribbean region where over two-thirds of our children are meeting their diversity needs, and in those regions and countries where there have been large social welfare programmes such as protection programmes, and we have also seen wasting levels really reduce. Unfortunately, in many regions in the world we are not seeing that progress.
It is not equal even within countries. The children from the rural areas, the poorest, the youngest, the most marginalised are the ones that are the most affected, and again this was touched on in your earlier panel.
Families are struggling to find and afford nutritious food for their children. What is sad is that there is a proliferation of ultra-processed, cheap food—what we would call junk food—on the market that parents are choosing to feed their children because they can’t find or afford nutritious food. One finding that I felt was quite sad was that when we interviewed mothers from 18 countries, over two-quarters of them said they had given their baby, aged from six to 23 months of age, an ultra-processed drink or food in the previous 24 hours because that is what they could afford. That is what their options are. They are under pressure, they are working, and their choices are limited—so this is a major challenge.
Then there are social, cultural and gender barriers in different communities where the mothers and caregivers do not have the opportunity to make the choices and purchase the food they wish to for their children. Finally, the other major reason is that this is not given enough attention. Policies and programmes are not being prioritised and the impact of Covid is increasing that further. That is an overview of what our findings provided.
Q28 Kate Osamor: I want to ask a little bit about the countries where there were some improvements; you spoke briefly about Latin America and the Caribbean. Can you give the Committee some reasons behind that success?
Grainne Moloney: Yes, absolutely. We have seen improvements in those countries. As well as in the last 10 years and more so in the last 20 to 30 years, there has been a general progression. It is in countries where they prioritise nutrition. They have nutrition policies and strategies, they have very large social welfare interventions that really target the poorest and they provide a holistic package of support to those families. It is looking at social protection interventions such as cash but it may be vouchers, or some sort of fortified foods. It is free healthcare and making sure that these children and their mothers have access to education, because it is a lifecycle issue. If a mother is stunted and wasted, the chances of her child being born malnourished are much higher.
It is that whole-system approach to addressing nutrition. It is not just about treating it with good food, although, of course, food is a major driver. It is really looking at a multi-system approach: health system, food system and the social protection system. Also the countries that report on nutrition, those that put it in their national targets, have a budget, and report and prioritise it, are the countries where we have seen the biggest success.
Q29 Kate Osamor: How can we use these good lessons learnt and apply them to countries like Yemen and Ethiopia?
Grainne Moloney: The first point is to say that it is not all doom and gloom. There is progress and we are seeing results. We have 55 million less stunted children now than we had 20 years ago. We have 900 million more exclusively breastfed babies than we did 40 years ago, so we are seeing progress. That is manifesting itself in improving overall survival and nutrition outcomes for children.
The prioritisation has to be looking at all of the systems. How do we have national policies that have indications of success that refer to nutrition? For example, reducing stunting, reducing wasting, reducing low birthweight are very important indicators. If governments have that as a priority in their national plans and then bring together their nine ministries to put together these large scale multi-sectoral plans to address nutrition, this is where we do see success.
One possibility that is supported by FCDO is the Global Action Plan on Wasting. This was commissioned by the Secretary General a couple of years ago because the wasting numbers were not reducing across the world. Through the four UN agencies, with major support from UNICEF, we are working with 20 countries, including Yemen, to come up with multi-sectoral plans that aim to improve child health, reduce low birthweight, and increase access to services for children that need services for wasting.
The kind of plans that pull together the health sector would look at maternal and new-born care and social protection but they would also look at how we increase access to nutrition, nutritious diets in early life.
All of that is the beginning part: first identify our issues and then put a plan in place. Then we need to fund it and the funding has to be done at scale, and in a way where we can see success. If we look at any governments in Europe or in the West how we recovered post-war was huge social reform, huge social welfare budget.
This is what we need if we really want to see change. We cannot expect massive improvements unless we are willing to put the money in, and put it in across the sectors. Everybody should play their role. There is a role for private sector. It needs to change its practices and to start making food affordable and available and nutritious for the youngest and poorest of our population.
Q30 Kate Osamor: What more could the UK Government be doing to work towards achieving sustainable development goal 2 by 2030?
