Equity and social justice.

1. Equity and social justice. The global context of extreme poverty and hungerProximate ultimate causes & how hunger will become history Allan J Davison PhD, Professor, Biochemist, Faculty of Sciences, Simon Fraser University Department of Biomedical Sciences & Kinesiology June 2011 Prepared as part of an education project of the Global Health Education Consortium & collaborating partners

2. Objectives Oncompletingthis module youwill be ableto: Describe the extent of malnutrition & its impact on people of the planet, and understand how MDGs depend on nutrition Analyze the factors that determine nutritional health Identify nutritional problems among individuals & populations, identify causes & appropriate solutions Assess risks at various stages of the life cycle & recommend strategies for diminishing risk Comparecompeting theories accounting for the inequities Predictoutcomes by projectingcurrent trends into the future & foresee a pathway toward a world without hunger Page 2

3. Section Break 6 Malnutrition: prevalence, causes, consequences 4 Major categories & measures of nutritional status4 Nutrition & crucial periods in the life-cycle; 4 Determinants of nutrition, dietary patterns & culture2 Nutrition and its relationship to disease4 Making hunger history - breaking the poverty-trap3 Trends in nutrition, food security & globalization3 Page 3

4. 6 Making hunger history breaking the poverty-trap cycle To find the remedy, we must know the causes Poverty trap Resource trap Then we’ll understand what “remedies” don’t work what is working dramatically why hunger will become history in this century

5. Page 5

6. Worldwide distribution of malnutrition Scientific American, Sept 2007 Over 20 million children suffer from acute malnutrition WHO. Page 6

7. “The bottom billion”(title of a book by Paul Collier) “The poorest of the poor” - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day • We define this subclass as people who don't get enough to meet the ordinary demands of life • They lack the resources to earn a living, or obtain what’s needed for normal, growth, maintenance & reproduction • It goes without saying that they are unable to provide the necessities for those who depend on them Page 7

8. “The bottom billion”(title of a book by Paul Collier) • Their lack of access to resources is such that a significant fraction will be unable to stay alive • They live mostly in isolated rural areas and most are subsistence farmers This means that what they eat this month is what they can take out of the ground from last month's planting Page 8

9. 7 Malnutrition & MDGs: cause, effect, cure 3 slides: • Trends in nutrition, food security & globalization • Agricultural trends • Nutritional inequities - Cause & consequence • Food security; Prospects for having enough food

10. 4 Determinants of nutrition, diet & culture 2 slides:

11. Worldwide, nutritional inequities follow poverty(as do health inequities & life expectancy) • Globally, there is plenty of food for everyone but …those who have more than they need find reasons not to share • The result – in the time you spend on this module over 1000 children will have died of hunger • Each day 1500 children go forever blind from lack of vitamin A • The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency). • About 2 billion people (56% of pregnant women) have iron deficiency. Their babies have low birth-weight, &  mortality Note D

12. Sub-determinants of nutritional sufficiency • Each factor has its own contingencies. Here are a few more: • Stability includes freedom from disruptive forces • war (revolts, invasion, political upheaval, social disruption) • exploitation from outside – unequal trading practices • corruption externally – multinational corporations offer bribes and rich nations tolerate this because it benefits them • corruption internally – where some developed nations set a poor example e.g. non-transparent procurement policies Note O Page 12

13. Determinants of population nutrition Any broken link can  nutritional inequities. (think about how …)

14. The mechanisms of hunger – many paths Notice how one path can feed-back to affect others As diagrammed by WHO in “Repositioning Nutrition as Central to Development:  A Strategy for Large-Scale Action”

15. Sub-determinants of nutritional sufficiency • Each factor has its own contingencies. Here are a few: • Economic development depends on agricultural sustainability • irrigation & soil maintenance (crop rotation, contour plowing) • seeds, fertilizers, appropriate insecticides • Agricultural productivity depends on good harvests • climatic: drought and floods • drought - and frost-resistant crops • hybrid seeds and related biotechnology • market for any excess crop, non-exploitative trade

16. Sub-determinants of nutritional sufficiency • Each factor has its own contingencies. Here are a few more: • Stability includes freedom from disruptive forces • war (revolts, invasion, political upheaval, social disruption) • exploitation from outside – unequal trading practices • corruption externally – multinational corporations offer bribes and rich nations tolerate this because it benefits them • corruption internally – where some developed nations set a poor example e.g. non-transparent procurement policies Note O Page 16

17. Poverty - greatest cause of malnutrition(hunger, blindness, disease, birth defects, maternal/neonatal death) The causes of poverty are disputed – no one wants to be part of the cause. What we know is…. • Poverty doesn't just happen, it is caused by economic, political, social & geographical circumstances & decisions • Usually these decisions are made outside the groups of people most affected by it! Note P

18. Poverty - greatest cause of malnutrition(hunger, blindness, disease, birth defects, maternal/neonatal death) • Old people, women and under-supported children are most likely to be impacted by poverty • Uneven distribution: 2/3of undernourished people live in Asia • Hunger is growing fastest in Sudan, Rwanda, Burundi, Chad D.R. Congo, Sierra Leone, Zimbabwe, Somalia Page 18

