“The Root Causes Of Malnutrition Can Be Summed Up In Four Words: Orphan, Invisible, Unmeasured And Voiceless”—Shawn K. Baker

Basanta K Kar: You will be taking on your new mantle on February 3. Your powerful message of August last year still resonates: “Wandering onward from India—a next chapter in nutrition.” What has been your journey like in the intervening time? And, in your own words, how you are planning to “contribute to the good fight against the gross injustice of malnutrition” from now on?

Shawn K Baker: First of all, a big thanks for this opportunity. Having worked in public health nutrition for over 30 years, I relish any opportunity to speak about it.

Following my moving on from the Bill & Melinda Gates Foundation, the most important thing I did was spend time with family in Dakar. I had two months with my children and my granddaughter. Taking care of the nutrition of a young child and young adults is very gratifying and reminds us of how essential good nutrition is for everyone. In addition to applied nutrition, I have kept engaged in global issues, particularly through my role on the Executive Committee of the Scaling Up Nutrition movement, as we prepared the Lead Group meeting in New York, the Global Gathering in Kathmandu and the strategic review which will inform recommendations for the third phase of the movement.

I was very struck in Nepal by the energy and senses of family and purpose even as the Global Gathering has expanded to over 1,200 participants. A recurrent theme was a desire to have better datato improve program design, tailor interventions to those populations that are most in need and track progress. We are clearly learning a lot about scaling up nutrition, but need to capitalize on that learning to meet the global commitments for 2030.

Starting on February 3, I will be taking on a new role with the United States Agency for International Development (USAID), as chief nutritionist, based in Washington, DC but with significant travel to the field. USAID is not only elevating nutrition across the agency but also working to coordinate across teams to ensure the whole is greater than the sum of its parts.

USAID has developed its Multi-Sectoral Nutrition Strategy and will establish the Center for Nutrition to provide technical expertise and guidance. This will be further complemented by the Nutrition Leadership Council, which provides leadership and coordination for nutrition strategies, policies, and programs across USAID. In this new role, I will chair the Nutrition Leadership Council and oversee management of the Center. I see this as an incredible opportunity to leverage USAID’s financial and convening resources to support governments and their partners in high burden countries in their efforts to scale up nutrition.

BKK: You have been exploring the Anganwadi centres of Dausa district of Rajasthan. What are your recommendations on skilling the 1.3 million women workers with new-generation knowledge and technology on nutrition to transform the landscape?

SKB: Anganwadi workers are a phenomenal asset, a front-line work force dedicated to nutrition that is lacking in most countries. I have seen Anganwadi workers in action before. What was new for me to observe during my visit to the Dausa district was the extent to which the panchayat leaders were engaged. They were conversant on the challenges of malnutrition, were investing resources to improve the infrastructure of the center, and using their influence to ensure that mothers attended.

The most fundamental role of Anganwadi workers is to be trusted partners supporting mothers and other family members in practicing good nutrition for women and children during the critical 1,000 day window. The evidence from successful social and behavior change is clear, quality and intensity of counseling are key to success. Everything has to be geared to supporting Anganwadi workers to reach all households at the right time, with the right messages in a compelling and respectful matter. Innovations such as the Common Application Software help Anganwadi workers better plan their work, tailor their messages and reduce reporting burden. Anganwadi workers are the front-line sales force of nutrition programs in India, and their ability to deliver to their clients is the most important ingredient for success.

BKK: You quoted Bill Gates at the Global Partners Forum in 2015: “If I had a magic wand, I would get rid of malnutrition”. How have you been a co-partner with Gates in this journey?

SKB: Both Bill and Melinda have been supportive of the nutrition agenda in many ways, really too many to be exhaustive. For Bill, a few that are particularly compelling include his launching the Nutrition Investment Framework during the World Bank spring meetings in 2016, co-convening with Alhaji Aliko Dangote the CEOs of all the major manufacturers of foods that fall under the Government’s mandatory fortification to get them to personally commit to meeting government standards, and his personally diving into all of the analyses of the University of Toronto’s work on exemplars in stunting reduction. For Melinda, some things that stand out are her launching of the new nutrition strategy and investment envelope at European Development Days in June 2015, a field trip to Burkina Faso where she saw health workers supporting mothers to breastfeed and women engaged in a program to improve incomes and nutrition through poultry rearing, and her engagement during World Breastfeeding Week last year.

