Global nutrition in the 21st Century
Opportunities and Challenges for the Developed and Developing Worlds
Allan J Davison, Ph.D.
Introduction: Where we are and how we got here
Food is a basic human need. With roughly 1 billion humans suffering from over-nutrition and a similar
number unable to find enough food to subsist, no one seriously disagrees about the urgency of addressing
world hunger. Hunger and malnutrition adversely affect physical and mental development, to the point that
one in six individuals do not get enough food to be healthy enough to lead a normally active life. Hunger
and malnutrition are leading risks to health and well-being worldwide. global nutrition concerns. Most who
work to alleviate world-scale malnutrition agree on dimensions of hunger, its causes, and indeed on how to
measure and address it [1]. Broadly speaking, the cost of alleviating hunger within a few decades amounts
to a levy on the rich of less than 1% of their earnings. Within 15 years, we can, and within 50 years we will,
empower the hungry to be self-sustaining. Meanwhile, the prospect is slow progress for several dozen
fragile or failing sites. many in Africa south of the Sahara. The obstacle lies within the political arena,
where national self-interest can conflict with goals that serve the global good. Despite an abundance of food,
and of funds to serve narrow interests on the world scale, some western leaders are reluctant to ask voters to
make even inconsequential sacrifices on behalf of hungry people far away. The purpose of this chapter is to
address misconceptions regarding world hunger and to assess prospects for eliminating it. As the chapter
unfolds, the reader might experience an uncomfortable mix of optimism, indignation, and impatience.
Global malnutrition is not new, but it was not until 1978 that a commission [2] identified the challenges
pivotal to the poor, namely: a) the magnitude of, and trends in, undernutrition1, b) the relationship of
malnutrition to infectious diseases, and c) orienting food policy and agriculture to problems of the neediest2.
What unfolded rocked the developed world. The figures were, and remain, unimaginable. In 1970, a third of
humankind – more than 1.4 billion people, went to bed hungry. Children were especially impacted –
1
The FAO WHO/UNU definition of undernutrition is habitual calorie intake below the calorie expenditure required to
earn an income or otherwise gain access to resources sufficient to maintain a body weight consistent with health and the activities
of daily life. There are problems with this, but it has utility in population studies.
2
The question of causes of hunger was not raised at this stage, but we will return to causes hereunder.3 Extreme poverty
refers to the condition of "the poorest of the poor – not having the means to afford basic human needs such as clean water,
nutrition, health care, clothing, and shelter. This is also referred to as absolute poverty or destitution. Relative poverty is having
fewer resources or less income than others within a society or country, or compared to worldwide averages. Regression analysis
shows that for a population the threshold income for extreme poverty is equivalent to US$1.25 at 2005 international prices. The
common reference value "$1.25 PPP" is the value corrected for purchasing power and inflation. Complexities will be discussed
later.
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undernutrition played a role in more than nine million child deaths annually, two-thirds in their first year of
life [3].
Prelude to the 21st century Where are we & how did we got here
Abruptly, the rich nations were convinced that "someone" must "do something" and virtually all people
of goodwill volunteered for the task of redressing global health inequities. There followed a decade of
ferment from which an unprecedented consensus emerged at the start of the 21st century. Acknowledging
the suffering as a major challenge, the world's nations committed themselves to action over the next 15
years [4]. A turning point MDGs. In a UN declaration, eight specific goals were established, the
"Millennium Development Goals" (MDGs), most related to nutrition. The goals included 21 quantifiable
targets, and 60 time-lined indicators. As a prelude to addressing their implementation and the consequences,
we need to understand who the hungry are and how they came to be in such extreme poverty1.
Nutrition, poverty, and self-sufficiency
Nutrition is the most immediately modifiable factor that affects individual and public health. A core
concern in the science of nutrition is how to deliver the essentials of a healthy diet to a hungry world. Now,
poverty is the major determinant of malnutrition – reflecting that the greatest difficult faced by the poor in
sustainably producing a sufficient diet. Consequently, there is little debate that improving nutrition is an
integral goal in development aid, even as health is a prerequisite to sustainable development. The
interdependence of nutrition in economic development and health is emphasized in the Figure 1.
Figure 1: The"poverty
trap":
roles of nutrition,
health, and economics
A vicious cycle:
economics,
hunger, health
Poverty  diminished
access to agricultural &
food resources 
malnutrition
nutrition
Physical & cognitive
impairment,
susceptibility to
disease, early death 
inability to earn an
income
Economic
marginalization
 inability to
provide for self or
family
Extreme poverty refers to the condition of "the poorest of the poor – not having the means to afford basic human needs
such as clean water, nutrition, health care, clothing, and shelter. This is also referred to as absolute poverty or destitution. Relative
poverty is having fewer resources or less income than others within a society or country, or compared to worldwide averages.
Regression analysis shows that for a population the threshold income for extreme poverty is equivalent to US$1.25 at 2005
international prices. The common reference value "$1.25 PPP" is the value corrected for purchasing power and inflation.
Complexities will be discussed later.
1
page 2 of 47
The poverty trap can begin with failure of any of the three links – malnutrition, ill health, or economic
marginalization. There is no release without outside intervention. Thus parents commonly transmit the cycle
through successive generations. When it occurs in countries the cycle of poverty is called the "development
trap".
The hungry and the poverty trap
Ironically, most of the poor are subsistence farmers on smallholdings in remote areas. They depend
for survival on what they scrape from an uncooperative earth. What they eat this month is what they can
take out of the ground from last month's planting, or what they can forage within several hours walk. A
day's work still leaves the family hungry. inaccessible areas, there is no paid work. If they have something
left over to sell, there is no one to buy it. If there is "spare time" it is invested in fetching water or fuel (often
animal dung) for fire. Construction or repair of rudimentary shelters is preempted by foraging. In a settled
community there will be a burial area where many small graves attest that one month's delay in the rainy
season can bring a deadly aftermath, or that medical care, drugs, or first aid were more than a day's walk
away.
Learning the needs of hungry people need not be difficult. Field workers hear the plea: "Please no
more anthropologists, no more needs-assessments. Look around. If you can't see what we need, ask us. We
will tell you". And it is obvious, and it is not money. Active listening can bring reality. At an Ottawa Global
Health conference the large number of North Americans understandably dominated much of the discussion.
Someone said quietly: "We in Africa find that when white people come, they have very small ears, and very
large mouths. We would prefer it the other way round". money has no intrinsic value – there is nowhere to
spend it, no shops. A trading post may be 30 miles away.
Their needs are much more fundamental than money. The needs are for water to drink, water for the
crops, quality seeds, fertilizers, low technology tools, mosquito nets, perinatal clinics, and dispensaries. It is
true that money can provide these things, but, in the absence of commerce, it must be spent elsewhere. This
means that due diligence is as needed, just as in any western country, when money is given to an
intermediary.
Outmoded beliefs about the hungry
Outside the Sahel it is no longer true that the poor nations are getting poorer. In fact, the difference
in average income between countries is diminishing. In contrast, within most countries, the income gap
between rich and poor is increasing. This is often termed "convergence" in that most of the poor nations are
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upwardly mobile on the ladder of development. The result is that the prevalence of most nutritional
problems correlate less with national income than with personal income within their geographical location.
It was never true that most of the poor lived in African countries with failing economies, nor that most of
the poor lived in the poorest countries. Currently, 80% of the poor live outside Africa, outside the poorest
countries. Indeed many live in economies that are growing impressively and that have increasing numbers
of wealthy people, countries like India, China, and Bangladesh. Conversely, poverty exists in every nation,
even in the richest countries of the world. In America, for example, 50% of children will have had to rely on
charity (food stamps) for their meals by the time they reach eighteen. Among ethnic minorities, the
proportion is 80-90% [5]. Stark inequities persist in China, even though it met the first Millennium
Development Goal fourteen years ahead of the 2015 target date. The richest provinces in China are Macao,
Hong Kong, and Shanghai with median annual incomes of $43202, $37691, $22,258, while the poorest are
Yunan, Gansu, and Guzhou, with median annual incomes of $2815, $2643, and $1945.
Country
Infant mortality rate GDP / capita
HongKong
1.8
$37694
Singapore
2.0
$44312
Beijing
3.1
$14840
Tianjin
3.4
$13751
Denmark
4
$34725
Utah
4.5
$36311
Cuba
5
$8329
S Korea
5
$22323
California
5.3
$47889
Sri Lanka
11
$3734
Mississippi
11
$27556
Syria
12
$4145
Washington DC 15
$138556
Hunan
$4218
20
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Infant mortality rates in the first 12 months of life correlate with perinatal nutrition and other aspects of
perinatal health care. These data are correlated to some extent with income per capita, but there are startling
inconsistencies. The lowest infant mortality rates are in HongKong and Singapore (2 or less per 100 live
births). Denmark, Utah and Cuba have infant mortality rates between 4 and 5. However, the first two have
an average income of $35000, whereas Cuba's is $8000.
Conversely, there are no longer poor nations in which almost everyone is hungry. Even in the poorest
countries, overnutrition has become a public health concern. In developing nations, overnutrition
increasingly contributes to burden of heart disease. Diabetes affects 12-20% of adults in many countries in
Asia, the Middle East, and the Caribbean. The WHO predicts that by 2025, 80% of the new cases of
diabetes will be in developing countries. The hungry and the overfed are now all around all of us, reminding
us that inequities bring problems to both rich and poor, and that the problems of the rich are not confined to
the rich nations.
