My column this month is prepared in collaboration with my dear colleague and friend Urban Jonsson. He and I share responsibility for the critique of the Scaling Up Nutrition (SUN) initiative, which is at the end of the column. Above, we are together at the ICN in Bangkok in 2009.

It seems that the UN System Standing Committee on Nutrition (SCN) is now among the living dead. But some of its key work needs to be preserved. This column also has some necessarily hard things to say about SUN, which has now apparently taken over the SCN. It is worth remembering here that several Association members wrote to the drafters of the SUN 'road-map' and to the SCN, asking for the human rights-based approach to nutrition to be incorporated. We were ignored.

Investing in nutrition is as much an issue of health, of care, and of food sovereignty, as it is of human rights, of economic welfare, and of social protection. Nutrition must be central to all renewed commitments and efforts to successfully realise the Millennium Development Goals.

Acute or chronic states of undernutrition are the direct outcome of an insufficient intake of food and nutrients, of losses of nutrients due to infection or of increased nutritional requirements as it occurs during infancy, early childhood, adolescence and during pregnancy and lactation. To address all these factors, investments have to be directed to the immediate, underlying and basic causes of preventable disease, malnutrition and deaths.

The numbers of children under 5 affected by acute undernutrition, or who are dangerously too thin for their height, are appalling. As you all know, those severely undernourished are at increased risk of death. Chronic undernutrition and growth retardation of children under 5, measured as stunted growth, also impairs brain development, and undermines the health, productivity and earning potential of those children as they become adults.

Leaving these problems unaddressed during the critical periods of growth (conception to 2 years of age) perpetuates them from one generation to the next at great social and economic cost. Malnutrition is a cause and also a consequence of failed development, as well as a gross violation of human rights, particularly of the rights of women and children.

Nutrition being a condition that runs through the different Millennium Development Goals (MDGs), it is a key global public health, human rights and development priority absolutely essential to all endeavours to realise the goals. Here is the evidence:

MDG1 . Eradicate extreme poverty and hunger
The detection, treatment and prevention of undernutrition is crucial to poverty and hunger alleviation strategies. Failing to take action on all forms of undernutrition incurs annual losses to national economic development in the billions of dollars through direct losses in productivity, indirect losses from deficits in schooling, and as increased health costs (1). Poverty and hunger are also perhaps the major causes of loss of dignity.

MDG2. Achieve universal primary education
Undernutrition causes losses in primary school enrolment, attendance, performance and retention rates. Undernourished children have poorer educational outcomes and lower earnings, losing up to more than 10 per cent of earnings in their lifetime: at country level, the Gross Domestic Product lost can be as high as 2-3 per cent. This all amounts to both the right to nutrition and the right to education being violated.

MDG3 . Promote gender equality and empower women
Undernutrition reflects gender biases in access to food, to health, to education and to other services, which are all violations of the human rights of women. Interventions to prevent and treat undernutrition can and do contribute to gender equality and empowerment by relieving women from carrying the disproportionate burden of hunger, disease, illiteracy and impoverishment. Although rural women produce more than half of the food in sub-Saharan Africa, they own less land or property than do men, as much as they have less access to credit and to other critical instruments and tools that lead to greater economic security. Undernutrition simply continues to hamper efforts to achieve gender equality.

MDG4. Reduce child mortality
Severe acute malnutrition contributes to over one million child deaths every year and thus represents a violation of the right to life. Common childhood diseases that are ordinarily treatable, often become fatal in the presence of undernutrition. About half of all deaths in children under 5 have undernutrition as a concurrent cause.

MDG5. Improve maternal health
Maternal undernutrition contributes to maternal ill-health and other complications during pregnancy, childbirth and after birth, and also to the poor health, growth and development of successive generations. Adequate nutrition and care during pregnancy and childbirth could prevent 3 of the 4 million infant deaths in the first month of life, and protect survivors from non-communicable diseases in adulthood (2).

MDG6. Combat HIV/AIDS, malaria and other diseases
Undernutrition dramatically reduces the ability to resist infection and increases the duration and severity of disease. In its presence, the progression of HIV to AIDS is accelerated, and malarial survival rates are reduced. In countries most affected by HIV, life expectancy has been reduced by more than 20 years, with a subsequent reduction of economic growth and deepening poverty levels (3) --not to mention the discrimination and denial of rights infected people are subjected to.