19. Dietary patterns across cultures 1. Hunter gatherers – the earliest category Benefits: mixed diet, well nourished in good times Risks: famine or drought, warfare & plunder, resource- depletion through population pressure Prevalent problems: starvation, thirst,  life-expectancy Note I

20. Poverty - greatest cause of malnutrition(hunger, blindness, disease, birth defects, maternal/neonatal death) The causes of poverty are disputed – no one wants to be part of the cause. What we know is…. • Poverty doesn't just happen, it is caused by economic, political, social & geographical circumstances & decisions • Usually these decisions are made outside the groups of people most affected by it! Note P

21. Poverty - greatest cause of malnutrition(hunger, blindness, disease, birth defects, maternal/neonatal death) • Old people, women and under-supported children are most likely to be impacted by poverty • Uneven distribution: 2/3of undernourished people live in Asia • Hunger is growing fastest in Sudan, Rwanda, Burundi, Chad D.R. Congo, Sierra Leone, Zimbabwe, Somalia Page 21

22. Fundamentals and emphasis As we consider cause and effect we must ask: How & why have such inequities come to be? Who and what factors impede solutions? What current initiatives will bring the resolution? To help answer these, we must will emphasize:Immediate causes - scarcity of specific nutrients Primary and secondary prevention Public health approaches to solutions Page 22 Page 22

23. World% undernourished 22% same data 14%

24. Prediction millions Number fed & under-nourished worldwide Target 33% 14% 11% 6% 24 24

25. A vicious cycle for malnutritionpoverty, health, economic deprivation Poverty: Diminished access to agricultural & food resources  malnutrition high birth rate Health: Physical & cognitive impairment, susceptibility to disease, early death  inability to earn an income nutrition Development: Marginalization  inability to provide for self or family Access to the ladder of development

26. Routes to famine Being landlocked Lesotho Discovering resources So.Africa Nigeria, Iraq Being on a trade or pipeline route Israel, Afghanistan Bad governance Zimbabwe, Italy, USA Externally initiated armed conflict Sudan, Afghanistan Uncertain rainfall & drought Sahel, Palestine Blaming the bonsai tree... Yunus:

27. 1 Malnutrition & MDGs: cause, effect, cure 3 slides: • Trends in nutrition, food security & globalization • Agricultural trends • Nutritional inequities - Cause & consequence • Food security; Prospects for having enough food

28. Paying for total strangers to eat? } Not us, not if it goes to corruptdictators”  28

29. “Development aid”, not spent on poverty or development Clawed back by unfair trade Emergency aid Debt relief Refugee, Tied to benefit rich “Phantom aid”, the wasted 47% Refers to ODA, notMDGs http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities

30. The Millennium Development Goals • At a UN Millennium (2002) summit, the nations of the world set eight MDGs to be achieved by 2015 • The world's main development challenges were identified • Specific actions and targets (the MDGs) • A commitment to provide the means was made by 189 nations & signed by 147 heads of state • The MDGs break down into • 21 quantifiable targets • Targets are measured by 60 time-lined indicators Some nations have kept their trust. But some of the richest in the world have announced that they will not meet their commitments

31. Primary goal is to eradicate extreme poverty & hunger Nutrition & Millennium Development Goals  Gender equity Empower ♀ see next 2 slides Achieve universalprimary education 1 HIV, malaria, other diseases  Child mortality  Environmentalsustainability Global partnershipfor development Nutrition – direct prerequisite to goals 1, 3, 4, 5 & 6; indirectly to 7 & 8  maternalhealth

32. Centrality of nutrition to MDGs 1, 2, & 3 1. Eradicate extreme poverty & hunger. Poverty is the main determinant of hunger. In turn, malnutrition irreversibly compromises physical & cognitive development & thus transmits poverty & hunger to future generations. 2. Achieve universal primary education. Malnutrition diminishes the chance that a child will go to school, stay in school, or perform well in school 3. Promote gender equality, empower women. Women’s malnutrition impairs the whole family’s health & nutrition

33. Centrality of nutrition to MDGs 4, 5, & 6 4. Reduce child mortality. Delivery of a live healthy child is dependent, above all, on a well nourished mother. Protein & folic acid are critical here 5. Improve maternal health. Malnutrition accentuates all major risk factors for maternal mortality, e.g., inadequate protein, iron, iodine, vitamin A & calcium 6. Combat serious infectious diseases. Malnutrition aggravates infections, immune competence, transmission & mortality in HIV, malaria, tuberculosis Adapted from Gillespie and Haddad (2003) http://web.worldbank.org/

34. 2 Categories & measures of nutritional status 4 slides: • Malnutrition, undernutrition, • Overnutrition / Overweight, Obesity • Energy requirements: calories, carboh, proteins, fats • macronutrients, micronutrients