How a nation becomes poor
Writers from the developing world [Kumi Naidoo, Raj Patel] point out that virtually all countries
had a sufficiency of food as a prerequisite to becoming populated. Hunger came later, and seldom from
reasons that were under the control of those most affected. Analyses of poverty from the developed world
support this conclusion. States fail for a multitude of reasons: armed conflict, being landlocked, uncertain
rainfall & drought, being the recipient of international boycotts (Cuba, Zimbabwe), differential initial
distribution of resources, and appropriation of resources without commensurate compensation [6,7].
Resource alienation
Farm land (Congo) food → oil, clean air have recently been commodified !
Most of the poor are not poor at all when one considers the natural resources of their territories
[Collier]. These often have great potential value to the inhabitants, were they allowed control . Yet
somehow, the copper of Chile or Katanga, or the oil of Nigeria disappears with no sustained trickle-down to
the poorest. The Gold Coast of Africa now has no gold and its people are none the richer.
Analyses from the developing world often cite a major misconception about poverty – that countries
fail because of some fault of their inhabitants. Muhammad Yunus likens the process to taking a seed from
the tallest tree in the forest and planting it in a small pot where it is fashioned into a Bonsai. It is futile to
examine the seed to learn why it became poor. The causes came from outside. The causes come from
outside, and the cycle of poverty springs the trap. The poverty of a nation can become embedded to where it
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will not be solved simply by the removing the cause [8]. It is futile to examine the seed to learn why it
became poor. Although the poor are often blamed for being ruled by corrupt dictators, corruption is no more
common among the poor nations than the rich. Much more commonly, this is cited by those ideologically
opposed to development aid.
However, the matter does not rest there. Paul Collier has reported that the discovery of rich resources
in a country is usually followed by deepening poverty for the populace. Afghanistan happened to be located
on a narrow isthmus that channels commodities, armies, and migration between Asia, Europe, and the
Middle East. One of the most valuable areas of real estate in the world, it remains one of the world's most
oshed poorest nations, as a result of being irresistible in turn to Macedonians, Hindus, Greeks, Persians,
Turks, Moguls, Sikhs, British, Russians, and now NATO [9]. The conclusion that a nation can become poor
by having resources may elicit skepticism in the wealthy nations, but it has considerable currency in nations
recently emerged from colonial status. The indigenous peoples of Africa remember the fever of the settlers
for their diamonds and gold, and the settlers remember the glitter in the eyes of the British when they
annexed the diamond fields of Kimberly and then declared war on the nascent Transvaal republic when gold
was discovered. Most countries experience dramatic improvements in health, nutrition, and GDP during the
decades after they emerge from colonial status [Rosling].
The loss and alienation of the land and commons are events on the road to poverty. Two examples: Fish
were historically a nutrient-rich food source for the poor, but ocean fish are increasingly being priced out of
reach. The destruction of the commons of the ocean, to which the developing world contributed little, is a
nutritional catastrophe for them. The disappearance of ocean fish stocks as a food source is aggravated by a
view in the developed world that farmed fish, The assumption that it is better to eat "wild" salmon puts
further pressure on fish stocks, driving prices upward to where they are inaccessible to poor in rich or poor
countries. Here again is an imposition, where an indulgence of the wealthy hurts the developing world. In
developing countries fish farming is increasingly providing necessary protein to many. To them, attempts in
the rich nations to roll back fish farming seem as anachronistic as earlier attempts to disrupt cattle ranching.
People who never thought of land as a commodity, are puzzled when demands of extractive industry or
appropriation fence off a long term source of food or water. The process of foreign land acquisition has
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increased dramatically. In the past five years, developing1 countries have seen the purchase of 5 million
hectares of farmable land by foreign interests. A billion dollars has flowed, and a report from two UN
bodies2 is titled "Land grab or development opportunity?". The Congo, Ethiopia, Mali, Ghana, Indonesia,
and other nations have sold potential farm land to agribusiness in the US, Norway Egypt, India, South
Africa, Saudi Arabia, and South Korea [10].
Multinational entities such as Goldman Sachs, Sun Biofuels, Kellogg, Agri-Vie, and others have
participated, presumably in the search for profit, with carbon credits and agrifuels providing an added
incentive [11]. Given recent swings in food prices, governments may merely be seeking stability by
securing alternative food sources. Whatever the cause, global warming or conversion of food to fuel, the
consequences to the poor are the same – the loss of farmable land. However, the developing nations are
accustomed to transactions on a tilted table [12]: "Market forces aren't just supply and demand. The hidden
hand of the market can never operate without a hidden fist … McDonalds cannot flourish without
McDonnell Douglas" [13]. On a fair bargaining table, a government selling land could exact concessions of
comparable value3.
Outmoded beliefs about hunger and poverty
It is no longer true that the poor nations are getting poorer Differences in average income between
countries are diminishing. Most lower and middle income countries are already on the ladder of
development. The exceptions are about 30 fragile or failing states, half of them south of the Sahara,. In
contrast, within most countries rich or poor, the income gap between rich and poor is increasing. By
clouding our concept of poverty and its distribution, the misconception impairs our ability to mitigate
hunger. It is not true that most of the poor live in African countries with failing economies. Currently, 80%
of the poor do not live in Africa or in the poorest countries. Most of the poor live in economies that are
growing impressively with increasing numbers of wealthy people; i.e., India, China, and Bangladesh [5].
1
The term developing country is inconsistently used, and so we will use the imperfect World Bank definition which
considers all low- and middle- income countries as "developing". In its most recent classification, countries with GNI
per capita below US$11,905 in 2008 were considered in this category.
7
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
7
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
page 7 of 47
Conversely, poverty persists even in the richest countries of the world. In America for example, 50% of
children will have had to rely on charity (food stamps) by the time they reach eighteen (among ethnic
minorities, the proportion is 80%) [14]. In China, which met the first Millennium Development Goal
fourteen years ahead of the 2015 target date, stark inequities remain. The richest provinces in China are
Macao, Hong Kong, and Shanghai with median annual incomes of USD$43202, $37691, $22,258, [15].
While widespread hunger is no longer a problem in China, average income in the poorest provinces is about
one tenth that in the richer. In Canada, too, 70% of Inuit children live in food insecure households, while in
the larger population 5.6% of households with children are food insecure [16].
Conversely, there are no longer poor nations in which almost everyone is emaciated. They too, contain
huge disparities in income, to the extent that problems of overnutrition have become major public health
problems. In these nations, obesity and diabetes increasingly contribute to the burden of heart disease. Of
the 250 million people with diabetes, 80% live in low and middle-income countries, where 12-20% of adults
in countries in Asia, the Middle East, and the Caribbean are affected. By 2025, 80% of the new cases of
diabetes will be in developing countries [17]. In these countries, diabetes is diagnosed at a later stage where
it is less treatable, and access to treatment is less. Consequently, the burden of diabetes, and the cost to
society, affect developing countries much more severely.
When comparing countries with widely differing GDP, there is thus a surprisingly large overlap of
income range. This phenomenong is called convergence1. It means that a person's nutritional status no
longer correlates strongly with their location, but instead closely follow individual income regardless of
country. Many of the rich nations who give little to overseas development aid also fail to provide food and
health services to the poor inside their borders. The burden of the income disparity falls heavier within the
developing nations, where the GNP may allow only a few dollars a person per year for health care.
What is working and what is not
Aid as a way out of the poverty trap
Almost no nation has achieved economic success without substantial outside financial help. The richest
nations in the world are in the European Union (EU) in part because of the Marshall plan designed to
rebuild Europe after World War II. There are, however, those who uncompromisingly object to aid of all
4
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
page 8 of 47
kinds. Overwhelmingly they cite two reasons: (1) all the aid given to date "has had no effect"; or (2) aid
"ends up in numbered bank accounts of corrupt dictators". Both assertions are wildly inconsistent with
reality. As indicated above, over years poverty is decreasing, and aid is at least partly responsible.
Moreover, while bribery is repellent and spread across all nations, it is no more common among the poor
than among the rich [18]. For every corrupt person who accepts a bribe there is a corrupt person who offered
one.
Ordinary Africans will applaud the edict that aid must reach those for whom it is intended. When a
dishonest official is bribed, the people suffer twice. First, a valuable resource flows out of their country at a
fraction of its true worth. Then the proceeds of the bribe go out of the country via a foreign bank account.
President Obama addressed corruption in a 2009 pledge to support the MDGs: "Developing nations must
root out corruption … opportunity cannot thrive where … business have to pay bribes". The implication that
western businesses are forced to offer bribes is disingenuous. As Dambisa Moyo has pointed out "Western
countries … could begin by stopping the corruption money flowing back" through numbered bank accounts,
and track and prosecute those who offer bribes and those who receive them. In fact, the overwhelming
majority of countries, whether inside or outside Africa, are rigorous in dealing with bribery, theft, and fraud.
Of the 53 countries in Africa less than 10% rank significantly lower than countries we habitually trade with
without accusing the leaders of corruption [16]. Twenty-four nations, mostly in Africa, have signed on to
the "Extractive Industry Transparency Initiative", which contains rules to eliminate covert deals in this
important area of trade [19].
This is not to applaud all kinds of aid. Aid carries risks for both donor and recipient. Indeed, certain
kinds of aid are not merely valueless – they are harmful; e.g., food aid originally conceived in the 1950s as a
way to dispose of U.S. food surpluses earmarked for burning. While bringing relief to famine stricken
recipients, it quickly diminished, and in some cases destroyed, local agricultural capacity. The obvious
solution is to give priority to purchasing food from farmers. This lowers cost of both grain and shipping –
the aid dollar goes twice as far and preserves local capacity. However, the solutions are usually undermined
by the agricultural and maritime lobbies in the donor countries. They secured legislation that the food must
be purchased in, and shipped under, the flag of their country. Inadequate local food supplies suggest a need
to emphasize agricultural aid. However, agricultural aid has drastically declined from 1980 to 2000. For
example, Canada, U.S., and New Zealand have each decreased agricultural aid as a fraction of their total aid
package by 20% to 4% [20].