Grainne Moloney: That has been highlighted in the previous session and I personally interacted for many years—I have loved partnering with FCDO and DfID over the years. The UK Government have been such a leader in nutrition and we were missing that. I think the UK Government did more for nutrition than most people did.
It is wonderful to have Minister Morton co-chair the action review panel on child wasting with our executive director of UNICEF, but having that leadership needs to also have financial commitments behind it. We need the UK Government to step up and start putting financial commitment and hopefully make those visible at the Nutrition for Growth Summit. You have seen the I Can brief. It means at least as a minimum £600 million over the next four to five years, about £120 million in nutrition and it prioritises addressing prevention of malnutrition efforts. This is where the funding towards the ODA objective that can be retargeted towards nutrition, about £680 million a year, needs to be focused on nutrition prevention.
Regarding data, I have referred to countries where we have seen success. Countries that have nutrition indicators at the top line of their prioritisation make that commitment. The UK Government do have this prioritisation on ending preventable deaths, and if you do not have the nutrition you are not going to achieve that goal. About half of under-five deaths are caused by malnutrition, so having FCDO step up and put that data into what it reflects as a result is core. Also, through the humanitarian social protection work it should not just be about those populations who access food but nutritious food and also tracking the children who are wasting.
All of the commitments are listed in the I Can brief and they are the minimum commitments that we are requesting FCDO to put forward at Nutrition for Growth. FCDO has done so much in recent years. For example last year with Covid we saw some fairly devastating impacts on service delivery. Global vitamin A coverage was an example. Children should get two doses of vitamin A supplement each year to meet their nutrition needs and to protect them against preventable disease. Normally at UNICEF we track and support vitamin A programmes in 65 countries. In 2019 we had a coverage rate of 60%, so 60% of eligible children in those 65 countries received two doses, which was pretty good. In 2020 that dropped to 41%. It is the countries that are reliant on campaigns, are fragile and are more food insecure where we have seen the biggest drop.
We also see some stars, for example Kenya. Where the UK Government have been supporting large-scale nutrition intervention, the coverage increased. That is because the investment in routine health systems was able to withstand the shock of the pandemic. Services were able to be delivered in spite of all of these other factors. There are success stories but there is so much more we need to do. We would really want to get FCDO back on as a global leader in nutrition.
Q31 Mr Virendra Sharma: My question is to Dr Chowdhury. As an organisation that provides nutrition support, how has BRAC had to adapt the services it provides in response to the Covid-19 pandemic?
Dr Chowdhury: BRAC has been working in the nutrition sector for 50 years. Starting from its inception, nutrition was the whole attention of its health intervention. During Covid, unlike other interventions, everything was disrupted and nutritional support was disrupted. Soon we realised this is very important because many people are sliding back into poverty, especially lower middle-income people who are not usually hit hard with any kind of economic shock, and with the usual shocks.
Due to Covid people lost their jobs and most of them went back to rural places and then they were either cutting their food costs or they were eating less due to their income shock. We thought that we have to restore our nutrition intervention with this Covid situation, so we have adopted several strategies.
One of them was, first, helping people with cash support. We have supported more than 700,000 people with a cash transfer. That was done through mobile transfers so that was very quick and people could use that. Around 600,000 people got their savings back from our microfinance programme that they could use to buy food and to meet their basic needs.
On top of that, we also continued our health intervention in some innovative ways. For example, we have 50,000 community health workers and volunteers working across the country. During Covid time they were not able to visit all the pregnant women and mothers of underfed children, and adolescent girls, for nutrition education. They had all their mobile numbers and they contacted the mothers and pregnant women with mobile phones and advised them regarding their nutrition needs at that time and also referred them to health centres if they were facing any health problems. We know that during pregnancy and childhood infection is one of the reasons that nutrition deteriorates.
We also worked very closely with government identifying the poor and marginalised people who really need our support and cash support, and provided the list to the government so that they are brought under the social protection support. We helped them that way during Covid.
Q32 Mr Virendra Sharma: Thank you, Dr Chowdhury. My next question is to all three. We will decide after the question who goes first. What impact have cuts to the UK aid budget had on the UK Government’s work on nutrition? I will start with Dr Chowdhury.
