Module 41b: Nutrition in Global Health Roadmap toward a world without hunger

1. Module 41b: Nutrition in Global HealthRoadmap toward a world without hunger What is the nutritional status of our planet? How does it impact the health of populations? How did we get here? What’s to be done? Where are we going? Allan J Davison PhD Faculty of Sciences, Simon Fraser University Department of Biomedical Sciences & Kinesiology Prepared as part of an education project of the Global Health Education Consortium & collaborating partners – 1 Sept 2009

2. Nutrition fundamentals for global health • This module deals with catastrophic inequities in the global distribution of foods • Almost a billion of us are too hungry to live a productive life, while an equal number are adversely affected by overweight • Nutrient deficiencies impact health throughout the life cycle: Water, protein, iron, vitamin A, iodine. • Childbearing women and children are hardest hit • What nutritional principles allow us to understand &cope with this • We will not avoid difficult questions about cause and effect: “How & why has this come to be?”; “Who is responsible?” Page 2

3. Other modules contribute to our understanding of nutrition in global health Modules dealing specifically with nutrition Module 41b World nutrition - What builds a better future & what doesn't Module 48 Acute malnutrition – Clinical aspects Modules dealing with mitigation of poverty – the most important cause of hunger

4. Pre-quiz • As a reality check as you begin this module, and to create “teachable moments” for what follows, we invite you to take a 5-minute quiz before you start. • You will be offered 10 true-or-false questions on common misconceptions that can mislead the unwary. Clearing up fog is essential if we are to understand nutrition in a world where some people deliberately mislead us • After completing the pre-quiz, we expect you to continue this module with greater interest and renewed clarity (remember to erase this box after reading) Use the separate GHEC Quiz template to create your quiz. Place this Quiz reference slide before the next continuing slide.

5. Learningobjectives After completing this module the user should be able to • Describe the extent of malnutrition & its impact on people around the planet • Analyze the factors that determine nutritional health • Identifynutritional problems among individuals & populations, identify causes & appropriate solutions • Determine risk factors in various stages of the life cycle & recommend strategies for diminishing risk • Comparecompeting theories accounting for the inequities • Predictoutcomes by projectingcurrent trends into the future Page 5

6. How to get the most out of this module If you are … We recommend that you … Pay attention to global & public health & policy implications. Pay attention to perspectives & realities in desperate situations Emphasize check-lists to prepare for field work & gather information to recommend & advocate for intervention. Use slides & resources in your information / teaching sessions • a nutritionist or student of nutrition • a student in public health • planning a project in regions with severe nutritional problems • a public health practitioner

7. Core concepts and skill-set • Why nutrition is relevant to global health? • Socio-economic determinants of nutrition & health • Nutritional principles that govern the distribution of problems across populations, & across the life-cycle • Nutrition as a determinant in global health & MDGs • Competing theories for how we came to this point • Prognosis: Given no change, where are we heading?

8. Nutrition in Global Health:Roadmap to a world without hunger • Why nutrition is crucial to global health • Overview of nutrition across humankind • Fundamentals of human nutrition for global context • Global dietary patterns and nutritional risks • Dealing with the top 5 nutritional problems • Nutrition through the life cycle, global comparisons • Determinants of nutritional population health • Where do we choose to go from here? Intro to 41b

9. Why nutrition in relation to global health? • Of the immediately modifiable factors that affect individual & public health … nutrition is the most important • Nutrition at every stage of life lays a foundation for health in the ensuing stage • For all nations, rich & poor, nutrition determines physical health / development through the life-cycle, including: Success in childbearing, cognitive function, socio-economic independence, educational achievement, & employability … ... now and on into the ensuing generations Health & economic development are contingent on provision of adequate nutritional resources & support

10. Where are we? Can we find a better way? About 55,000 people die of hunger each day - 2/3 are children • Each year 3 million newborns die in the first week of life • Almost an equal number in EU&USA are dying of over-nutrition • The world produces enough food to feed everyone but somehow we lack the political will to distribute it as needed • One person in 5 in the developing world (1/3 of world's children) are undernourished & will never lead a productive, active life. • To feed them for a year, & start them on the development ladder would cost less than the world spends on armaments in 30 days Can it be very difficult to improve on this?