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Aid can also come with unacceptable strings attached. A common requirement in World Bank loans is
that recipients must open their markets to product, including foods from the developed world. Most
developed nations subsidize farmers and so their foods can flow, below production cost, into the recipient
country, beggaring their farmers [12]. Meanwhile, the rich countries, almost universally, close their markets
to food products from the developing world. The most visible critic of this kind of aid is again Dambisa
Moyo [21]. She asks: "Why is Africa wasting its time in the World Trade Organization, which will never
remove trade barriers. Instead Africa should foster its relationship with countries that are interested in
actually buying African produce". "If Western markets don't want to trade with Africa for reasons of
protecting their own markets, Africa should focus on China and India" [22].
In most developed countries, the citizenry tend to favor more generous aid policies than their
governments. Surveys show that in most countries, people believe that the government provides more aid
than it really does. Sometimes governments seem to resort to smoke and mirrors to confuse voters. Despite
its name, the US Millennium Challenge Corporation has goals rather different than the MDGs, and bypasses
the UN, using political criteria to select recipients. A common belief that "the USA gives more aid than
anyone else" should also be questioned. Even in the most recent absolute amounts, the EU gave over $59b
while the U.S. (with roughly the same population) gave less than half that amount [23,24]. Moreover, a
major fraction of aid from the NATO states goes to nations that have strategic importance to NATO rather
than to the neediest.
Progress toward the MDGs at the half way milestone
All eight MDGs have made steady progress. The rub is that they have moved forward consistent with
funding, and funding was overestimated at the outset. The 15-year timescale of the MDGs was set by the
professed willingness of the 20 wealthiest nations developed nations to provide resources. They declined to
provide 1% of their gross domestic product (GDP) to development aid, but agreed to ramp up to 0.7%. On
this basis, a 15-year timeline was agreed to. In the event, five European nations have consistently provided
the pledged 0.7% or more (Sweden 0.98%; Luxembourg 0.92%; Norway 0.88%; Denmark 0.82%;
Netherlands 0.80%) and most of the others are paying more half (0.35%). Nations outside the Development
Assistance Committee are stepping forward – Kuwait reportedly gives 0.82% of its GDP, Saudi Arabia
0.4%. For the rest, well-intentioned heads of state were apparently unable to convince their parliaments or
senates to provide the funds pledged, and so the promises evaporated when the media turned their attention
page 10 of 47
elsewhere. Thus Greece, Italy, Japan, and the U.S. are paying 0.2% or less [21] because the vast sums of
money promised "have brought no benefits", or that the money promised has turned out to be "excessive".
Steady progress, therefore does not mean that progress is on schedule. In fact only one goal (primary
education) is likely to be met by 2015. The first "primary" goal, the mitigation of hunger, is one that will be
delayed. We will examine that goal in some detail, because of its centrality, its successes and failures will
affect the progress of the other goals.
In part to assess progress to the first MDG, specific measures of hunger and poverty are tracked by
numerous organizations including the World Bank, Food and Agriculture Organization of the United
Nations (FAO), U.S. Department of Agriculture (USDA), OECD, and others. It should be noted that the
organization assesses hunger by differing criteria [25]. The most prevalent measure is the World Bank's
USD$1.25 per day purchasing power parity (PPP)1 [26]. The major conclusion from all data sources is that
more people are fed every year than ever before, with the number doubling since 1980 and increasing by
32% since 1990. This means that despite population growth, the world's, agricultural productivity has more
than kept pace.
Figure 2 World Bank tracking of extreme poverty and hunger
====================
Insert Figure 2 near here
====================
Figure 2, shows the percentage of people below $1.25 PPP per day based on World Bank data [27].
Note that, between 1980 and 2005, the percentage of people in poverty decreased at an overall average of
about 1.25% per year. With the exception of the few failing states, measures of health, such as infant
mortality and life expectancy, also improved [28].
A caveat; the worldwide data conceal discrepancies among countries, and most of the overall
improvement reflects progress in the large population economies in East and South Asia. In Latin America,
improvements are small. While Africa as a whole is improving, the Sahel2 and war-torn nations inside and
3
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
3
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
page 11 of 47
outside Africa, are deteriorating [29]. Afghanistan remains one of the poorest countries in the world. Haiti,
too, is a example of a failing state . Long the poorest nation in its region, its economy has deteriorated
steadily for fifty years, and without help it seems destined to become one of the poorest in the world. The
misery following the devastating earthquake of 2010 has captured the world's attention and brought
promises of sustainable aid that will, perhaps, this time be kept.
The 2008 world recession has impacted global hunger and this has elicited outrage from those affected.
The increased loss of life is immense, unnecessary, and deplorable. The response of the rich has been
inadequate, failing even to protect the hungry inside their own borders. The developed nations conclude
that, again, they are bearing the major consequences of events caused by irresponsible planning elsewhere.
Catastrophic fears that the level of hunger will never recover are, however, unhelpful and unwarranted. On
current data and projections, the current recession will have an impact similar to those in 1986 and 1996
(Figure 2). GDP (inflation adjusted) dropped by 2.5% from 2008 to 2009 in sub-Saharan Africa (excluding
South Africa). Projecting the data beyond the recession, a minor recovery begins in 2010, and GDP will
overtake pre-recession levels in 2012 [30]. This aggregate for sub-Sahara likely reflects worldwide events,
since they agree with FAO historical data that recessions typically lead to a one or two year downturn, with
4 to 6 years required to overtake pre-recession levels. Although the setback will be temporary, it will not be
without cost. Many lives will be lost.
The increasing population of some developing countries certainly steepens the path to achieving the
MDGs, but this was factored into the timeline. There is undoubtedly a limit to the world's agricultural
capacity, but it probably will not be reached in the next 15-20 years. Nevertheless, Malthus cannot be
ignored indefinitely. Unless the world moves to contain population growth, limits to food and other
resources are likely to be reached this century.
Looking at the larger picture, the regional data clarify our priorities so that aid can be focused on a
shrinking population, in defined areas. The increasing number and wealth of the rich means that a given
fraction of their income has a greater impact year by year. Steady progress, even if slow, means a shrinking
problem and greater assurance of continuing or even accelerating progress.
Successes and hopeful signs for MDG early in the century
An inventory of successes in the MDGs is available on the Bill and Malinda Gates Foundation "Living
Proof Project" web page in the form of a series of progress sheets. An overall "Successes in Global Health",
summarizes eight detailed reports covering progress towards: immunization, maternal newborn child health
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nutrition, and against malaria, HIV/AIDS, tuberculosis, polio, and neglected tropical diseases [31]. Beyond
these progress sheets, the site offers videos, photo galleries, and interactive graphics. Comprehensive,
readable, and up-to-date, each category contains quality resources to inform, but also useful as aids in
presentations community meetings, conferences, and classroom or web based courses.
Looking beyond the current recession, the number of hungry and the percentage of hungry are
decreasing. Detractors emphasize that population growth slows the rate of decrease in the percentage of
hungry. Again, by all measures, the number of people fed each year continues to increase significantly. A
cautious projection toward the future should assume that the nations that are currently failing to meet their
aid commitments will continue to do so, and that the nations that are steadfast will continue to pay 0.4% or
better. On this basis, the MDG should be met in 30 years instead of 15, except that we must add a four-year
delay from the current recession. Conservatively we would contend that world hunger will diminish to half
of its 1990 levels by the mid 2030s, and begin to disappear around mid-century. In the new millennium the
above challenges will continue, but there is additional hope in formidable new enterprises that are not
dependent on the vagaries of government funding. It is time to examine some of these.
Beyond the MDGs
Among several collections of goals for eliminating global nutrition disparities, the MDGs are
considered byProspects for the MDGs as a route out of the "development trap"
World agreement on the MDGs sets the stage for our perspective on global nutrition in the 21st century.
The "first and primary" goal is to diminish the incidence of extreme poverty and hunger by 50% from 1990
values. What then would be a reasonable timescale? In 1974 the 20 wealthiest nations were asked to provide
1% of their gross domestic product (GDP) to "overseas development aid" (ODA). Some demurred and in
the end, the intention was a target of 0.7% of their GDP. Few kept their promises, and for the MDGs the
signatories committed to 0.7%. On this basis, 147 heads of state signed the MDG agreement in 2001 by, and
189 nations pledged a 15-year timeline based on a quick ramp-up to a funding level of 0.7%.
Did concrete action follow the declaration? To a limited extent. As with previous commitments, many
promises evaporated when the media turned their attention elsewhere. Five nations are currently paying
their share. For the rest, well-intentioned heads of governments were apparently unable to convince their
parliaments or senates to ante up the funds. Some of the richest, including Canada, Australia, Japan, and the
US, are decreasing their contributions on the grounds that the vast sums of money spent have "had no
effect", or that the amount of money promised turned out to be excessive!
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What then are the prospects? At the 8-year point, the MDGs are moving forward at a rate consistent with
funding. While all goals show steady progress, only one goal is likely to be met on schedule. A further
setback is rooted in the global recession of 2008 which resulted in increased poverty and hunger through
2009. In response to this crisis, developed nations increased ODA to the highest level ever. Although still
not at 0.7%, this will hasten the return to a trend in which levels of hunger are again diminishing.