MDG7. Ensure environmental sustainability
Around 90 percent of all diarrhoea cases are linked to poor sanitation, unsafe water, and more globally an unsafe environment. Repeated or protracted water-related diseases episodes, easily lead to, or exacerbate under-nutrition. The newly recognised right to water is being flagrantly violated. Increasing access to safe water and sanitary services will contribute to maternal and child care practices, reduce the burden on health services, and decrease health care costs at household level and in national accounts. Environmental sustainable food production and mitigating the impact of climate change also increases food and nutrition security in the longer term.

MDG8. Develop a global partnership for development
The underlying causes of undernutrition pertain to three core areas of human survival. These are year-round sufficient food of adequate quality, access to primary health care, clean water and sanitation, and better care practices for mothers and children. In addition to these underlying causes, the whole host of basic causes have to be tackled as the core of development interventions at global and country level; this is crucial for comprehensive and effective action on undernutrition for survival and for growth and development. Donors are unlikely to fully comply with this goal, which was the only one imposed by lower-income countries during MDG negotiations. Therefore, the key to achieve this goal is the social mobilisation of claim holders.

Comprehensively and sustainably addressing the problem of undernutrition needs direct prevention and treatment interventions, and also simultaneous interventions and mobilisation that decisively address underlying and basic issues. These include claim holders demanding more equitable access to local, national and global resources, and fair access to world markets.

Governments and their partners in development can only achieve the goals as and when policies and practice assure an equitable access to resources at all levels. The effectiveness of direct nutrition interventions has been tested and proven, but remain subject to underlying and basic causes being addressed. This fact is too often dismissed or just appended as an afterthought. With this proviso, direct nutrition interventions remain crucial for optimal aid to those countries with the highest burden of undernutrition. It is an achievable means of increasing the impact on maternal and child health and other development initiatives. But what is needed for the achievement of the MDGs requires, but goes beyond, direct nutrition interventions. This point cannot be over-emphasised.

Here is what the World Public Health Nutrition Association should now do, and what Association members and supporters should press for:

• Prioritisation of nutrition as an indispensable cross-cutting issue requiring investments in nutrition, as well as in scaled-up programmes that address the social and economic determinants of malnutrition.
• Nutrition interventions in support of the MDGs of a type that hold international duty bearers accountable for the implementation of direct nutrition programming, beyond the SUN initiative and its 10 billion dollars annual financial investment identified by the World Bank. No 'packaged' interventions are going to get us where we want to go. Packages are utterly top-down and have come about in a non-participatory way. (Isn't the SUN initiative primarily top-down?). We have to change this.
• Better use of available evidence on the scale, location and severity of under-nutrition in all contexts, disaggregating data by gender and by socioeconomic and ethnic groups. Claim holders and duty bearers can then, together and proactively, address non-emergency nutrition problems, rather than by reacting to them after the event.
• Prevention and treatment of undernutrition in national health systems that foster really sustainable solutions. Such integration should include the transfer of skills, as well as the building of capacity for policy work across the health, agriculture and education sectors, and also to foster human rights learning and learning about the political economy of nutrition.
• Integration of nutrition actions within the food security, health, water, sanitation, hygiene and education sectors and, in all of them, integration of the human rights framework. Only this will have a better and more sustainable chance to address malnutrition and poverty and their social determinants. This integration is to foster effective collaboration at local, national, regional and global level by setting up ad-hoc partnerships and initiatives that look at and address undernutrition from a more appropriate holistic and thus human rights perspective.

With only less than four years remaining to 2015, the target year to achieve the MDGs, and with the imperative for aid to be effective, it is time to tackle the problem of undernutrition decisively and definitively. Failure to do so will continue to exacerbate the plight of the most vulnerable groups in society, and will blight national development plans and global efforts to eradicate malnutrition.

In reaffirming our commitment to the MDGs, we must insist that nutrition is key to a fair development for all. Are you ready to contribute?