BKK: You worked extensively in Bangladesh, shaping the nutrition movement there decades ago. Today, Bangladesh is an exemplary country. What are the key drivers on malnutrition in Bangladesh?

SKB: Bangladesh has made some remarkable progress. The latest Demographic and Health Survey (data collected in 2017-2018) shows exclusive breastfeeding rebounded from 55% in 2014 to 65%; initiation of breastfeeding within the first hour increased from 57% to 69%; infants and young children fed with at least three practices increased from 23% to 34%; stunting has decreased from 36% to 31% (continuing an impressive downward trajectory from 2007 when it was 43%; wasting has decreased from 14% to 8%. These changes are driven in large part by a focus on delivering high-impact interventions through community-based services supported by the health system, and media. In addition to government efforts there has been consistent support from donor, UN, civil society and research partners committed to fighting malnutrition. There are other important factors as women have better access to family planning and education, social safety nets that target
the most vulnerable households, and agricultural programs are increasingly focused on production of nutritious foods and reaching smallholder women farmers. Bangladesh also has strong data systems to support design, monitoring and accountability. The “stories of change” study on Bangladesh led by the International Food Policy Research Institute provides great insights (https://www.sciencedirect.com/science/article/pii/S2211912416301018).

The progress has been remarkable, however there is still work to do, including addressing the disparities across regions and socio-economic groups, and maintaining vigilance to prevent
backsliding. A good example of addressing regional disparities is that the Health Sector Support Project, financed by a loan from the World Bank that includes essential nutrition services is focusing on the Sylhet and Chittagong divisions where indicators are lagging

BKK: Increased wasting between 2006 and 2016 is a cause of concern for India. How should it be fixed? Is there any lesson from other countries?

SKB: The emergence of community-based management of acute malnutrition (CMAM) about 15 years ago was a revolution in how to respond to children with severe wasting and the evidence is clear that this is a cost-effective, life-saving intervention that can be effectively delivered by front-line workers. Many countries adopted CMAM and several have demonstrated impressive scale up of treatment. However, despite the World Health Assembly target to “reduce and maintain childhood wasting to less than 5%” we have not made much progress in reducing the global burden. The UNICEF, WHO, World Bank Group Joint Malnutrition Estimates from last year indicate that there were still 49.5 million wasted children in the world in 2018 (moderate and severe). I think there are several reasons for this failure, including: It has long been perceived that wasting is a result of humanitarian crises, whereas the greater proportion of wasted children is in stable situations but routine programs have neglected to mainstream screening and treatment into the core package of community and primary health care services; Community outreach platforms are inadequate to reach the bulk of children needing services; Treatment algorithms are overly complex and there is confusion about use of mid-upper arm circumference versus weight for height; There has not been enough progress on developing evidence-based guidelines on prevention of wasting; And there remains an unhelpful divide between treatment and prevention.

While I am dismayed about the lack of progress, I am generally optimistic about the way forward, and I think that India has many of the elements in place to start tackling this issue. Weunderstand much better how much of the burden is starting in utero, and delivering quality health and nutrition services as we scale up antenatal programs will put infants on a much better growth trajectory. Simplified protocols are being developed which will allow community-level workers to screen and treat those in need in the community, getting to them earlier and resulting in better outcomes. There is new evidence on the impact of products such as small quantity lipid-based nutrient supplements on preventing wasting and mortality, as well as stunting and anemia. There are compelling programmatic models of how to bring these pieces together to break down the treatment/prevention divide and provide a continuum of care approach that provides the essential services that are required to the children who need them.

There is a continued need for research to understand the drivers of wasting to further improve our package of prevention programs, however that should not stop us from delivering what we know works. Given India’s impressive delivery and research infrastructure, I think the country could be on the forefront of the developing the new generation of approaches to prevent and treat wasting.

BKK: As you know, anaemia is pervasive and prevalent across all age groups. In fact, in many Indian states it has increased in the ten-year period, 2006-16. How should India deal with this public health menace? What are your thoughts on this?