The schedule is barely achievable, if promises and deficits were made good – a prospect that seems
unlikely. What is more likely is a hiatus, on past experience 4-8 years, before hunger returns to prerecession levels and a downward trend resumes.
On the positive side, five European nations are providing 0.7% or more and others are moving closer to
the target. Nations outside the Development Assistance Committee are stepping forward – Kuwait gives
0.82% of GDP, Saudi Arabia 0.4%. In terms of providing health personnel, pharmaceuticals, and
infrastructure, many nations, some as small as Cuba, have left a mark on southern Africa. African nations
increasingly seek out competition for their resources beyond the western nations and are able to conclude
better deals, and avoid crippling trade agreements. Where altruism is in short supply, it is increasingly
replaced by a realization that desperate poverty and hunger are a cause of armed conflict, and that it is in the
interest of the wealthy to end them: "This is a problem we can solve at a fraction the cost of ignoring it"
(Sen Geo McGovern at FAO).
Offshoot initiatives provide an additional basis for progress
Baseline resources sufficient for slow process are flowing from the MDGs thanks to a steadfast few
nations, strong leadership within the WHO and FAO. New enterprises are bringing substantial resources
targeting the most fragile locations in Africa and South Asia. These include the Millennium Village
Projects; "microcredit" and its successors; an infusion of research funding for global health and the
underlying technology; an unprecedented outpouring of philanthropy to supplement the flagship Bill and
Melinda Gates Foundation; and a groundswell of effective advocacy among people positioned to make a
difference.
Now, before we take a stance that may seem heart-warmingly positive in the developed world, a caveat
from the south is in order. As we begin 2010, the situation remains unacceptable.
http://edition.cnn.com/2009/WORLD/europe/11/17/italy.food.summit/ Ban Ki-moon: "Today, more than 1
billion people are hungry. Six million children die of hunger every year – 17,000 every day. Urgent action is
page 14 of 47
critical, In 2050, the world will need to feed 2 billion more mouths – 9.1 billion in all". The solution: "The
small-holder farmers are the heart and soul of food security and poverty reduction. Our job is not just to feed
the hungry but to empower the hungry to feed themselves". A major goal is to "provide farmers with seeds
and land and offer them access to better markets and fairer trade".
All this suffering is unnecessary, in that there is no worldwide shortage of food. Given the will, the
means to produce it could be provided to all nations for less than what the west spends on warfare in a
month.
A decrease from 1.6b hungry to 1b brings cold comfort for those who anticipate the ensuing decades
with horror. As a direct result of the delays and broken promises, many millions will die unnecessarily. The
western nations that donate funding should not expect unreserved gratitude from the recipients, who did not
create the problems they are now experiencing. "If any game of chance were to produce such unequal
results, we'd have no doubt that the game was rigged" [@@32]. Among those denied the means to survive,
indignation can turn to outrage. In the case of nations recently emerged from colonialism, that outrage may
be directed at the empires that garnered great wealth at their expense.
Summing up the trends of 200 years, a projection of current MDG progress, and new catalysts of change
that have emerged from them, we predict that extreme poverty and hunger will evaporate over a timehorizon of 25-40 years. To make this claim credible, we must look beyond our current crises to embrace the
massive global changes that will snowball throughout the next few decades, and we must dispel some
widely held misconceptions and misinformation. We will deal in turn with trends in malnutrition, an
understanding of those affected by it, a balanced view of development aid, and the new engines of optimism
and agents of change.
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Trends in the incidence of extreme poverty and malnutrition
http://www.ers.usda.gov/Data/Macroeconomics/
We can be clear about progress toward the first MDG. The goal is to decrease the relative incidence
of extreme poverty and hunger by 50% relative to 1990 levels. The most widely used measure of poverty at
the level synonymous with hunger is the World Bank's "$US1.25 per day PPP1. Progress through the 20
years
before the MDGs and the ensuing 7
years using current World Bank data2 are shown in Figure 1 [33]. The most recent data are from the FAO
report on world hunger for their 2009 Rome meeting: The State of Food Insecurity in the World 2009 [34].
Figure 2 Worldwide incidence of extreme poverty – Percentage of people below $1.25 PPP per day
[35]
The percentage of people in extreme poverty and hunger has decreased dramatically over the past
three decades. Since 2000 the incidence of poverty has declined at 1% pa, about half that needed for a 50%
decrease in the 25 years of the MDG. Concomitant data support this decrease in poverty. For LMICs as a
group, GDP growth in over 10 years has averaged 5% per year. Across Africa, median child mortality has
dropped to half of 1974 values, and currently stands where the US was in 1933. Worldwide cereal costs
declined in 2009, a relief after the dreadful spike in 2008. However, not all the data are encouraging. figure
1 shows hunger as a percentage and this hides the fact that the decreases in absolute numbers are in fact
minimal. The figure also hides discrepancies between countries. Most of the improvement reflects the
1
The figure of $1.25 represents original World bank $US1, adjusted for inflation to 2005, corrected country by country
for "Purchasing Power Parity", and further adjusted within a country for urban and rural lifestyles reflecting the sources and costs
of food, shelter, and other necessities of life.
2
We will be cautious in drawing inferences. However, we will sidestep the valid debate regarding the methodology and
motives. of the World Bank The uncertainties fail to detract from the broad pattern of events proceding steadily over many
decades.
page 16 of 47
massive populations in East Asia and South Asia. In Latin America, improvements are small, while in the
Sahel relative poverty increased in 2008.
A rational response to the data includes relief that the absolute number of hungry people in the world
has diminished by 50% (from 1.6b to 800m) between 1974 and in 2005. Even if we assume that the2008
spike to 1b hungry is temporary, we cannot acquiesce to eight hundred million hungry neighbours. Three
facts are promising: (1) the regional data clarify our priorities – the world is focusing efforts on a
diminishing fraction of its population, in a defined area, the Sahel; (2) the cost of eliminating hunger is
spread over a growing number of increasingly wealthy people; (3) a large number of new initiatives are
bringing new resources and strategies to the areas where these are most needed. Overall, the message is
clear. Steady progress, but disappointingly slow.
A decrease from 1.6b hungry to 800m brings cold comfort for those in poverty must who anticipate the
slow progress with horror and indignation. As a direct result of the delay and broken promises, many
millions will die for causes related to their inability to obtain an adequate diet. The MDGs will not be met
by 2015, but we can.
Reasonably expect that the goals will be met halfway through the century. Those who find this delay
interminable will continue to be suffer, and expire, and those who work for a solution will be increasingly
impatient, determined, and energized. With these statistics for background, we now turn our attention to
how it happened that so many are hungry.
Integrating – a balance between positive and negative trends
Together with the MDGs and 200 years of history, these compel the conclusion that the 21st century will
see the virtual elimination of world hunger.
There should be no doubt that this trend is unstoppable. From the perspective of centuries or decades, it is
robust and formidable [36]. The MDGs and subsequent synergistic enterprises that build on it add
momentum to a longer term trend [37].
=================================
Reframing aid – what works and what does not
Having included the MDGs, MVs, and GF among the forces that will end global hunger, we have
already taken a position regarding the kinds of aid than can be effective. In contrast, certain kinds of aid are
not merely valueless – they are harmful. One such example is the kind of food aid originally conceived in
the 1950s, as a way to dispose of food surpluses earmarked for burning. While bringing relief to famine
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stricken recipients, it quickly demolished local agricultural capacity. Obviously, where possible donors
should buy food from local farmers. This preserves capacity and the local economy, and is much more cost
effective. Transportation costs are lower and the food is less expensive. Needs beyond the capacity of local
sources should be provided along with agricultural development. Governments in the rich nations, however,
capitulated to the agricultural lobby and legislated the food must be purchased in the donor country. The
maritime lobby too secured the concession that most or all of the food must be transported by shipping
corporations from the donor country. To make matters worse, proposals to emphasize agricultural and other
capacity-building aid were also undermined. Across the developed world agricultural aid has declined as a
fraction of total aid – Canada 22%→4%, US 18%→4%, New Zealand 25%→3%, Multilateral institutions
35%→7% [38].
Countries receiving Western European, North American, Japanese development aid are usually
required to open their markets to agricultural products imported from these countries. These rich countries
subsidize their farmers, sell their produce at below production cost in the poorest countries, and totally fail
to open their markets to what poor countries have to offer. The most visible critique of aid that doesn't work
is Dambisa Moyo author of Dead Aid. She asks: "Why is Africa wasting its time in the World Trade
Organization, which will never remove trade barriers, instead of fostering its relationship with countries that
are very interested in actually buying African produce?" And: "If Western markets don't want to trade with
Africa for reasons of protecting their own markets, Africa should focus on China and India". For a recent
critique of the WTO see [39].
Aid must be kept out of reach of bureaucracies, corrupt multinationals, and politicians
Ordinary Africans will applaud the simple statement that aid should reach those for whom it is
intended. They suffer twice when a dishonest official is bribed. First, a valuable resource flows out their
country at a fraction of its true worth. Then the proceeds of the bribe go out of the country into a foreign
bank account. This is a very old story in Africa. Obama underlined this in his pledge to support the MDGs
"Developing nations must root out corruption … opportunity cannot thrive where … business have to pay
bribes". The implication that businesses are forced to participate in corrupt is disingenuous. Moyo has
pointed out corruption requires western complicity: "Western countries … could begin by stopping the
corruption money flowing back" into numbered bank accounts. They should track and prosecute those who
offer bribes and those who receive them. Turning a blind eye is however extremely profitable to western
corporations and their governments. In fact, in the overwhelming majority of countries, whether inside or
page 18 of 47
outside Africa, prosecutors are rigorous in dealing with bribery and fraud. There are exceptions. A former
prime minister of Canada recently acknowledged receiving while in office $300,000 in cash to help a
foreign corporation secure a deal in Canada. He did not declare this, nor report it as taxable income for
years. He failed to describe any services he had provided. He received strong a reprimand. The "Extractive
Industry Transparency Initiative" contains simple rules that, if enforced, could quickly eliminate dubious
international dealing, and most Africans would support them. Twelve nations have already signed on.