Dr Chowdhury: We had a strategy partnership arrangement with FCDO, the former DfID, for 10 years. With that generous funding we had been supporting over 10 million people in Bangladesh, including over 4 million children, through BRAC schools and approximately 1 million families through extreme poverty eradication programmes with the Ultra Poor Graduation programme. On top of that we had also a health programme and a water, sanitation and hygiene programme, a nutrition programme and a women’s right programme. All these programmes have been shut due to this budget cut.
I would also like to mention that through this strategy partnership, from 2011 to 2016, BRAC delivered 17% of the UK’s global food security needs. That means that there was a huge contribution of the UK Government in food security, the health system, extreme poverty, education, and empowerment of women. Everything was lost. Now 12 million children under two—6.2 million of them are girls—are at risk of nutritional deficiency because they will not get the support from the UK anymore. Two million vulnerable households will be facing climate shocks because of the lack of climate sensitive programmes. That is, in a nutshell, the impact in our programme.
Grainne Moloney: Thank you so much for this important question. I can give a very frank example from South Sudan. UNICEF South Sudan was running a UK aid-funded nutrition programme, which has been receiving about £20 million a year and this year it was cut to £5 million. This cut will result in about 73,000 children with severe wasting who may not be reached. That is because there will not be money to pay for the outreach workers and for the commodities. These are the children at the highest risk of death. We are talking about life and death here. These cuts are devastating. Therefore, for the UK Government to step back up and bring forward those very important commitments as soon as possible is crucial to protect the lives of the most vulnerable. Thank you.
Dr Kalibata: Thank you for that question. Let me come at it from a perspective of what I consider to be the success of nutrition programmes, the ability to impact productivity of critical commodities, especially, in this case, some of the ones that we have seen extremely helpful, like biofortified crops. These programmes, all the way from research to getting them introduced to getting them adopted, are things that are still being funded from the perspective of development assistance.
The markets around which theses things are marketed, how we produce this food, how we package it—I will give you an example. AGRA has been participating in a programme in Rwanda that produces baby food, ensuring that the 1,000-day programme is taken care of. We have been planning to get a number of those programmes introduced across countries, in Ethiopia and Nigeria, where they have some of the biggest problems with malnutrition. If we do not manage to get them there because we do not have access to resources—and “we” means all of us, you and us—it is a cost to people. The number of children that have access to nutritious food definitely is impacted. Right now, we are dealing with about 45% of children under five living with malnutrition.
This particular programme that AGRA participated in has demonstrated that you do not only impact children and their nutrition. You are able to impact whole household nutrition by showing their parents that they are contributing from a productivity perspective, that they are able to contribute and participate and have an opportunity to have a better livelihood. I think we should look at it from the complexity of things that get impacted, from institutions that you have been supporting that are advancing nutrition to programmes that directly or indirectly impact on nutrition and can no longer function.
That is even more so today, where you have Covid-19 having completely undermined the ability of some of the most vulnerable people and some of the most vulnerable families to have the right food on the table. The thing that gets sacrificed first is nutrition. You will probably get some food on the table, but definitely the quality of nutrition has suffered from everything that Covid-19 has impacted on our economies.
For me the issue is: was this the right time to withdraw aid, when everybody else is suffering, when the most vulnerable among us are suffering? That is really how I would look at it.
Q33 Mr Virendra Sharma: Thank you, Dr Kalibata. What impact do you expect the decision to reduce the aid budget to 0.5% of GNI to have?
Dr Kalibata: I could start. I want to look at it from two perspectives. The first one is the impact on the UK’s own way of doing business, its leadership in the world. We just finished a Food Systems Summit. My hope at the Food Systems Summit—because we are looking at how we deliver against 2030 and we have the whole 2030 agenda, where we are behind on all critical indicators, starting with zero hunger, poverty and nutrition as some of the most critical—was that countries step forward and accompany their actions with commitments that support countries that need to be supported, but also, domestically, you have some of those challenges that you need to deal with.