11. Yunus: Blaming the poor for their poverty • “Poor people are like a bonsai tree. You take the seed of the tallest tree in the forest and plant it in a flower pot. All you see is a tree this high. It looks exactly like the tree that you saw in the forest, but a scaled-down version. You wonder what happened. ‘Is there something wrong with the seed? No, we selected the best seed.’ The problem was it was not given space to grow. Poor people are bonsai people. There is nothing wrong with their seed. Simply, society never allowed them the space to grow, so they remain stunted and we pity them. If you had provided them the space, they would be as tall as anybody else”. Poverty as an imposition: Mohammad Yunus (Nobel Prize 2006)

12. J Sachs: “Exploitation is the result of poverty” “Affluent nations have plundered and exploited poor countries through slavery, colonial rule & unfair trade practices. Yet … exploitation is the result of poverty (which left impoverished countries vulnerable to abuse) rather than the cause” “Poverty is generally the result of low productivity per worker, which reflects poor health, lack of job-skills, patchiness of infrastructure, chronic malnutrition etc. Exploitation played a role in producing some of these conditions, but deeper factors –(geographic isolation, endemic disease, ecological destruction, challenging conditions for food production) tend to be more important and difficult to overcome without external help”.

13. Section C: Nutrition in global health Where do we choose to go from here? Where are we, where do we choose to go? Is the situation hopeless? Absolutely not Can a single person ameliorate hunger? Yes! What are the wild cards? Module 41b: What works & what doesn’t

14. Predicted progress - % of people living in poverty http://go.worldbank.org/K7LWQUT9L0

15. Is the situation hopeless? Let’s see … • Extreme poverty is decreasing, worldwide. Failures in the Sahel are outweighed by successes in Asia - Africa needs attention • MDGs will mostly be mostly met - not in the promised time frame; unless NAm & EU follow through on their commitments • Only 4 countries give the 0.7% of GDP agreed to in 1970. Denmark, Norway, Netherlands, Sweden • “Does development aid do more harm than good?” Only, if wrongly delivered - We know what works & doesn’t • Science, not polemics or ideologies point the way • Argument about strategies is counter-productive. The situation demands multiple approaches!

16. Where do we choose to go from here? • What the future holds depends on who you talk to! • What options we have for the future, what we are choosing, what works and what doesn’t ...... these topics will take up most of Module 41b • The next few slides will provide a preview. • Some see the MDGs as viable & forsee dramatic decreases in poverty, hunger, & the burden of disease • Others write off the developing world as doomed, by corrupt dictators, HIV, and civil wars • Let’s see what those who follow the evidence agree on

17. Food prospects in an uncertain economic future • The World Bank report Dec 2008: Food Crisis - Global Economic Prospects 2009 • http://www.worldbank.org/html/extdr/foodprices/ • Food production is likely to maintain pace with demand over the next few years. • While the economic collapse can diminish demand for fuels (thus moderating prices), people still have to eat, and there will be no decrease in demand for, or the price of, food. • The price of foods will devastate those who currently cannot afford even a minimally adequate diet. • As LMICs strengthen their economies, consumption of foods increases most in poorer countries: by 6% vs 1 or 2% in the rich. • As oil prices rise above $50 per barrel, it becomes increasingly profitable to convert food to fuel. Fuel costs impact food costs • Climate change, too has an unsettling effect.

18. Factors limiting future food availability • Increasing cost-burden of food & food production • New priorities for spending - the war on terrorism • Resource depletion - increasing energy costs • Increasing cost of oil - chemical fertilizers, food diverted to fuel • Globalization & the increasing power of the food conglomerates • The global economic melt-down; differential impact on the poor • Preoccupation of rich nations with their own problems • Debt crisis & borrowing by the rich countries → inflation • Printing money → inflation • Mega-dollars spent on the war on terror • Decreased government revenues → increased taxes • All these lead to revocation of previous aid promises • Uncertainties around climate change & many others

19. War and instability are incompatible with good nutrition “The U.S. has just established a new military command in Africa, declaring Africa to pose new security threats to the U.S. But even as the U.S. spends more than $600 billion on the military, and even as U.S. counterinsurgency forces spread out across the impoverished stretches of the Sahel, the U.S. will never achieve peace if it continues to spend less than one hundredth of the military budget on Africa's economic development. An army can never pacify a hungry, disease ridden, and impoverished population”. Economic Solidarity for a Crowded Planet2007 Reith Lectures Jeffrey Sachs

20. Hunger is incompatible with peace “I firmly believe that we can create a poverty-free world if we collectively believe in it. In a poverty-free world, the only place you would be able to see poverty is in the poverty museums. When school children take a tour of the poverty museums, they would be horrified to see the misery and indignity that some human beings had to go through. They would blame their forefathers for tolerating this inhuman condition, which existed for so long, for so many people”. Muhammad YunusNobel Prize address 2006 Poverty is a Threat to Peace

