The fundamental problem with malnutrition is that it’s not visible: Shawn K Baker

India has all the ingredients in place to make progress. It has a veritable battalion of front line workers, Anganwadi workers, ASHA workers, Auxiliary Nurse, Midwives, there are almost 2.5 million front line workers. It’s got policies that are very much in sync with global best practice.

Shahid Akhter
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Shahid Akhter, editor, ETHealthworld spoke to Shawn K Baker, Director, Nutrition (Global Development) Bill & Melinda Gates Foundation (BMGF) , Seattle, USA to know more about his views on India’s struggle to tackle malnutrition and the role being played by BMGF to augment this process. Edited excerpts:

1. India has introduced several policies and initiated programs to address the maternal and child mortality incidences. Where does nutrition and malnutrition stand in the scheme of things and what are the aspects being focused on by Bill & Melinda Gates Foundation in this space?

There are two engines of Nutrition – undernutrition is the attributable cause of 45% of under 5-mortality, meaning if India or any other country in the world is going to take the next great leap forward in reducing child deaths, we have to address undernutrition.

Secondly, what is growing increasingly apparent is that nutrition is also the fundamental basis for human capital development. So, we talk a lot about nutrition in children who are stunted i.e. too short for their age but in fact we are not worried about their physical size it means that stunting is an indicator that their overall development has been deprived. This essentially means populations that have not had adequate nutrition during the ‘first 1000 days’ and are not developing enough, so they are always going to be struggling more than populations who are surviving.

Hence, nutrition is essential both to save lives and to build the future of families, future of communities and the future of entire nations.

This is the reason why within nutrition, at the Bill and Melinda Gates Foundation we have really increased our efforts in nutrition working in partnership with countries like the Government of India, because we see it is essential for the future generations. We are focusing particularly on the ‘1000-day window’ so from conception to 2yrs of life a real focus on maternal nutrition, focus on breastfeeding and focus on making sure children from 6 to 23 months are getting a good nutritious diet.

2. Poshan Abhiyan is a landmark program by the government and there is a lot being done to promote it. Do you think it is going to be enough?

I want to position the ‘National Nutrition Mission’ or ‘Poshan Abhiyan’ in its context, when colleagues globally ask me what has happened in nutrition in the last year that excites you, I cite two things – the global nutrition summit in ‘Milan’ which was a huge moment where actors across the globe including ‘Kofi A. Annan’ former UN secretary general ‘and ‘Graca Machel’ former first lady, both beacons of south Africa led the charge to commit new resources to nutrition and to me equally or perhaps even more important is the launch of the ‘National Nutrition Mission’. The reason is that India represents at least 1/3rd of the worlds burden of undernutrition. If we do not accelerate progress in India the world will not meet its targets to end all forms of malnutrition by 2030. Personally, I get incredibly excited because India for a long time has had this constellation- ‘all the ingredients in place’ to make progress. It has a veritable battalion of front line workers (FLW’s); with Anganwadi workers, ASHA (Accredited Social Health Activist) workers; Auxiliary Nurse; Midwives, there are almost 2.5 million front line workers. It’s got policies that are very much in sync with global best practice. It has this amazing emergence of self-help groups which are empowering women to be able to feed their children better. To get this level of political attention and focus on actually making sure all of these schemes work for the people for whom they are intended is a huge opportunity. Hence, I have been very energized by my visit here during this week.

3. The government has announced the month of September to be celebrated as ‘Poshan Maah’ – a step in the direction towards transforming this into a ‘Jan Andolan’ or ‘Mass Movement’. What do you think of this? What more can be done?

To put this into context – the fundamental problem with malnutrition is that it’s not visible! I think when the public thinks about malnutrition they only think of that severely emaciated child who needs treatment but in fact the burden of malnutrition is huge and almost always hidden. If you are suffering from a deficiency in Iron or deficiency in Vitamin A it’s not visible but when you go into a village and every child is too small that just is the norm. So to make nutrition visible is a huge contribution to society building the awareness how fundamental nutrition is.

I do think that due to the new government’s commitment to actually delivering on these multiple platforms that can deliver good nutrition it is a good reason to celebrate and having a month which is dedicated to raising the profile of nutrition in my mind is a huge step forward. My aspiration would be that we move from a nutrition month so that every hour people think about nutrition because when you think of a mom, who is the most essential caretaker for nutrition, she is worried about nutrition of her infant and her young child each and every hour.

4. The ‘1000-day window’ has been hailed as a critical intervention for nutrition. Could you share where India measures up on this viz a viz other country?

‘1000-day window’ had a global breakthrough, perhaps starting with the 2008 Lancet series on under nutrition that led to the understanding that most of the damage in malnutrition is done from the time of conception to the first 2 yrs of life and once that damage is done, it’s almost irreversible. I like to flip this to the other side that if we lock in good nutrition during this period we have made an investment that child now is on the road to a healthy productive life so it’s an incredible opportunity.