For me, it is how it impacts already agreed international frameworks like SDGs. It is how it impacts partnerships that you are in. The institution I work for, AGRA, is working with the FCDO in a partnership with a number of other institutions and other nations. We are working with USAID, BMZ, the Bill and Melinda Gates Foundation and the Rockefeller Foundation on the understanding that we all agree on the impact we want to have and we build on each other’s resources. When one of the partners withdraws, definitely the rest of the partners get impacted. That leadership and ability to take advantage of existing resources in the landscape is lost.
From a very practical perspective, I sit on the board of one of the institutions that you have been supporting around nutrition here in AGRA. You support us from a Regional Food Trade and Resilience perspective. These programmes are critical. Small-holder farmers and communities that are living in poverty need functional markets, need the ability to deal with climate change and need resilience. When you withdraw from these programmes that you had identified as critical to supporting the rest of the world, what is at stake is eroding the gains you had already made. Is this the time when even what we have already invested in gets eroded because of this type of withdrawal? I know these are difficult times for all of us but we have to find ways of ensuring that gains already made are sustained.
Also, dealing with resilience and working with communities that are struggling to deal with resilience, with things like climate change, Covid, and nutrition, many vulnerable communities and many vulnerable countries are impacted. For me, it is just not the right time to be doing this.
Chair: Could I ask for brief answers to this, please?
Grainne Moloney: Sure. First of all, we will not know the full impact of Covid on nutrition outcomes for a few years. We can see impact on services and behaviours now but we not know yet how that translates into numbers of stunted and wasted children in the future.
It is really about the leadership role of the UK Government being out there and supporting very important, strong interventions. A great example is the current intervention that FCDO is supporting with UNICEF called the PARSNIP intervention, a match fund of ready-to-use therapeutic food whereby FCDO puts in X% of the budget and other governments in low-income countries also contribute a matched amount of money.
These types of interventions can leverage domestic resources and we have seen that success in 2021 in Nigeria, Senegal, Uganda and Mauritania. These types of interventions show that it is not business as usual and that is why the UK funding it is so important. It is different, it is innovative, it leverages domestic resources, it shows commitment, and I think it would be such a shame if that cannot continue. These innovative, leveraging types of partnerships are also crucial to the future of the types of programming we can do together. Thank you.
Dr Chowdhury: I will concentrate on the current situation with Covid. If I give Bangladesh as an example, Bangladesh has made progress in achieving some of the SDG targets—you have heard about it—but still we have a long way to go. We have only picked the low-hanging fruit so far. There is chronic malnutrition. Stunting is still 28% in Bangladesh and 52% of children under five are suffering from anaemia. Half of women are suffering from anaemia as well. In general, almost half of people are suffering from some sort of malnutrition. That means that there is a chance that if we do not keep this going, it will get worse again.
Covid is making the situation worse. I told you that Bangladesh has 16 million new poor and they are not coming back to a normal economy within a short time. It needs time. They need support. This is the time when we invest more rather than investing less. I urge everyone and the UK Government to come forward and invest at this time so that we do not slide back to increased low body weight, increased anaemia and increased stunting. There is no return from this once we go back to it. It took us 50 years to come to this level and it will take five years to go back to that position. We have to hold it and we have to pick the higher-hanging fruit. This is the time of challenge and we need real support from you. I will stop there.
Q34 Mr Virendra Sharma: Thank you. Briefly, how has the merger of DfID and FCO affected the UK Government’s work on nutrition?
Dr Kalibata: There could be a number of very practical ways that it is affected but for me, as a person who does not work directly on nutrition but works in the agricultural sector in general, what I saw was a little bit of hesitancy or delay in the taking off of the work, a slowdown of the work that was being done, which is expected, but also a reprioritisation. As you bring institutions together, some things get sacrificed and other things move forward. From a nutrition perspective, some of the institutions that were being funded definitely received lower budgets. We deal with two partners that work directly with nutrition and those received—
Grainne Moloney: UNICEF has a long history of working very well with the UK Government for children around the world, helping to save and improve the lives of millions of children. I cannot comment as such on the merger but we recognise the current challenging financial situation facing all governments across the world and again we want to highlight that the needs of children, particularly the most vulnerable and the poorest, have never been greater.