SKB: While it is always important to continue research, I think the top priority has to be focusing on effective delivery of existing interventions. There are huge opportunity gaps. Looking at the National Family Health Survey 4 results, nationally 51% of pregnant women had at least four antenatal clinic visits, however only 30% consumed at least 100 doses of iron-folic acid. At the state level, falter point analyses show that the biggest constraint is lack of supply. India has been a pioneer in the double fortification of salt, with iodine and iron. Continuing to improve the quality and scaling up nationally will make major contributions. The International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) which is headquartered in Hyderabad has taken the lead in developing iron-rich varieties of peal millet which have important potential in some states. There is a huge opportunity to rapidly introduce multiple micronutrient supplements for
pregnant and lactating women, transitioning from iron-folic acid alone, and use this transition to galvanize improvements. More effective approaches for screening and treatment for severe anemia are being developed and when ready, the growing antenatal clinic coverage will provide a platform for scaling these up.

BKK: Why do you think malnutrition has been such an enigma in the sub-continent, despite growth and development?

SKB: I often summarize the root causes of malnutrition in four words: orphan, invisible, unmeasured and voiceless. Orphan because it is seldom clear which part of government is on point to deliver nutrition. Invisible because the public image of the problem is the severely emaciated child needing treatment, and the magnitude of low birth weight, stunting and deficiencies in essential vitamins and minerals is not visible. When virtually every child in a community is stunted that becomes the accepted norm. Unmeasured because there are seldom robust data systems that assess status, quality of diets and coverage of essential interventions. Voiceless, because those most at risk of undernutrition are those who have the least voice in political processes. I think the idea that there is some ‘enigma’ is contradicted by the evidence. Some states in India vastly outperform others, with stunting rates of 20% in Goa and Kerala compared to 48% in Bihar.

Some other South Asian countries have demonstrated remarkable progress we have discussed the progress in Bangladesh. Nepal has also systematically brought down stunting levels from 66% in 1996 to 36% in 2016. What does stand out starkly in South Asia is the amount of damage done during the gestational period. The latest estimate of low birth weight for the region is 26.4% and the wider  burden of small for gestational age is even greater. Nutrition and health of women during pregnancy have been neglected globally, and this neglect is particularly acute in South Asia. With major improvements in antenatal care coverage in India there is a huge opportunity to improvequality of nutrition and health services and address a significant proportion of the burden. I do not think that sustaining a mythology of the “enigma” of malnutrition in South Asia is helpful. What we need are evidence-based policies and action and political will.

BKK: Micronutrient malnutrition has been a cause for concern, and it is all pervasive across age groups. Is new breakthrough research coming up to address this problem in a sustainable way?

SKB: I fully concur. The more we look at the true burden of micronutrient malnutrition, the more damage we see, and there is a risk of these deficiencies being neglected. One updated estimate of the number of lives lost to deficiencies in essential vitamins and minerals is about 820,000 per year, and that is not taking into account the huge damage done in terms of reduced cognitive development and disabilities. I attended a meeting in Laos in November organized by the Government and the New York Academy of Sciences that reviewed emerging evidence of the burden of thiamine deficiency, a problem that has been recognized for a century but overlooked. The paradox is that these deficiencies are probably the most solvable part of the global burden of malnutrition.

One area of promising developments is improving our measurement tools. The current difficulties in assessing micronutrient status exacerbate the neglect. There is urgent need for more rapid, more field-friendly tools to assess status of the essential nutrients.

On the solution side, I think the biggest promise is innovations that provide much more flexibility as to which nutrients can be added to which food vehicles. As I discussed around anemia and
iron fortification, India has been on the forefront, recognizing that adding iron to wheat flour would have a limited impact because such a low percentage of wheat is industrially milled. The
innovations to add iron to salt (along with iodine) greatly expands the potential for impact.

We have become too complacent with fortification and accepted adding the usual nutrients to the usual food vehicles. Folate is a good example. A recent review estimates that even with existing programs, 235,000 lives are lost each year due to neural tube defects, and that over 156,000 deaths could be averted each year with high coverage of folic acid fortification. Currently we almost exclusively use cereal flour to deliver folic acid fortification. This is a proven strategy where populations consume adequate amounts of industrially processed cereal flours. But where cereals are milled at household or village level at-risk populations are neglected. Using ‘novel’ food vehicles for folic acid fortification such as salt or bouillon cubes has huge potential to stop this neglect and stop this totally preventable tragedy. This is just one example of a major gap that can be filled and innovations in food technology will allow us to better match the nutrients we put into food vehicles that reach at-risk populations with the nutrients they require.

A further set of solutions that can play a bigger role are crops bred for nutrient density. In addition to iron-rich pearl millet that I mentioned earlier, there are nutrient-dense varieties of wheat, rice, maize, sweetpotato and cassava that are being deployed.