Development aid must be provided with transparency
While applauding much of Moyo's stance, we take issue with her on a few issues. First, the free
economy model has not been shown to work well for the poorest of countries. Africa is fragmented into
countries whose economies are small compared with many multinational conglomerates. It is difficult for
such a country to bargain on a level playing field. In such unequal negotiations western government have
used as "inducements" economic sanctions, armed uprisings, or occasionally assassinations on invasions to
gain favorable terms for their own corporations. This has given the "free market" an unconvincing track
record in emerging states or fragile economies. Second, she has identified the problems of bureaucratization
and corruption, without supporting transparency and routing terms that could avoid these. We would argue
that most of the MDG or Millennium Village aid contains adequate precautions against misdirection..
Most of us would agree that well planned aid builds capacity & self-sufficiency. We need specific
criteria, and an analysis of what kinds of aid meet them. Paul Collier has specific recommendations for
competitive bidding and transparent awarding of contracts that will bring major benefits. Different kinds of
aid are needed for needy nations at different stages of development. There should be no shame or surprise
when people need help. Rosling says Almost no nation has ever achieved economic success without
substantial outside help.
Questions to ask when our governments tell us how generous they are with our tax dollars
Most nations sanitize their contributions to overseas development aid so voters can see their
government as good. One often hears that "in absolute terms the USA gives more than anyone else". By
some measures, this may be true. However, in the most recent figures, the EU gave $57.5: while the USA
(with roughly the same population) gave $22.74. In terms of fraction of the GDP there is no doubt that the
USA and Japan are now last among the developed nations. One also has to ask where the aid goes to? To
what extent does a nation restrict its aid to places that have military or geo-political utility. Some nations are
inexplicably omitted from the listings of aid donations by various nations. From obscure sources we learn
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that Kuwait gives 0.82% of GDP, Saudi Arabia 0.4%. How much does China give, or India? If we consider
donations in kind, does Cuba possibly give the highest amount in terms of % of GNP?
====================
New engines of optimism & agents of change
The Millennium Development Goals
Among several collections of goals for eliminating global disparities the MDGs are the most
compelling. They acknowledge the inseparability of health, nutrition, and development, and emphasizing
poverty as an underlying mechanism impeding progress toward all three. The best of the subsequent plans,
including the Millennium Village project, intergovernmental agencies, major philanthropies, and the
Grameen enterprises have synchronized their activities with the MDGs.
The MDGs are the best conceptualized plan we have of the steps and milestones on the path toward
the elimination of hunger. Among the details are essential elementsof quality control to monitor what works
and what does not and to find ways to do it even better. The MDGs have proved able to implement
impressive changes across many countries and across a broad range of targets. The pace of change is
disappointing, but we know the reason, and the places to apply pressure. Fortunately, most of the funding
for the MDGs comes from the steadfastly concerned nations, and they will deliver the goals.
Table 1: Involvement of nutrition in all eight MDGs
Goal
Relationship of nutrition to the goal
1. Halve the percentage of Poverty is the main determinant of hunger. In turn, malnutrition irreversibly
extremely poor and those
compromises physical & cognitive development & thus transmits poverty &
suffering from hunger
hunger to succeeding generations.
2. Achieve universal
Malnutrition diminishes the chance that a child will go to school, stay in
primary education
school, or perform well in school
3. Promote gender
Women’s malnutrition impairs the whole family’s health & nutrition, in
equality, empower women pregnancy, perinatal health, child-rearing, and contribution to family income
4. Reduce by two thirds the Delivery of a live healthy child is dependent, above all, on a well nourished
under 5 mortality rate
mother. Protein & folic acid are critical here
5. Reduce by two thirds the Malnutrition accentuates all major risk factors for maternal mortality. NB
maternal health
protein, iron, iodine, vitamin A & calcium intake
6. Combat serious
Malnutrition aggravates infections, weakening defense systems. Loss of
infectious diseases
immune competence increases transmission/mortality in HIV, malaria,
tuberculosis
7. Global partnership for
Agricultural and economic development leads to improved nutritional status
development
8. Mitigate impact of
Directly impacts food production
global warming
Note: (i) Reduce means between 1990 and 2015. (ii) Adapted from Gillespie and Haddad (2003)
http://web.worldbank.org/
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The progress of each of the MDGs is being tracked, but the concepts are complicated.
Oversimplifying only slightly, we offer the following table as a summary.
Progress toward achieving the MDGs
Most of the goals are making steady progress toward being partially met. Only goal 2 will be
completely met on schedule.
Table 2 Progress toward achieving the MDGs at the half-way point
Goal
Sub-targets likely to be achieved
Action still needed
1. reduce extreme
Steady progress, but too slow. Cost of
½ those in sub-Saharan Africa live on
poverty & hunger
servicing external debt fell by ~50%
< $1/d; ¼ of children are
by ½
underweight. Fairer trade policies
seem unlikely
2 Universal primary Primary school enrolment is now at least
Progress is promising – stay on course
education
90%
3 Gender equality,
The gender parity index in primary
Of 113 countries 18 may achieve
empower women
education is better than 95%
parity in secondary education. Parity
in employment & politics seems
unlikely
4 Reduce child
 Measles deaths - 89% of children receive Child mortality has dropped by ½
mortality
overall, but not significantly in
vaccinations
southern Africa
5 improve maternal
Some progress, 500,000 pregnant
health
women still die of complications
annually
6 infectious disease Malaria prevention tripled, AIDS: deaths
Some 2.5 billion people, ½ developing
& safe water
world, live without approved
new infections, tuberculosis, 1.6b
sanitation
people have gained access to safe drinking
water
7 Global
Unprecedented verbal agreement &
In reality, aid expenditures declined
partnership for
generous promises
for 2 years. Few meet 0.7% of GNP
development
The Millennium Village Project (MVP)
This astonishing initiative reflects the energy and infectious optimism of one man, Jeffrey Sachs.
A renowned economist, with achievements for the World Bank, he came to see the limitations of free
enterprise aid in dealing with the problems of the poorest of the poor. The Millennium Villages are sets of
villages selected for their suitability for partnership, each in a north-south development team. If the MDGs
represent global thinking, the Millennium Villages are the local expression of the global strategy of the
MDGs.these goals. To avoid dependence on the vagaries of governments, funding for each location is
committed in advance from private sources and NGOs, often sponsored by a university. Each village
becomes a demonstration project for implementing the MDGs in a 5-year, 5-step project, with specific
amounts of funding year by year. Their rapid success, and the level of support they have received from
donors, compensates for some of the disappointing pace of the other MDG initiatives.
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By the end of 2008, the MVP had been operating for three and a half years. In that time, it served
over 400,000 people in 14 sites in ten countries. By the end of 2009 there were 80 Millennium Villages,
each with about 5,000 inhabitants. Standards for each village are carefully thought out, with a
clinic/dispensary/first aid station in the village or reachable in a one-day round trip walk. The 14 locations
are: Koraro, Ethiopia; Bonsaaso, Ghana; Dertu, Kenya; Sauri, Kenya; Gumulira, Malawi; Mwandama,
Malawi; Tiby, Mali; Toya, Mali; Ikaram, Nigeria; Pampaida, Nigeria; Mayange, Rwanda; Potou, Senegal;
Mbola, Tanzania; and, Ruhiira, Uganda. A report from the Earth Institute at Columbia University suggests
that the objectives have been met and exceeded. Over half the facilities have three nurses and a clinical
officer (nurse practitioner or physician) on staff. A nurse or midwife provides at least 4 prenatal visits to
expectant mothers before delivery. The clinics, in turn, will have collaborating district hospitals within reach
of ambulances (4 wheel, motorcycle, or bicycle powered). By the end of 2008 fifty-one clinics were in
place, and during the year they served 300,000 outpatients – an increase in 25% from the previous year..
One could make an argument that the rapid success of this venture, including the level of support that they
have received from donors, and the recipient countries compensates for the disappointing pace of the
government supported MDGs.
The vision is for each Millennium Village to seed itself many times, spawning a dozen in the
surrounding locality if successful. Funds flow in from donors and governments hosting the villages.
Projections to date indicate that this vision will be exceeded. At a donor roundtable in June 2008 the
government of Mali presented a plan to scale up the MVP approach to 166 of its most vulnerable
communities covering approximately two million people. This initiative is being supported by a joint
taskforce including the Earth Institute, FAO, Millennium Promise, the MDG Center for East and Central
Africa, UNCDF, UNDP, UNICEF, and UNV. Based on its experience, the government of Nigeria is
proposing a national MDG scale-up effort in 111 local government administrations, reaching approximately
20 million people. In Uganda, the Ministry of Health has expressed strong interest in scaling up across the
country the midwife program launched in the Millennium Village site of Ruhiira.
The Millennium Village Project is being supported by a joint taskforce including the Earth
Institute, FAO, Millennium Promise, the MDG Center for East and Central Africa, UNCDF, UNDP,
UNICEF, and UNV. Oversight of the work of the Millennium Villages is by a Scientific Council composed
of the UN Millennium Project and The Earth Institute at Columbia University, both of which are headed by
Jeffrey Sachs. Millennium Promise is a supporting NGO, co-founded by the economist Sachs and the
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philanthropist Ray Chambers. In September 2006, the financier and philanthropist George Soros pledged
$50 million to Millennium Promise to fund 33 Millennium Villages. The 2008 MVP report makes
breathtaking, heart-warming reading [40].