We are continuing our engagement with your government on our shared commitment and trusting that the commitment to reinstate the 0.7% GNI spending target will be in place as soon as possible, particularly to meet the needs of the nutrition sector. Thank you.
Dr Chowdhury: I will add just one point. According to a report from Save the Children from May 2021, we generally spend 80% less on helping feed children in poorer nations than before the pandemic. The British Government has spent less than £26 million in this year on vital nutrition services in developing countries, a drop of more than three-quarters from 2019. That is the side effect of the merger, I guess.
Q35 Chris Law: I will direct my next questions to Dr Kalibata. Do you mind if I call you Agnes, Dr Kalibata?
Dr Kalibata: No problem. Go ahead, please.
Chris Law: Not least, it is a beautiful name. It is my grandmother’s name, I am happy to share.
My first question is about Michael Fakhri, who is the UN’s Special Rapporteur on Right to Food, who said that the Food Systems Summit, which you touched on earlier, “categorically failed” to respond to the Covid-19 pandemic and that the summit continues to focus on all the wrong things. Do you agree with this assessment?
Dr Kalibata: Thank you for that question. The summit was mobilised before the Covid-19 pandemic, specifically recognising that we are behind on the SDGs. The summit was really focused on achieving SDGs. Does that mean we do not focus on Covid-19? No. We did recognise it. I would even say part of the success of the summit was the energy coming from basically the challenges of Covid-19.
Covid-19 helped us recognise so many challenges that are sitting in our midst and helped us reprofile some of the things that we were working with, for example hunger. We have 161 million people who have gone hungry. We are talking about hunger in new ways. The number of people that are hungry this year is the same number of people that we thought would be hungry in 2030 if we did nothing. Nine years ahead of time, we have exactly the same number of people who are hungry.
Second, let us look at vulnerability and equity and all the things that are happening in that area. Some of the most vulnerable people among us have suffered the most. As a result, we actually have equity profiled as one of the areas that needs to be profiled again, recognising—let us be honest—that today’s living wage is not buying a decent meal for any family today. Again, this is a thing that has been profiled as a result of Covid.
Michael Fakhri has his way of pulling out and profiling things he wants. Michael Fakhri was on a lot of the committees that were advising the summit. I completely disagree. To not have picked up some of the challenges that Covid-19 has thrown our way would have been wrong. We did not just pick them up, we profiled them in ways that they had not been profiled before. Again, the cost of not dealing with the challenge of the quality of life for women, for children, is now an action track.
By the way, let us talk about the most popular coalition that was launched. It was school feeding, recognising that 320 million children, during Covid-19, lost out on meals. School feeding was bought into by nearly every country and it was given the centre stage in the Food Systems Summit. Just to say that I do not agree with his analysis.
Q36 Chris Law: Thank you, Agnes. What do you think, in that case, were the key successes and, perhaps, some failures of the Food Systems Summit? Did you see any failures?
Dr Kalibata: Let us go to the successes. Last time I met you all I challenged the UK Government and one of the biggest successes was that the UK Government was one of the governments that submitted a quality national pathway that not only recognises domestic challenges and the need to deal with domestic challenges but also recognises international responsibility. I want to congratulate Minister Victoria Prentis, who is the one who signed it, but also Lord Goldsmith, who has been participating in the pre-summit and in the national dialogues. So, engagement, participation secured.
But on a global scale now, moving out from the UK, we had 165 member states participate in the summit. We had 78 heads of state step forward themselves to commit to a food systems approach. This is the success, the fact that these pathways are talking about a whole of food systems approach to doing business, recognising that we need to impact people’s nutrition but at the same time that we need to recognise our impact on the environment and the fact that our economies, of course, are impacted by what we do from a food perspective. For me, that was success.
Of course, there were a number of coalitions that were launched, recognising some of the biggest challenges in our midst, all the way from ending hunger to resilience. Maybe one of the things I should say is that the biggest success for me is how much we were able to organise people out there and establish a certain sense of—not anxiety, it is not anxiety—“we need to do this now”. As an Englishman, you might tell me the right word. It is a certain sense that we need to move, we need to get this done yesterday. For me, having that as something that we are now talking about globally, having a certain sense of discomfort out there that our food systems need to change, is extremely important.