The last important innovation I would mention are multiple micronutrient supplements for pregnant and lactating women. We know that nutrient requirements of women increase as they go into pregnancy and lactation and these supplements have been standard of care for most industrialized countries for decades. The research is clear that their benefits are greater than just iron and  folic acid, and with progress in production there is almost no cost difference. We should lose no more time in transitioning from iron-folic acid to multiple micronutrient supplements and use  this transition to galvanize major improvements in our delivery of nutrition and health interventions to mothers.

BKK: How important is data in nutrition programming and policy? Is it a global concern? And should this data gap be fixed?

SKB: Former UN Secretary General, Kofi Annan, wrote a commentary for an article in Nature in 2018 that mapped growth failure rates in Africa – and he said it much better than I could “… This  shows how crucial it is to invest in data. Data gaps undermine our ability to target resources, develop policies and track accountability. Without good data, we’re flying blind. If you can’t see it, you can’t solve it.”

There was a huge transformation of HIV programs starting in 2007 under the mantra of “know your epidemic, know your response.” We need a similar rallying to drive shape our nutrition programs based on better knowledge of the problem, and better understanding of how we are delivering solutions. We need to be more consistent in accurately assessing birthweight, anthropometric and  micronutrient status and quantifying quality of diets. There are innovations going on in all of these areas which will make these assessments easier and less expensive to do under field  conditions. These efforts will help us to better “know our epidemic”.

But the progress that excites me the most right now is new consensus on the right indicators to measure coverage of the essential nutrition interventions, which will enable us to much better  “know our response”. There is a strong consensus on the high-impact interventions we need to deliver for women and children, and now there is a strong consensus on how we should measure our  delivery of these interventions. We need to rapidly integrate these indicators into population-based surveys such as the NFHS as well as district health management information systems.

Again, drawing lessons from HIV, if we are serious about data, then we must be serious about investing in it and using it. We cannot afford to “fly blind” anymore if we are going to live up to our promises of delivering adequate nutrition to women and children.

BKK: India’s POSHAN Abhiyaan, Prime Minister Narendra Modi’s flagship programme, is a significant milestone in the nutrition history of the country. Looking at it closely, and now from a distance, what is your perspective on its design and effectiveness?

SKB: POSHAN Abhiyaan is built on an amazing set of assets: The overall policy framework is strong and aligned with global best practice. There is a tremendous frontline workforce of Anganwadi workers, ASHAs, auxiliary nurse midwives and a rapidly expanding network of self-help groups who can support mothers and families to provide good nutrition. There are public sector investments of upwards of $10 billion per year in programs that are mandated to have nutritional impact. After nearly a decade-long data ‘drought,’ there is now almost a data deluge with the National Family Health Survey IV, and the recent national micronutrient survey.

The most fundamental missing ingredient so far has been political will to drive performance across the various sectors and actors that need to be coordinated effectively to produce results. This political will needs to be informed by smart information systems that focus on the ‘what’ that needs to be delivered and can inform course correction and continuous improvement. Simply put, to achieve strong nutrition outcomes, the health, food and social protection systems need to work in concert. India has enormous capacities and investments in these sectors, and now needs to work on the orchestration and accountability to get them to perform their mandates to deliver good to nutrition to mothers and children.

This is why I am so heartened by the creation of the National Nutrition Mission which gives a level of political prioritization to nutrition that can lead this orchestration and accountability at every administrative level. The critical components are in place, the National Nutrition Mission provides the opportunity to ensure that they all operate effectively.

BKK: What would be your advice for a media website on nutrition, like the Outlook Poshan initiative, for the road ahead? How do you think it should proceed, issues it should touch upon, to make nutrition a household name?

SKB: I will go back to the four root causes: orphan, invisible, unmeasured and voiceless. I think that they media play an essential role in making nutrition visible and given those at risk ofmalnutrition a voice. I applaud Outlook Media for taking on this initiative. Nutrition can seem complex and faced with the nutrition challenges in India, the road ahead can seem daunting. You canplay an essential role in translating the scientific evidence into actionable steps. It is also important to celebrate success and underscore the progress that is being made, and the champions that make this progress happen every day. Furthermore, to solve malnutrition we need to be engaged for the long term, and we know that complacency can lead to backsliding on progress. You can will serve the cause by keeping up a constant drumbeat to make sure that the current attention and political will is not a flash in the pan—but a long-term commitment to make India malnutrition free.