Microcredit and the Grameen family of social enterprises
If the MDG programs have been underfunded and slower than predicted, the opposite is true of this
monumental family of programs. They germinated from a $79 gesture in a small village in Bangladesh by
which Muhammad Yunus accidentally initiated a tiny program of microloans led in a few years to a multibillion dollar enterprise spanning 37 countries. It's success brought the 2006 Nobel Peace Prize which was
accepted by Yunus on behalf of the Grameen Bank's seven million co-owners (borrowers) of the Grameen
Bank, nine of whom came with him to Oslo to receive the prize [41]. The trust Yunus inspires has opened
door after door, branching into a labyrinth of associations. Worldwide and more opportunities. Now an
order of magnitude larger, the Grameen Family of Social Enterprises is by far the most influential NGO
worldwide in its impact on the poor and in public support. An enormous momentum has emerged for
projects directed toward seed-loans with a business plan to become self-sustaining. The Grameen
Community Development Bank is a small segment of the family, and it is now dwarfed by increasing
number of Grameen Family of Social Businesses. The family includes some 14 mammoth enterprises
initiated purely to benefit the poor: risk capital for small-medium business; (2) the largest telephone
company in Bangladesh; (3) soft & hardware networking; (4) village aquaculture & dairy; (5) renewable
energy in remote regions; (6) educational loans for literacy & technology, (7) nutritious food at near cost,
(8) poverty alleviation for the working poor (9) the Grameen Trust which exists to seed social enterprises
worldwide – in 37 countries to date [42,43]. . Most are non-profit, and provide their services at cost. Almost
half are for-profit enterprises that invest their profits in growth and will, in the end, be owned by the poor.
Grameen Trust exists to seeds social enterprises worldwide – in 37 countries to date [44,45].
Two examples of Grameen social businesses must suffice to give a flavor of the rest. In Bangladesh
villages, the Grameen Danone Corporation sells a yogurt called Shakti Doi "power yogurt". At a
competitive 5c per 100ml an it sells well. Being sweeter and richer than most local yogurts it appeals to
children, while it provides their protein and micronutrient requirements. The enterprise started in 2006 when
Danone, a giant dairy company, approached Yunus in Paris for a meeting. Within an hour, they had reached
a $1m agreement to manufacture and distribute fortified dairy products in Bangladesh. Profits would not be
returned to those providing the funding; instead they would be reinvested "to bring health through food to
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the people of Bangladesh". Typically a Grameen lady, funded initially by a Grameen loan, works a four
hour shift daily to sell 100 or more cups of yogurt to wholesale or retail customers. Local farmers with
perhaps seven cows each provide milk to the factory. Several hundred farming and distribution jobs are
created locally by each factory. In 2007 Grameen-Danone launched a mutual fund to raise $135 million
(paying an interest rate of 3% to 4%) to finance a second facility to generate 3,000 tons of dairy products
annually. The business plan calls for 9 more factories and other social businesses to fight malnutrition and
poverty in LMICs. The funders, Danone, will eventually recover their initial capital, but no more. The stock
exchange on 17th Dec 2009 approved the second Grameen Bank Mutual fund, the largest mutual fund the
Dhaka stock exchange has ever approved.
There is some protest from those who believe that the poor are hard-pressed enough to find salaried
employment and that it is asking a lot to set them on the path of entrepreneurship for which they may have
neither the risk-tolerance nor the aptitude. Others correctly point out that for the poorest of the poor, getting
the present day's sustenance requires vast entrepreneurial efforts. Moreover, many of these are in regions
that lack the infrastructure to support cottage industry. Mitigating this, Grameen has innovations applicable
to very poor communities with payback as soon as the next harvest.
Of course, all of these are valid paths for doing good, and we must applaud all loudly or quietly, or
give, according to their own preferred path. For the Grameen family, Yunus has insisted that all profit must
stay in the business, so that it will eventually return to the poor. He is not opposed to a profit making
business creating a spin-off business where the growth and profits are set aside for social purposes, as in the
Grameen-Danone enterprise. However, he is concerned that the Grameen model should avoid the thin-edgeof-the-wedge that manifests itself at board meetings where announcements of an increased profit (to
shareholders) is greeted with applause, while setbacks receive worried looks, or even a transfer of
investment elsewhere.
Microcredit is an idea whose time has come, and it has already made a visible impact on the
economy of Bangladesh. As of 2008, four million poor have been helped and 1,000,000 microloans have
been generated with almost no defaults. Grameen will continue to snowball. The concept has expanded to
most countries under one name or another. It is suitable for communities that are at a various stages of
development, and a microcredit for beggars has been established, where the loan is indefinite. There is no
shame if it's never repaid, but presumably no further loans either. A report from the Grameen Foundation
provides details. [46]
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An unprecedented outpouring of philanthropy
In terms of overseas development aid, individual contributions are usually dwarfed by the sums that
governments provide. However, in recent years there has been a cascade of extremely large donations from
the super-rich. Forbes Magazine identifies fourteen of the world's 793 billionaires who have each given
away more than a billion dollars, "the Kings of Philanthropy". Some are young and accompany the donation
with a passionate idealism to invest in a cause. Consequently, the funds are rigorously monitored. Sums that
rival the income of many small nations, and initially obtained from the public, are channeled without public
accountability. Some of the goals may seem idiosyncratic, but it is churlish to complain about such
overflowing generosity. At the same time, philanthropy is rightly held to high standards, and those giving
away large sums may have to go to extremes to get honest criticism [47]. The Forbes survey covers only
individuals foundations, not families or institutions, and so it does not include many worthwhile charity
foundations such as the Ford Foundation, the Rockefeller Fund, the Clinton and the Carter Foundations, to
name a few. The Foundation Center lists the US sources of funding by asset size [48].
Among the philanthropies that relate to global health, nutrition, and development The Bill and Melinda
Gates Foundation is not only the largest, but the most influential, having received the confidence of at least
two other billionaire-philanthropists Warren Buffet and George Soros. Consequently it deserves special
attention. To those engaged with global health, whether academics seeking to mitigate inequities, or those
experiencing inequities the priorities of the Gates Foundation are important. A major priority is laid out in a
webcast: "Living Proof: Why we are Impatient Optimists" and its accompanying website [49].The
foundations sees great urgency in ensuring a continued and expanded commitment of his government to
overseas development assistance, including the MDGs. The magnitude of the US contribution is crucial.
Given the track record, budgetary deficits and competing demands for funding global warming, it should not
be taken for granted. The webcast suggests the importance of public support for aid, and the associated
website provides a kaleidoscope of resources that give access to provides accurate, well organized
information regarding the myriad successes to date [50].
The 2010 priorities for the Foundation are outlined in the Annual Letter from Bill Gates [51]. They
include innovations in agricultural techniques, means to improve seed quality including transgenics gene
sequencing of plants, and marker-assisted breeding. Also the need to improve access to markets. There is
stress on the importance of involving farmers in selection of capacity-building tools that fit local needs. On
the educational front, there is a need to strengthen the quality of teaching, the use of new tools in education,
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including of web-based education and the development of quality products. Accreditation services,
improved access and quality control measuring tools for classroom and web-based resources. The
commitment to immunization, micronutrients, and mosquito nets continues.
There are many examples of synergism between the MDGs, the Millennium Villages, Microcredit. Thus
the Gates Foundation is supporting both these initiatives. The foundation provides general funding for
Millennium Village Projects. It also supports micro-financing with $38m in grants to make financial tools
more available in the developing world. In addition, a feasibility study is positive about scaling up microlending schemes for water and sanitation projects to a market estimated at $12 billion over the next 10 years
[52].
Where are we headed in the second decade of the 21st century
Malnutrition: problems and what is making a difference
SixIt is part of our optimism for the future that the three giant enterprises described above
complement each other. The MDGs, where the donor-nations may or may not be reliable; the the
Millennium villages, where the funding is in place in advance; and the third, the Grameen Enterprises where
the funded comes in the end from the poor themselves, and the "donors" recover what they loaned.
Rapid dissemination of innovations through networked technology
A major characteristic of the 21st century will be the continued explosion of the means of
communication unimaginably beyond email, text messaging, and social networking. as costs diminish to
zero tool to diminish inequities The changes are most dramatic in the poorest countries where shared
telephone services and web access are reaching the smallest villages. The educational impact of the web is
in the rich countries is dramatic, but most in most web-based courses the web serves as the "world's biggest
photocopier", and the product is a second choice to classroom education. We are just beginning to see
products that fully exploit the capabilities of intelligent machines. An groundbreaking example is the
breathtaking Nutrition in Medicine CD set [53] for teaching nutrition to medical students, nurses, and
nutritionists. Heavily subsidized it is affordable for adoption by any institution, even an impoverished one.
Modules are already available for perinatal nutrition, pregnancy, and lactation. When it is expanded to be
more relevant to the needs of developing countries, training specialized nutritional personnel will be
accomplished for little more than the cost of selecting the students. The the Global Health Educational
Consortium, (which will include three nutrition modules) are available free, and follow a modular structure.
There is no end in sight to the faster, cheaper, phenomenon. This allows rapid spread of new appropriate
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technology inventions for efficient food production. Along with the web comes unprecedented
misinformation, economic exploitation, and a need for evidence-based discernment and due diligence.