On failures, because you asked, and missed opportunities, because you asked as well, let me first talk about disappointment. Disappointment, for me was that we reached out to everybody and certain groups of people decided they do not want to sit at the same table with other people. I do not know how our world became so intolerant that even having a conversation when you are challenging someone becomes something that is not acceptable. I think we should all be sitting together and having conversations, even when they are uncomfortable conversations. That is number one. Certain groups decided not to participate, especially in civil society.
On missed opportunities, there is a number of things we could have done with a Food Systems Summit. The most important of them, for me, is how we link food systems to the conversations now. I hope COP26 sees an opportunity, recognising that transforming food systems is at the centre of dealing with the challenges of climate change. I hope that is not going to be missed.
Secondly, it was an opportunity for the rest of the world to step forward and discuss some of the discomforts around our world. We barely touched on some of the areas that are uncomfortable because some member states felt like we are not ready. Some member states did not want certain things touched, and I will just mention them.
Is livestock an issue we should be talking about as a contribution to climate change? Is big business—what is it called, industrial agriculture—something we should be talking about? We can bury our heads in the sand; these problems will not go away. Three years later, we will come back to the same challenges. For me, not being able to discuss some of these challenges that we know are part of managing our food system is what I would call a missed opportunity.
Q37 Chris Law: Agnes, I hear both your passion and your sense of urgency, and I was just thinking of something I heard in your voice about sitting around a table. We should learn to be comfortable to be uncomfortable with each other. Perhaps that is a successful way forward.
I have one last question for you. What should ODA donor countries be focusing on when it comes to food systems? Do you think, in all honesty, that the UK is focusing its efforts in the right area, yes or no?
Dr Kalibata: You want a yes or no that you can quote.
Chris Law: You can start with the end and go back, if you like.
Dr Kalibata: Let me start with the other one because yes or no is not easy. On what countries should be doing, we had goodwill and a number of countries signed up to pathways that are considering strategies for advancing food systems. Many of these countries won’t have the resources to advance food systems, so being able to step forward—we talked about it earlier—and show that we support these countries to do that would be really good.
Climate change is something that is impacting countries here in Africa more than people understand. Out of every two seasons, one has failed. Being able to prioritise things around climate change is extremely important because, again, these countries at the equator are having failed seasons every so often and it is eroding all the investments we have made in the past, all of us. That is something that must be looked at. Then we need to look across the five areas we have talked about.
There are a few things that came out very clearly. We need to fund these areas that we agreed on. We have increasing hunger, we have increasing malnutrition, we have increasing death, we have all sorts of challenges, but most important is that we need to come through for each other.
I am going to say this. You can say, okay, the UK Government are looking at this from a UK Government perspective. Honestly, climate change is not my problem, but it is my problem today because we cannot produce food. Covid is not my problem, but it is my problem today because it reaches every corner of the world. There are some things that we just have to step up and do something about.
Is the UK doing the right things? The areas that the UK has been working on in the action tracks, the focus around ending hunger, the focus around nature-positive production and working with the planet issues and the focus around resilience are extremely important. I would add the action track on equity, decent work and living wage. Those are things that are extremely important.
My last point before we move from food systems is just this. We need to make sure that we are actually transforming food systems. Rather than we participated in the summit, we need to use this as an opportunity to transform food systems and work together to transform food systems. It will contribute to a 30% reduction in emissions and it contributes to feeding so many people. The opportunities are immense.
Chris Law: Thank you, Agnes. I can see nodding from colleagues also on this panel here who are very much in agreement.
Q38 Chair: The last question is a very broad question, apologies for that. If I can start with Dr Kalibata, in Africa, what are the main obstacles preventing nutrition equity, if I put it that way?
Dr Kalibata: The main challenge, when I look at Africa and why many of the things we are trying to do are not working, is really the issue of markets and trade. We are working with the FCDO on markets and I appreciate the support we are getting on markets and trade. We, as a continent, we need to work through our challenges. We have all sorts of challenges that are locally based that we can work through and we are working through them—harmonisation of trade, removing barriers and all that—but markets will not function unless we also think through investments.