35. Categories of nutritional status Nutritional status is assessed as one of four categories • Good nutritional status: All nutrients (right quantities, time & place) allow optimal, growth, maintenance, & reproduction • Overnutrition: An excess of a nutrients (usually calories) is being consumed, so that health is negatively impacted • Undernutrition: Insufficient food is consumed to allow for the energy needs of the individual. Inevitably dietary (& then body) protein is burned for energy. A secondary protein deficiency ensues – thus: "protein-energy-malnutrition" • Malnutrition: Energy consumption is adequate, but there is an imbalance among constituents of the diet and health is impacted Note C

36. Worldwide distribution of malnutrition Over 20 million children suffer from acute malnutrition WHO. Scientific American, Sept 2007

37. Worldwide, nutritional inequities follow poverty(as do health inequities & life expectancy) • Globally, there is plenty of food for everyone but …those who have more than they need find reasons not to share • The result – in the time you spend on this module over 1000 children will have died of hunger • Each day 1500 children go forever blind from lack of vitamin A • The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency). • About 2 billion people (56% of pregnant women) have iron deficiency. Their babies have low birth-weight, &  mortality Note D

38. “The bottom billion”(title of a book by Paul Collier) “The poorest of the poor,” Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day • We define this subclass as people who don't get enough to meet the ordinary demands of life • They lack the resources to earn a living, or obtain what‘s needed for normal, growth, maintenance & reproduction • It goes without saying that they are unable to provide the necessities for those who depend on them

39. “The bottom billion”(title of a book by Paul Collier) • Their lack of access to resources is such that a significant fraction will be unable to stay alive • They live mostly in isolated rural areas and most are subsistence farmers This means that what they eat this month is what they can take out of the ground from last month's planting Page 39

40. http://www.who.int/mediacentre/factsheets/fs290/en/index.htmlhttp://www.who.int/mediacentre/factsheets/fs290/en/index.html http://www.fao.org/mdg/en/ http://www.un.org/millenniumgoals/reports.shtml#mdgs

41. http://www.who.int/mediacentre/factsheets/fs290/en/index.htmlhttp://www.who.int/mediacentre/factsheets/fs290/en/index.html http://www.fao.org/mdg/en/ http://www.un.org/millenniumgoals/reports.shtml#mdgs

42. Percentage stunted http://www.unicef.org/media/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf 60% http://ije.oxfordjournals.org/content/32/4/518.full.pdf Africa Asia 40% Latin Am 20% 1980 & every 5 years Last 2 or 3 points are projections

43. Unhelpful misconceptions about aid False: “Most aid money goes into the Swiss bank accounts of corrupt African dictators” “Aid creates dependence & impedes self-sufficiency” “Despite all the aid $, the problems are only getting worse” The truth is: Overwhelmingly African leaders are not corrupt. When they are, most bribes come from the West Well planned aid builds capacity & self-sufficiency Overall, hunger worldwide is diminishing. MDGs go forward because of the countries that honour their pledges! Note E Page 43

45. 6 Making hunger history - breaking the vicious cycle of the poverty-trap 3 slides: • Worldwide distribution of malnutrition & its relation to poverty • Societal costs of malnutritionincluding effects on young children

46. We now know what works! Widespread agreement at conferences! Tool-kits for elimination of extreme poverty & hunger exist MDGs, change agents, Grameen, Millennium Village, Agencies & foundations for development. CIGHR, GHEC, Supercourse, Universities, Spokespersons for the developing nations We know what we can do to help right now. Need govt action! Resources, personnel, sharing what works, time needed to get on development ladder We know we can do it better! Need info & research New knowledge production, dissemination, data mining, knowledge brokering & application

47. The poorest - don’t give them money Money? No way to get it & useless! Jeffrey Sachs • No one to employ anyone, no one to sell things to • No shops to spend money in • What they eat this month is what they can take out of the ground from last month's planting • Hungry & stunted kids tiny unmarked graves • Hospital, dispensary, emergency > 1 day walk More immediate than money – (1) to SURVIVEWe don’t need studies to learn what’s needed

48. What do they need? The greatest nutritional problems are well known: Protein energy malnutrition Vitamin A Iron Iodine

49. What do they need? Millions saved oral rehydration solution ready to use foods Short term – “Give a man a fish ...” Emergency rations, safe water, first aid, antibiotics, public health – vaccinations, drugs, etc In conflict zones, shelter, safety to live, plant, harvest In drought “safe-water straws” Page 49

50. Emergency aid isn’t intended for development “Phantom aid”: 47% is “wasted” http://www.globalissues.org/article/35/foreign-aid-development-assistance#GovernmentsCuttingBackonPromisedResponsibilities • Evaporating aid - promises … broken as soon as cameras turn elsewhere • $ flow benefits the rich nations – tilted trade • Aid with strings attached, contingent on UN votes, WB loans, unfair trade • Dumped food surplus   local farm economy • Money given by corrupt rich people to “corrupt dictators” UK banks in Nigerian corruption Paul Collier: The bottom billion 50