What's working against the top 5 global manifestations of malnutrition
Of the 6 million children who die unnecessarily each year, five million die from consequences of
caloric or protein deficiency commonly complicated by diarrhea from an unsafe water supply, while one
million die from consequences of deficiencies of vitamin A, folic acid, iodine, iron, or zinc. In this section,
we highlight selected innovations that have brought life-saving solutions on a global scale to these
problems.
A billion of earth's six billion people lack safe drinking water. Clean water and sanitation can do
much to reduce poverty, decrease the number days away from feeding the families. Providing safe drinking
water and sanitation is part of the MDG, but progress is slow. In India, contaminated water kills 300,000
children annually. Simple, relatively inexpensive solutions are increasingly in use and include boiling,
chemical treatment, or filtration. Breast-feeding is the simplest way to provide safe milk to babies and at the
same time to confer substantial immunity. "Kangaroo care" where newborn spend time on a mothers bare
chest can promote breast-feeding, or provide a makeshift incubator for premature babies. Low technology
early-warning test kits are now available for fecal and total coliforms. "Safe-water drinking straws" can
filter pathogenic bacteria from two liters of water a day over a 2-year life.
One million individuals a year die from lack of vitamins and minerals – micronutrient
deficiencies. Advances against protein-energy malnutrition that have saved lives include Oral rehydration
solutes (ORS) are the most dramatic success against deaths from protein-energy malnutrition due to
diarrheal dehydration following starvation or kwashiorkor. Simple and inexpensive, ORS are astonishingly
effective, and have saved 500,000 lives each year for the past ten years. Diarrhea consequent to starvation or
kwashiorkor killed approximately 5 million children each year in the late 1970s. For relief work they come
in pouches which simply require the addition of water or a vegetable soup to dissolve the salts. Beyond the
reach of aid packages, an effective substitute can be made by a nurse or a mother from 1 teaspoon of salt
plus 8 teaspoons sugar dissolved in a liter of water. Simple and inexpensive, ORS is astonishingly effective
in treating diarrheal dehydration. Now, one of every four of the world's children have access to ORS. Where
not available, diarrhea remains the leading cause of death of children, and remains responsible for a quarter
of child deaths [54]. Ready to use foods (RTUF) are now used by many agencies for famine relief or
prevention, or for giving to the mother of a child in fragile nutritional status [55]. [@@].
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Novel foods
Nutritionally adequate bread and cereals, fortified cookies. A simple example is the introduction of
tilapia farming. In the Philippines tilapia ponds have contributed to increased protein intake for 30,000,000
people.
Regarding the one million deaths in toddlers that result from lack of micronutrients, the main
bottleneck is the delivery, rather than the cost of what is needed.
Among the 40 or so vitamins and minerals required for optimal physical health & development
through the life-cycleWorldwide, vitamin A, folic acid, iodine, iron, and zinc are the most crucial
micronutrients. One million deaths from lack of micronutrients are reported in toddlers annually., the five
listed above are crucial in lower and middle income countries. Deficiencies of all these nutrients are
prevalent in Africa and Asia. For over 100 million children under five years old, vitamin A supplements will
reduce mortality by 23 percent. Night blindness is a warning sign. In parts of Africa, 60% of children are
anemic – often they are iron deficient as a result of bleeding from parasitic infections. WHO in 2003
estimated that 1.6 billion people lack adequate iodine, and hundreds of millions of children suffer variable
degrees of IQ loss. The nutrients themselves are inexpensive, and the consequences of a deficiency
devastating, so a recent analysis ranked micronutrient provision as the most cost-effective way to improve
global health. The solution is to get the vitamins or salts to those who need it. The Micronutrient Initiative
[56] and the Global Alliance for Improved Nutrition GAIN [57] have58 has taken up this challenge, and
thanks to multiple sponsors in the MDG programs the problem is shrinking.59
Excellent summaries of progress in promoting better global nutrition come from the Gates
Foundation Progress towards Nutrition [60], and from the International Food Policy Research Institute's
Millions Fed [61].
4) Advances in appropriate technology for agriculture
Soil impoverishment has long been a problem to be solved by peoples recently turned from
hunter-gatherers to settled farming. Pre-modern intensive farming utilized very effective techniques,
including contour plowing – which decreases rain runoff and mitigates soil loss to erosion; terracing –
which brings previously unavailable land into productive use; and crop rotation – which helps impoverished
soils to recover. An innovation in more recent times has been the use of informally trained "barefoot"
agronomists who learn these tools on educational farms, and travel from region to region teaching others to
teach them. South Africa, China, India, Bolivia and other countries have used such advisors, to good effect,
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and these farming strategies are now widely practiced [62]. At another level, the African Centre for Crop
Development at University of KwaZulu-Natal and Rockefeller University, is a training program for PhD
students in Africa. Here students from all over Africa train in selection and improvement of seed quality.
They will return to rural areas to implement grass-roots programs for seed improvement. The goal is to
contribute to agricultural water supply and food sufficiency in Africa and eventually to a continental surplus
[63]. production
Water is a crucial commodity in drought-prone regions. Where water is scarce, as in the Middle
East, "ownership" may well become vested in those with military power. A number of solutions are
available to extend water resources. Several of the best inventions come from Israel.
-surface drip irrigation may seem like a low cost substitute for watering cans, but it allows a given amount
of water to be used many times more efficiently. The strategy has spread rapidly One model is simply a
drum on a pedestal with a ¼" diameter pipe long enough to siphon water mixed with manure to the plants.
The outlet end is pushed about 2-5 inches into the soil among the roots and a roughly metered amount of
water is applied to where it diffuses and evaporates more slowly than the surface water. More complex and
more expensive systems allow unattended drip irrigation over many acres.
Deficit irrigation64 involves supplying crops with far less than the amounts of water needed to
promote optimal growth. The decrease in crop yield is less than proportionate to the decreased water used
so, although crop yield per acre may be down, crop yield per gallon of water is significantly increased.
Three very old techniques are spread, often by "barefoot agronomists", in regions that may be
unfamiliar with them. 1) Contour ploughing to decrease rain runoff and soil loss to erosion, and 2) terracing
that in addition brings previously unavailable land into productive use. 3) Crop rotation helps impoverished
soils to recover.
In regions where rainfall is intermittent but heavy when it comes, much is lost in runoff and
evaporation. Rainwater collection pits are dug, perhaps 6' wide and 6' deep and 20-30' long, with rows of
stones to direct runoff into them. These can be surfaced with foam sheets or pellets to deter evaporation, or
plastic lining to deter seepage. When empty the bottom remains damp and crops are planted there.
Low technology $25 treadle pumps can irrigate ½ acre, increasing crop yield by $100 per year
compared with watering cans or bucket brigades. For the initial start-up, four factories were set up to make
treadle pumps, produce spare parts, and repair them. Two years later there were 75 factories. 66
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"Playground pumps" are a novelty which has attracted multimillion dollar funding from US sources.
Several hundred have been installed in African locations. They consist of a merry go round which turns an
underground pump driving water into a high water-tank. The Play Pump can lift 1,400 liters of water per
day to an elevated 2500 liter tank. [67]
Zero-tillage wheat-seeder drill. This device looks like a rotary plough and costs $100 in its simplest
form. Farmers who buy one rents it out to pay off the loan. It has been successful enough that the original
two factories have grown to 100 in Haryana & Punjab. It's a labour-saving device, that increases yield by
getting the work done faster. Earlier planting increases yield, perhaps allowing a second crop in a growing
season.
New and old technologies are spreading. Simple donkey carts for transporting crops or fertilizer can
be sold for $200 which among several farmers can be recouped in a couple of months. [5]
"Agrobiodiversity" may include drought-resistant seeds 11 or hybrid rice which in ed is credit with
nourishing tens of millions of additional people.
"Agrobiodiversity" may include drought-resistant seeds or hybrid rice which is credited in China with
nourishing tens of millions of additional people1.
Where not otherwise specified, descriptions of most of the above can be found at [49].
These are merely a few examples. A recent book is available for purchase or free download which
details a score of advances in food technology in the last 50 years. [68] Powerful initiatives are coming from
inside Africa. Ruth Oniang'o is Editor-in-Chief of the African Journal of Food, Agriculture, Nutrition and
Development, a peer reviewed Journal for articles on the "revitalization of Africa's agriculture, for
enhancement of food security and nutrition".
5) An unprecedented outpouring of philanthropy and passionate idealism
In terms of overseas development aid, it is unprecedented for individual contributions to come
anywhere close to what governments are able to provide. However, in recent years there has been a cascade
of solid meaningful donations from the super-rich. Forbes Magazine identifies fourteen of the world's 793
billionaires who have given away more than a billion dollars, and the Canadian Broadcasting Corporation
poetically deems them "the Kings of Philanthropy". These donors are often young and have the energy to
invest in how the money isused. Consequently, the funds are more rigorously monitored than usual in the
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past. Amidst the applause, some issues have been mooted. These supposedly include a possibility of
distorting the aid process; and a possibility of subverting democracy. Sums that rival the income of many
small nations, and initially obtained from the public are channeled without public overview or indeed any
accountability. Certainly, for some foundations the goals seem idiosyncratic. Even delegating control to
entities unbeholden to government or commerce, like universities, can lead to an overemphasis of initiatives
that seem primarily to serve the appetite of universities for "basic" research. There's a need in philanthropy
to set very high goals, and the person giving away large sums may have a hard time getting honest criticism.
