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Nutrition—the Forgotten MDG

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January 28, 2008––The new Lancet series on nutrition, co-authored and co-financed by the World Bank, depicts the lamentable state of under-nutrition worldwide, and a corresponding negligence on the part of the development community to meet the challenge decisively. Under-nutrition represents the non-income face of poverty. And the world is off track on meeting this goal.

The scientific facts, raised by the Bank’s own ”Repositioning Nutrition as Central to Development” report of 2006 and reiterated by the Lancet, are compelling: under-nutrition—which includes stunting or poor fetal growth, and micro-nutrient deficiencies—is the underlying cause of at least 3.5 million deaths, and 35 percent of the disease burden in children younger than 5 years of age. Countries with “higher overall logistics costs are more likely to miss the opportunities of globalization,” say the study’s lead authors Jean Francois Arvis and Monica Alina Mustra of the Bank’s Poverty Reduction and Economic Management (PREM) group.

World Bank's Human Development VP, Joy Phumaphi,right, with World Bank's Human Development Nutrition Adviser, Meera Shekar after The Lancet series launch.

Also, the number of global deaths attributed to under-nutrition constitutes the largest percentage of any risk factor in this age group; maternal nutrition and iron-deficiency anemia increase the risk of a mother’s death at delivery and account for more than 20 percent of maternal deaths. And, remarkably, 90 percent of the world’s malnourished children live in only 36 countries.

In typically blunt fashion, an editorial in The Lancet, which has been published every week since 1823, concludes: “This latest Lancet Series concludes, not surprisingly perhaps, that the international nutrition system is broken. Leadership is absent, resources are too few, capacity is fragile, and emergency response systems are fragmentary.”

Tried and True Solutions

The Lancet is undoubtedly on the mark with its critique of the development community, but there is little debate that we have the proven interventions to hand to make a difference.

Under-nutrition in an infant’s first 24 months of life leads to irreversible brain and physical damage, including shorter adult height, lower attained schooling, and reduced adult income. Prevention measures, such as exclusive breastfeeding and complementary feeding for infants, are therefore long-term investments that can greatly improve the quality of life for present and successive generations.

Conception to 24 months of age is a crucial window of opportunity to prevent or reduce under-nutrition. As the Bank and The Lancet both agree, we should focus strongly on this critical period. 

Crucial Investments

"The Bank’s investments in nutrition over recent years have focused on the crucial window of opportunity between pre-pregnancy to 24 months of age; however, it is clear now that we need even greater investment in this age group," said Joy Phumaphi,  World Bank’s Human Development vice president, who was a co-panelist at the Washington launch of the Lancet Series. “Malnutrition robs youngsters of their human potential, and poor countries of vital economic growth, which is why the Bank will step up its work in the 36 countries where 90 percent of the world's malnourished children live,” she added.

Phumaphi says that stepped up action in these countries could spur the eradication of hunger as required by Millennium Development Goal (MDG) 1b, and also greatly leverage the achievement of MDGs 4and 5with fewer child deaths and improved maternal health respectively.

A Fragmented and Dysfunctional System

Other key points in The Lancet series argue that the architecture of the international nutrition system—made up of international and donor organizations, academia, civil society, and the private sector—is fragmented and dysfunctional.

A three-old battling malnutrition and related physical disabilities.

“On top of these defects in the global system, there’s not enough development aid for under-nutrition; it’s unwisely dominated by food aid and supply-led technical assistance; and we also need a new global governance structure and leadership for greater accountability and participation by civil society and the private sector,” says Meera Shekar, the World Bank’s Human Development Network’s senior nutrition specialist, who co-authored The Lancet series. She also wrote “Repositioning Nutrition,” which rallied the global community, including the Gates Foundation, around the nutrition agenda.

Having made the technical case to do vastly more on nutrition for mothers and their newborns, The Lancet poses this challenge: “an agency, donor, or political leader needs to step up to this challenge. There is a fabulous opportunity now for someone to do so. But who?”

A Role for the Bank

Shekar responds to the question by arguing that the Bank is well-positioned to take this leadership role in partnership with others. She and Julian Schweitzer, World Bank’s Human Development director of health, nutrition, and population, suggest that the Bank could fairly claim a leadership role in continuing to implement three key steps:

  • Raise the profile and the understanding of the long-term implications of malnutrition at international and national levels: Under-nutrition perpetuates generations of cognitively impaired citizens, and continues to marginalize progress on the other MDGs (especially MDGs 2, 4 & 5); and, none of the donors, including the Bank, have responded at an appropriate scale to this challenge to-date.
  • Provide an existing platform for urgent action: To mobilize new impetus in the 36 high-burden countries, provide leadership in donor harmonization (including space for the private sector), apply lessons from innovative financing mechanisms such as results-based financing, and invite other partners to join. The call should be for urgent action and results at country level, using the Bank’s existing platform—not for another new vertical global initiative or a new secretariat to harmonize the donors.
  • Provide the leadership in “delivery science” across multiple sectors that could achieve better sustained results. Useful innovations in this area could include Results-Based Financing, Conditional Cash Transfers (CCTs), new service delivery approaches, commitment and institutional capacity-building at country level, etc. The Bank’s Development Grant Facility could provide seed money for such an effort.


Thanks to The Lancet series, and the Bank’s own case for reversing under-nutrition, this neglected MDG is about to become less obscure and stake a claim on the development priorities of countries, donors, and aid agencies alike.

Speaking just ahead of his participation at the World Economic Forum in Switzerland over the weekend, World Bank Group President Mr. Zoellick said he would use the Davos gathering to “draw attention to hunger and malnutrition, the forgotten Millennium Development Goal.”

Fighting malnutrition, he said, was essential to success on other development fronts, such as reducing infant mortality, improving maternal health, and strengthening primary education.

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