How is India doing – a lot of room for improvement but there are huge opportunities. I think globally and in India specifically there has been a big neglect of maternal nutrition in the first 9 months. Let me give you an example – In Bihar the health system is getting tetanus toxoid 2 rates that are delivered through the anti-natal clinic platform up to around 80% but Iron folic acid which is essential for moms is only about less than 10% so if we start prioritizing nutrition we can have some great increases. Similarly, one of the most important things you can do is initiate breastfeeding within an hour and exclusive breastfeeding for 6 months. Again, going back to Bihar almost 75% of women now give birth in facilities but only about 40% of women are initiating breastfeeding within the first hour so here if we can just make sure that every facility is providing the support necessary to moms to start breastfeeding within one hour we can increase those rates dramatically with just that attention on performance. Hence, focus on ‘1000-day window’ is one of the huge opportunities for India to accelerate progress.

5. Do you think data and science can be used to alleviate malnutrition the way it has been done to eliminate polio and increase vaccine coverage?

I think data to drive better performance is going to be absolutely essential. If you look at the story of polio eradication in India it was all understanding where is the problem and what do I need to do and tracking it. India for nutrition was in a data drought for 10 years because there was a 10 years hiatus between the Nation Family Health Survey 3 (NFHS-3) and National Family Health Survey 4 (NFHS-4). For a country of this size and for an issue so important such as Nutrition not having good data on nutritional status and coverage of nutritional indicators was a real handicap. Now with the National Family Health Survey 4 (NFHS-4) there is vast amount of information to understand where the problem is and what needs to be done and there is a commitment from the government to do these surveys every 3 years so that’s going to be a huge advantage.

There have been some other innovations in data that are quite exciting. Let me go back to Anganwadi workers- 1.4 million Anganwadi workers out there. I have worked in nutrition all my life and to me this is a treasure trove of frontline workers but we have saddled them with filling out physical registers in some states 23 registers, other states 11 and weighing 8.5 kilos. So, this Anganwadi worker who should be focused on counselling the pregnant mom, counseling the mom who has just given birth and counseling the mom who is feeding her child and no she is been spending all her time filling out registers. Hence, the Common Application System (CAS) is putting all this on the digital platform, a regular cellphone like you or I use. Its freeing up her time from all these registers to really focus on what she should be doing and is giving her the information she needs to know -whom should I be reaching out to, at what time and for what service because if you have just given birth I want to talk to you about exclusive breastfeeding, if your child is just turning 6 months I want to talk to you about introducing other foods into your diet, if your pregnant I want to talk to you about making sure you are going to ANC Services (First Antenatal Care), that you eat well and you take your Iron Folic Acid tablets. So, both at the national level down to that frontline worker, I think data can be essential to drive better performance and focus on what needs to be done.

6. Are you working with the government to address malnutrition? What are good things that are happening? What are the challenges and how does the Gates Foundation plan to address them?

I have worked in the field ofpublic health and nutrition for about 30 years and its only when I joined The Gates Foundation that I started getting engaged with India and what I find extraordinary here is the opportunity and that collaboration with the government is an essential part of it. In most countries, you are desperately looking for frontline workers who will support moms and their families, here India has 2.5 million of them.

You want to make sure that food security has been addressed with the governments schemes of food distribution through the public distribution system, the integrated child developmental services, the mid-day meals, there is a huge commitment to ensure ‘basic food security’. The policy environment in India for nutrition is well aligned with global practice and there is this incredible women’s empowerment platform growing even stronger every day with self-help groups.

Here, you have a government which is investing in human resources, financial resources and policy resources, and I think this is where we see this collaboration to ensure that these complex systems are honing in to the key nutrition action, where we think is the biggest opportunity. Let me share an example by going to back to Bihar and the ‘Iron Folic Acid’ story one of the reasons is that there is this big opportunity gap between the percentage of women attending ‘Antenatal clinics’ and the percentage getting ‘Iron Folic Acid’ tablets because there was a breakdown in supply and by assisting the government of Bihar to fix that supply chain, while we don’t have the data yet, our anecdotal reporting so far shows that there is huge promise and huge opportunity for increase. So, we have worked a lot with governments hand in hand both at the state level and national level to really focus on how do you help these systems to perform better. We are also thrilled to see the other philanthropies like the ‘TATA Trusts’ and ‘Azim Premji Philanthropic Initiatives(APPI)’ are also supporting the government to execute on the government’s own priorities.

One of the things we are extremely excited about in terms of execution of the ‘National Nutrition Mission’ is how do you actually help districts develop a strong action plan for nutrition and ensure that somebody is waking up every day to see that it is executed and ‘TATA Trusts’ is working to in fact provide that consultant support to the districts because that’s where everything comes together.

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