The global nutrition challenge: getting a healthy start

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the Pacific Health Summit

Distinguished delegates, ladies and gentlemen,

First and foremost, let me thank the organizers for focusing this summit on nutrition.

We face some alarming disease trends, at the global level, and some striking recent events, with global causes, that are directly related to nutrition. Both point to the need to give nutrition much greater attention in discussions about health, whether in rich societies or the developing world.

Any discussion about nutrition has to look at the food supply. The provision of an adequate and safe food supply is one of those fundamental responsibilities of government that are often taken for granted until something dramatic goes wrong.

In wealthy countries, the drama usually follows an outbreak of foodborne disease. This brings headlines about the number of cases, the pattern of spread, the source of the guilty food, and the costs of the usually massive recalls.

With the headlines come the questions. How did this happen? Who is responsible? Is the government doing its job?

Outbreaks of foodborne disease are costly, disruptive, and sometimes deadly, but they are circumscribed events. They come to an end. This is not at all the case for many other health problems linked to nutrition and the food supply.

Today, the global nutrition situation is a picture of extremes. Of fasting and feasting, of wasting, stunting, and obesity. At one end, undernutrition, and more specifically, deficiencies in essential nutrients, are the underlying cause of an estimated 3.5 million deaths each year, largely in young children and pregnant women.

At the other end, we have a global epidemic of obesity, increasingly starting in childhood. We have millions of people at increased risk of developing diet-related chronic diseases, like heart disease, cancer and diabetes.

Long considered the companions of wealthy societies, these chronic diseases have changed place. They now impose their greatest burden in low- and middle-income countries. Contributing factors include longer life expectancies, urbanization, lifestyle changes, the industrialization of food production, and the globalization of food marketing and distribution.

Ladies and gentlemen,

We have some other major problems. In developing countries, something very fundamental has gone terribly wrong. I am referring, of course, to the crisis caused by soaring food prices.

Food riots around the world and a toppled government have turned on the spotlight, sparked the headlines, and started the questions. How did this happen? What policies brought this on? Who is responsible?

Public health asks a different set of questions – not about who is responsible, but about who will suffer and what must be done.

The health sector had no say in making the policies that shaped this crisis. But health, and most especially in poor and vulnerable populations, will pay the price.

The crisis forces a hard look at the fundamental importance of nutrition to good health throughout the lifespan. It forces a hard look at policies.

Simply stated: what does it mean for global health when millions of people can no longer afford to eat properly?

Ladies and gentlemen,

I have been asked to talk about the role of global leadership in nutrition. I see two main areas where leadership is needed, and can make a significant difference for health.

First, we need leadership to deliver interventions for nutritional deficiencies to those in greatest need. The interventions already exist. They are cost-effective, and many bring spectacular results. Here, the need is for leadership and innovative in devising delivery systems.

Second, leadership is needed to ensure that policies governing agriculture, food production, and trade are firmly anchored in human nutritional needs and are shaped by health concerns. This is a need for political leadership.

To guard against diet-related chronic diseases, we need policies that make healthy food choices the easy choices. To support better nutrition among the poor, we need policies that do a much better job of ensuring food security.

Neither of these leadership roles is easy. In looking at some very complex issues, we can be guided by one clear conclusion, on that is based on substantial evidence. Interventions suitable for a population-wide approach that do not require behavioural change will have the greatest impact. This is especially true when addressing the problem of undernutrition.

At the other extreme, I want to stress an additional point. High income is not the main determinant of overnutrition. Very poor people can suffer from obesity and from a greater risk of diet-related chronic diseases. I will return to this point later.

Ladies and gentlemen,

Health problems associated with undernutrition are overwhelmingly concentrated in the developing world. For pregnancy outcomes, 99% of the deaths linked to undernutrition occur in low- and middle-income countries.

I have mentioned the fundamental importance of nutrition throughout the lifespan. Adequate nutrition allows the bodies and brains of young children to reach their full development potential. Poorly nourished children are more likely to die from common infectious diseases.

Nutrition contributes to the survival of people affected by HIV/AIDS, tuberculosis, malaria. Good nutrition helps prevent disabling conditions in the elderly.