With climate change, the equity challenge I talked about and what the UK is doing with the just transition, the time has come to start thinking about developing African markets in ways that can lead to transformation of the continent. Nutrition comes from good pay, a good job, access to employment and from food. It does not just come from getting fed. We do not need to feed people, we need to give them opportunities to feed themselves. As long as African markets are not functioning, Africa will not be able to feed itself. If there was one thing I would do, working with you all, it is to double down on markets, ensure that we as Africans are removing all barriers, doing our best, but also growing the opportunities for markets and building investment.
Chair: Powerfully said, thank you. Dr Chowdhury, the same question to you but looking specifically at Bangladesh and elsewhere in south Asia: what are the main obstacles to nutrition?
Dr Chowdhury: Nutrition is a multisectoral issue and it is interrelated with social concerns like poverty, access to basic education, sanitation, social and gender norms, as well as other food components like market systems, core crop diversification, food fortification, the supply chain, and food adulteration.
I would like to mention one thing specifically, which is the social behaviour regarding nutrition. In the Fed to Fail? report you see that in Bangladesh and south-east Asia, the authorities on feeding a child or feeding a pregnant woman are her husband or in-laws. The decision-maker is not the person herself or the mother herself. This kind of norm still exists and is hindering the nutrition choices in the community.
This is a real problem that has to be addressed through community-based approaches. Community health workers are very interconnected with people and they can influence the whole family when they talk with in-laws, husbands and mothers together. Research done by BRAC found that if we talk with all the family members together, it is possible to change the family dimension and family food distribution and the husbands are more inclined to buy nutritious food. Through this type of intervention, body weight could be increased by 56% and low body weight could be reduced by 11%. This is a huge gain without any cost transfer or cash transfer. You have to organise them and show them, give agency to women and given an enabling environment in the family.
The other thing is motivation in positive nutrition behaviour. Nowadays, so much aggressive marketing is happening for unhealthy food for kids. A social movement is required towards healthy food promotion. NGOs like BRAC, bigger NGOs, can play a crucial role here. They can engage with the community, talk about it and create a whole picture of good food and bad food, real good food and bad food, because culturally there are norms or misconceptions regarding bad food and good food. That has to be addressed.
The third thing is the absence of nutrition services at the primary healthcare level. Our community clinics are overburdened with clinical care, antenatal care and other services along with regular healthcare services, so addressing nutrition is their second or third or no choice at all. They do not have time to talk about nutrition at all. This has to be addressed with manpower and with a proper allocation of time.
Q39 Chair: Thank you. I will pause you there because I want to bring in Grainne. From what we have heard from the two panels, but particularly just now, nutrition seems absolutely central to equality, whether that is economic equality or gender equality. Do you believe that the donors are aware of that and their strategy is a joined-up one so that nutrition is at the heart of, for example, a climate action response?
Grainne Moloney: I believe there is a lot of understanding of how important nutrition is, but whether or not it is represented in those other sectors—I think there is a lot more work we need to do as a nutrition community, but also we need to sit together with the climate community, with the food systems community, and say, “The ultimate outcome of all of our efforts is a healthy population”. The major driver right now in the increasing rates of both undernutrition and overnutrition is the quality of diet, especially in early childhood. If we can prioritise the quality of diet in early childhood, our populations will thrive.
There is one very clear example: the development of this product, ready-to-use therapeutic food, which we use to treat children with severe wasting. When severely wasted children receive that product, they grow, they recover, they succeed. We know that when children, even as sick as they are, are given the right balance of nutrients, they can thrive. We owe it to every child in this world to have access to those nutrients.
We owe it to them that the food system provides that nutritious food, that it is affordable, available, and governments prioritise that. How do we get that message across that this is the ultimate priority of governments, and that then the donor community needs to support the lower-income governments in making those commitments to make sure that every child has that good nutrition early in life so that they can be a successful adult?
Chair: Thank you very much. I think you have made it incredibly clear. ODA spend is meant to be about reducing and removing poverty from this world, and unless we embed nutrition right in the heart of that, that is clearly not going to be achievable. Thank you so much for your time today. I really appreciate the Committee members’ time as well.