Here we make a brief critique – and very critical it is, too – of The Road Map for Scaling Up Nutrition. This document is supposed to detail the means by which national, regional and international actors will work together to establish and pursue efforts to make nutrition interventions more impressive and effective in countries with a high burden of malnutrition 'utilising proven interventions and through multi-sectoral and integrated nutrition-focused development policies and processes'. SUN follows the May 2010 WHO World Health Assembly resolution 63.23 on infant and young child nutrition, and is anchored in the guiding principles developed by the UN Standing Committee on Nutrition in 2009 in Brussels. These seek:

'To ensure that nutrition policies are pro-poor, pay attention to people with specific nutritional requirements (especially children under the age of 2 years), are rights- based, offer integrated support (food, health, care and are socially based, participatory (building on local communities, engaging their institutions and are inclusive of women's and children's interests), and do no harm' (page 8).

Although this is a smorgardsbord sentence in the SUN document, it is a very good one. But unfortunately, we cannot find anything else of this in the rest of the SUN Roadmap. We also object to SUN's proposed 'pro-poor' orientation; we rather favour measures that address disparity reduction and stop 'targeting' the poor since this is equivalent to victimising them as if they are responsible for their ill-health and then throwing them a crust of bread. This is the flaw we always saw in 'nutrition with a human face'.

Section II of the document proposes: 'common principles for stake-holders involved in scaling-up nutrition, for mobilising support from development partners, and for ensuring that national needs, variations in country contexts, and programme priorities are always brought to the fore. It indicates the importance of strategic leadership, synergy among institutions and coordinated mobilisation for action. It shows how the SUN effort builds on successful institutions, infrastructure and programmes, and it identifies some of the tools, processes and mechanisms for increasing impact' (page 8).

Read the whole statement slowly and think about what it really says. It is one of the best examples of empty rhetoric, because it says everything and therefore means nothing. Moreover, it ignores the fact that there are claim holders and duty bearers involved in all of this, and that it is only their dialectical engagement that will move the 'nutrition process' forward. This fact was brought to the attention of the drafters of the SUN Roadmap, in writing, and the request for concrete changes in the wording received no response whatsoever.

Another typical rhetorical statement that reflects the naive political attitude of seeking harmony and consensus among nutrition professionals, is the total absence of any reference to the processes of exploitation and power abuse/imbalances. We read the following:

'Alignment within movements will encourage synergy and complementarities, through common goals and agreed actions, inspiring mutual respect, confidence and trust between participants, and minimising potential conflict of interest through shared common codes of conduct' (page 10).

We ask: In which world are the authors living? …and this was written in 2010.

On some more technical issues:

• One cannot simply take SUN's proposed benefit/cost estimates seriously at all.. Moreover, the cost effectiveness it purports to improve is purely based on outcomes and is oblivious to processes. The World Bank is spending U$12 billion a year (page 12) with an extremely limited scientific basis.
• SUN's emphasis prioritises mostly technical interventions. It mixes up terms like 'malnutrition', 'undernutrition' and 'hunger'. Also, the outdated and misleading terms 'nutritious food, 'food and nutrition security', and 'freedom from hunger' are still used in the document. This just highlights a pervasive lack of clarity.
• When identifying monitoring indicators, only outcome and not delivery-related and impact indicators are suggested (page10). All serious development scholars today agree that there is a need to include process indicators. This is true for all development approaches, not just human rights-based approaches. Why are, for example, none of the Paris Principles on Human Rights mentioned as a basis for monitoring indicators? This is not an oversight; this is the result of an ideological bias.

Almost throughout the whole document, one unavoidably gets the feeling that the different interventions that are being called for, are utterly 'top-down'. The text in the 'road map' is not only inadequate. There is also absolutely no reference made to anything resembling an Assessment, Analysis and Action approach. Why? Again, only an ideological bias can explain this --and a clear bias there is! Another unavoidable feeling one gets is that there is hardly anything new in the document, both as far as content is concerned and in the proposed conceptualisations. Have twenty years gone by in vain?

References

1. UNICEF. Progress for Children: A Report Card on Nutrition, 2006. www.unicef.org/publications/index_33685.html
2. Department for International Development (DFID). Child Mortality, 2007. www.dfid.gov.uk/pubs/files/mdg- factsheets/childmortalityfactsheet.pdf
3. UNAIDS. Global Report on the AIDS Epidemic, 2008. www.unaids.org/en/dataanalysis/epidemiology/ 2008reportontheglobalaidsepidemic/

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: : Schuftan C. The Millennium Development Goals, and the Scaling Up Nutrition Initiative [Column] Website of the World Public Health Nutrition Association, July 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Geoffrey Cannon.