Though nutrition is important for all age groups, the health economists tell us to invest most in good nutrition for the very young. Poor nutrition during the first two years of life can have multiple life-long consequences.

On the positive side, a well-nourished child means better physical and mental development, better educational outcomes, and better economic productivity. All this means a chance, for children, to realize their human potential and, for countries, to realize their economic potential.

Without question, solutions to the problems of food insecurity and undernutrition are fundamental to progress in socioeconomic development.

Ladies and gentlemen,

Let me turn to some policy issues.

We face a dilemma. Better nutrition is essential for health. Yet the factors that determine the adequacy and quality of the food supply lie outside the direct control of the health sector.

This simple reality has tended to place health ministers in the developing world in a passive role. This is the thinking: improvements in nutritional status must await poverty alleviation, increased agricultural productivity, and better infrastructures for food transportation and storage.

In this 21st century, improved nutrition also depends on trade policies that contribute to an adequate and affordable food supply, and yet do so in ways that do not erode the livelihoods of smallholder farmers.

All of these policy changes are important, but they simply take too long to bring improvements in nutritional status to the poor people of the world.

The international community has committed itself to time-limited development goals, including a reduction in world hunger. Nutrition is fundamental to the attainment of goals set for improving child and maternal health, and reducing deaths from AIDS, malaria, and tuberculosis. In addition, the target set for engagement with the private sector underscores an important route to better nutrition.

Let me outline three areas where leadership can help accelerate progress, right now. All address the same central challenge: finding ways to deliver existing interventions.

Primary health care is the first and foremost delivery system for many simple interventions with a huge impact. Let me give just two examples. Counselling of mothers can help reduce the estimated yearly 1.4 million infant deaths that are linked to suboptimal breastfeeding.

As a second example, the recent development of ready-to-use therapeutic foods, often based on peanut butter, allows severely malnourished children to be managed in homes, with outstanding results.

A second strategy is to piggy-back nutrition interventions on existing delivery systems. For example, the use of childhood immunization programmes to distribute vitamin A supplements has resulted in dramatic gains in population coverage, especially in hard-to-reach areas.

The third strategy is to collaborate with the food industry to fortify widely used food items with essential nutrients. This strategy is being pursued, most notably, by the Global Alliance for Improved Nutrition, or GAIN.

Established in 2002, this Alliance works with the food industry to develop food fortification schemes, and uses existing food marketing channels to deliver better nutrition. The fortification programmes are locally developed, sustainable, and inexpensive. They achieve high population coverage with no need for behavioural change. This is a most encouraging way forward.

Ladies and gentlemen,

A discussion of leadership, especially at the policy level, must take a hard look at the current food crisis. We must understand where policies that paid insufficient attention to health have led us.

Poor households spend well over half of their disposable income on food. Food choices are highly sensitive to price. The first items to drop out of the diet are usually the healthy foods – fruits, vegetables, and high-quality sources of protein – which are nearly always more expensive.

In urban areas, fatty or sugar-filled processed foods become the cheapest way to fill hungry stomachs. In rural areas, families are forced to rely on low-energy, nutrient-poor staple foods.

The food crisis is thus a dual threat to health: one threat arising from undernutrition, especially in young children, and a second threat from the many chronic diseases that are strongly linked to unhealthy diets.

WHO and many other UN agencies are responding to the crisis in our respective roles, under the leadership of the UN Secretary-General. But I want to stress an important point. The intense planning and actions and fund-raising currently under way are, in a sense, a rehearsal for what we will see as a result of climate change.

The warming of the planet will be gradual, but the effects of extreme weather events will be abrupt and acutely felt. We know that agriculture is extremely sensitive to climate change. We know that developing countries will be the first and hardest hit. Crop failures of up to 50% are predicted for parts of Africa within the next twelve years.

Ladies and gentlemen,

Let me close with a final observation.

The policies that govern agriculture, food production, and trade nearly always have a strong economic dimension. But where is the foresight when it comes to the effects on health? What will it cost governments and the international community to address the health consequences of the food crisis?

What will it cost to address future humanitarian crises caused by more and more storms, floods, droughts, famine and hunger? Again, where is the foresight?

I will leave you with these thoughts.