21. Harbingers of change ... • ... new credible voices call for a better world • Philanthropists: Bill Gates, Warren Buffet, George Soros &c • Microcredit: Muhammad Yunus (Nobel Prize 2006), Danone • Writers who speak for the dispossessed: Chang, Clapp, Collier, Curtis, Lappe, Maxwell, Naidoo, Patel, Sachs, Stiglitz, others • Young people: Two new graduate programs in Global Health in Canada, received over 1500 applicants from all over the world. • From direct contact, the students were spectacular: brilliant, well prepared, strongly motivated to become agents of change • Zinn’s Global Values 101 discovered a similar enthusiasm • Social Business: Beyond belief, the Grameen wellspring of innovation, hope, & faith in humanity towers above all

22. We now know what works & what doesn’t • All nations agreed to accept & work toward the Millennium Development Goals for the elimination of poverty • An unrestrained marketplace has failed to bring prosperity to either rich or poor countries • Strident voices allege that aid does no good. However, the problems with misdirected aid are easily overcome • Unless we alleviate hunger, we cannot create a world without unrest. Neither can we pacify the hungry for long with bombs

23. Wildcards and unknowns Economic meltdown; will it bring more sympathy & help for the hungry, or less when demand for food is increasing? Will the richest continue to redirect development aid to spreading a “war on terror”? The worlds richest nation now has a president with vision. Will he be allowed to “change”? In Africa, for whatever reasons, most nations are turning to China. Will they be made the theatre for a new cold war? Will the eastern nations, on whom the sun is now rising, be better global corporate citizens than those who went before? Cuba has done a spectacular job in providing excellent nutritional health for itself & others. Will we use its example? Climate change, will we find a fairer globalization, trade barriers

24. China & India - future role in development 1 of 3 In the ensuing 50 years, the combined GDP of two Asian countries will likely be more than double the total of their nearest 3 rivals. Clearly that has implications for development aid & relief of hunger, particularly in Africa

25. China & India - future role in development 1 of 3 The situation in complex, & only hindsight is 20-20 Nevertheless, the present & its prevailing trends are clear China has been forthright in its motives – to develop good relations with resource-rich Africa, & to take advantage of political and strategic blunders of its rivals on that continent In the economic climate prevailing in 2009 African economies are in strong decline. Simultaneously OECD investment is decreasing Chinese investment, aid, and loans have been increasing dramatically since 200

26. Hope for Africa ... from China & Indiaaccording to the Government of Canada Mr. Obhrai insisted that the government understands Canada's obligations in this regard and is committed to increasing ODA. He thought it more useful to focus on dollar values than ODA percentages. He empha- sized that Canadian ODA is going up and now totals $4.4 billion, “a lot of money," he pointed out. It is twice what Canada was spending a few years ago and represents an extremely strong commitment by this government to development assistance. A more important question, Mr. Obhrai suggested, is how this money is being spent. Aid has to be effective and, to this end, the government is narrowing its focus from 107 to 25 countries. Unfortunately, recipient countries do not always have the capacity to absorb the money available. There is no lack of money, especially now that China and India have joined the ODA game; the challenge is to make effective use of it. India and China have already succeeded in moving large numbers of people out of poverty and this is what will happen in Africa. Mr. Obhrai underlined the necessity of investing in capacity to make a difference. The Gov- ernment has significantly increased spending in defence and development with a view to Canada reassuming its position of leadership in the world.

27. There has seldom been a more pivotal time An upwelling of energy for action

28. Review your pre-quiz to confirm that you have advanced your knowledge. As we move now to think of the future, here is part of the pre-quiz for module 41b Does globalization promote nutritional health? For whom? Is free enterprize good for everyone? If not, for whom? Are African leaders dictators? Does most aid to Africa end up in their Swiss bank accounts? Does food aid do more harm than good? Academics argue fiercely about what should be done. Does that mean that we don’t know what to do?

29. Summary: What you’ve learned & its applications Nutritional health is not equitably distributed worldwide Correcting nutritional inequities is crucial to a viable future We've reviewed nutritional principles in global context Nutritional health, public health, & economics are inseparable Worst nutritional risks: water, protein, iron, vitamin A, iodine. This helps us know what to look for and what to recommend Across the life cycle, kids & mothers are at greatest risk • So we know priorities &best practices for risk mitigation We have seen setbacks, slow progress toward the MDGs We have substantial agreement about what needs to be done • We see powerful signs of hope: fortunes given away, crazy ideas, lending money to the poorest & getting it back, fresh voices • We join those working for a better world with new clarity & energy Page 29

30. Credits [Add author 1 information] [Add author 2 information] [Add … ] Slide instructions Place this Credits slide before the End of module slide. Please erase this box after its reading.

31. End of module Please refer to the supplementary contents for more information about this module. [Reserved for GHEC notes]