Comparisons are odious, and it seems invidious to rank donors in order of the amounts given, but
those with a mind can visit the original article. [69] Besides, most large donations are piecemeal rather than
in a single lump sum. The Forbes survey covers only foundations given by individuals (not families or
institutions) and so it misses many worthwhile endeavors, Ford, Rockerfeller, Clinton, Carter, to name just a
few. The Chronicle of Philanthropy, is a useful source of information on US philanthropy, and the
Foundation Center lists the US sources of funding by asset size. [70] Internationally the task is more
complicated. Perhaps it is time for the US-based web sites to cast a wider net?
==========================
Perspective on the 21st century toward the future - problems and promises
Near term - initiatives
It is time for an end to posturing among politicians, and hair-splitting among academics
As mentioned earlier, there is remarkable lack of discord among those actually working to diminish
global health inequities. However, there are high profile rancorous exchanges in the media or public debates
where at least one is an armchair philosopher. Such exchanges can make a fundamental truth that both sides
agree with seem debatable. Often the differences reflect differences in ideology or political affiliation. Such
conduct is also seen among academics whose reputations depend on splitting hair over nuances of meaning.
We have wonderful role models in, for example, Yunus has been asked all the tough questions. Do you
believe in free enterprise, free trade, GM seeds, , birth control / condoms ,globalization? His answers are
always a qualified "yes". Globalization? Yes I believe in the kind of globalization that is fair, that works for
the poor as well as for the rich. Free enterprise? Yes I believe it it so long as it is truly free and benefits the
poor. Hans Rosling says change the dataset or your mindset. Jeffrey Sachs looks for solutions and asks for
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the evidence. We look forward to seeing more global problem-solvers beat their swords into ploughshares.
We can learn from those who have large ears and small mouths, who look for common good, who keep an
open mind.
Quality assurance / quality control agencies for evaluating effectiveness of social enterprises, etc
& database of evidence-based local coping strategies
The existence of the MDGs, Grameen Foundation, and the Bill and Melinda Gates Foundation has
spawned a huge need for external entities capable of fair and honest quality control. Both of the feasibility
of proposals and completion of due diligence, and in the ongoing monitoring and final assessment of
completed projects. The agencies are keenly aware that they are not the best people to assess their own
performance, and that those they are funding are liable to avoid being the bearers of bad news or criticism.
The need for trusted evaluations will grow exponentially as individuals gain the chance to invest financial
instruments like Grameen mutual funds where a person can park money for socially useful loans and draw it
all out again any time. This will be a healthy development, since already some of the "green" investment
funds, not to mention charities, contains some very dubious candidates.
As is common on the web, many resources are set up to cope with a single need, and then there is a
shakedown until a few assume leadership and become the most comprehensive. A growing number of
burgeoning websites disseminate information regarding evidence-based tools for nutrition, foods,
agriculture, much of it specific to rural or vulnerable populations. As the number continues to grow, the
need for quality-control becomes more and more apparent. Eventually, something will emerge for global
nutrition and global health that will have the stature of the Cochrane database of systematic reviews for
evidence-based medicine.
Village health workers (VHWs)
Sometimes ambiguously called community health workers are chosen by the community to cope
with critical shortages of conventionally trained skilled professionals. They are given a limited training to
provide health, nutritional, perinatal, or agricultural and other services. Programs involving VHWs in
China, Brazil and Iran have demonstrated that utilizing such workers can help improve health outcomes for
large populations in under-served regions. “Shifting functions from professionals to VHWs has been shown
to improve the health of millions at low cost. Barefoot doctors in China in the 1940s grew to 1.7 million
shortly before their replacement with professionals in 1981. A similar plan in Brazil in the 1990s covered
36% of the population by 2002 during which the infant mortality rate fell by almost half to 29 per 1000 live
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births, and provided some evidence that their effectiveness was as good or better than those with longer
training periods. In Iran these workers do home visits from 14000 “health houses”. They teach breastfeeding, contraception, provide vaccinations, and monitor child growth. Coincident with their employment,
infant mortality dropped by half and immunization rates rose from 20 to 95%. As a result of advice on
contraception, fertility dropped from 5.6 in 1985 to 2 in 2000 and maternal mortality dropped from 140 per
100,000 in 1985 to 37 in 1996. In other countries, similarly spectacular results have been obtained as a
result of training programs lasting a few days for ante-natal planning.. In Ethiopia, with one year of
intensive post high school training in first aid, sanitation, disease prevention, "Health Extension Workers"
relocate to "Health Outposts" in rural areas to provide basic medical services and preventive health care, on
site and by home visits to the most remote areas.
Foods for the future
The reactance against genetically modified seeds exists primarily in the rich nations. We see it being
replaced by a more balanced, evidence-based stance. These have been under development for some time,
but none has shown traction. In South Africa in 1952 "Bremer bread" (named after the then Minister of
Health) was offered at a discount everywhere bread was sold. It was enriched with high-quality protein, and
to this writer's palate at least, it was delicious. Unfortunately, it never became popular with the people who
would have benefited most from it, and it was withdrawn after about 7 years. There has been
experimentation with cereal grains modified to be richer in the limiting essential amino acids. The
nutritional value of a high lysine maize has been demonstrated to approach that of skim miIk. It is was
approved for food use in Japan, S. Korea, Canada, Australia and New Zealand, and for cultivation in the US
and used as animal feed. However, in late 2009, it was flagged by the EU because it was a genetically
modified food, and then rejected based on its high lysine content. This may be another situation like the
banning of DDT where Africa has suffered because of fastidiousness in the USA or the EU. High lysine
wheat continues in the development phase, but large-scale production in the foreseeable future is doubtful.
Undoubtedly, further nutritious seeds will be developed from approaches that are not visible at this time.
Biofortification
The promise of selective breeding and biotechnology to yield crops with enhanced nutrient density,
remains elusive. Testing of novel foods is costly and onerous. High lysine wheat has for decades been in the
development phase. High lysine maize with a nutritional value reportedly approaching that of skim milk
proved unpalatable. A more palatable variety was approved for food use in Japan, South Korea, Canada,
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Australia and New Zealand but, because of an EU presumption of risk for genetically modified foods,
production has for the moment been abandoned. A few promising initiatives are in progress include
carotene-enriched (orange fleshed) sweet potato that improves the vitamin A status of children. The 2009
World Food Prize went to Dr. Gebisa Ejeta of Ethiopia. In 1992 he developed a high-yield sorghum, then a
added drought resistance, and finally weed resistance. Since crop yields in times of drought were 5 to 10
time higher than the native seeds the cultivars spread widely, and they currently improve the food supply of
hundreds of millions of people in sub-Saharan Africa.
Supplementation of cereal grains
Thanks to sponsorship from the MDG programs and Gates Foundation, the use of fortified foods is
continuing to spread in the developing world. In Egypt wheat flour supplemented with folic acid and irons is
widely used in a staple flat-bread; in South Africa a similar program with folic acid supplement maize meal
and wheat flour decreased folic acid-related birth defects by 30%; in China soy sauce supplemented with
iron is decreasing the incidence of anemia; Meanwhile table salt supplemented with iodine remains one of
the most widespread and cost-effective means of saving lives [71]. A manufactured rice grain supplemented
with vitamin A, zinc, folic acid, thiamin, and iron, is intended to be mixed in small amounts with with local
rice. It has passed tests for efficacy and acceptability and production is being expanded.
Great advances in web education
Teaching materials are increasingly available online and barriers to brining these into the classroom are
now permanently breached. Materials for classroom use are increasingly available. The Global Health
Educational Consortium provides, at no cost, modules on health inequities (including nutrition for
developing countries) for classroom or web teaching. Commercial materials for nutrition instruction
accompany textbooks too expensive for use in the developing world.
In the developing world, web based education is flourishing because it is cost-effective. For example, the
University of South Africa now has over 200,000 distance-learning students and it now has satellites in four
countries. In nutrition education, we have recently seen the first product to utilize the computer as an
intelligent assistant in the learning process. In 2002 a consortium of universities in the US produced a set of
CD modules for teaching nutrition to medical students [72]. From the opening meeting of the student with a
patient, it is a stunning example of an on-line course that makes most classroom instruction seem pedestrian
in comparison. Subsidized by the NIH it is affordable at $100 per set. Modules cover the full range of topics
for medical students, including perinatal nutrition, pregnancy, and lactation. When adapted to needs of
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developing countries, it will be invaluable where there are shortages of skilled personnel. This is a foretaste
of the future when it will be eclipsed by even more brilliant products. For better or for worse, a few superb
products will set the standard across universities where they will replace hundreds of mediocre courses.
AbundantFoods for the future
The reactance against genetically modified seeds exists primarily in the rich nations. We see it being
replaced by a more balanced, evidence-based stance. These have been under development for some time,
but none has shown traction. In South Africa in 1952 "Bremer bread" (named after the then Minister of
Health) was offered at a discount everywhere bread was sold. It was enriched with high-quality protein, and
to this writer's palate at least, it was delicious. Unfortunately, it never became popular with the people who
would have benefited most from it, and it was withdrawn after about 7 years. There has been
experimentation with cereal grains modified to be richer in the limiting essential amino acids. The
nutritional value of a high lysine maize has been demonstrated to approach that of skim miIk. It is was
approved for food use in Japan, S. Korea, Canada, Australia and New Zealand, and for cultivation in the US
and used as animal feed. However, in late 2009, it was flagged by the EU because it was a genetically
modified food, and then rejected based on its high lysine content. This may be another situation like the
banning of DDT where Africa has suffered because of fastidiousness in the USA or the EU. High lysine
wheat continues in the development phase, but large-scale production in the foreseeable future is doubtful.
Undoubtedly, further nutritious seeds will be developed from approaches that are not visible at this time.
Trends that determine the trajectory toward the long term future
Information technology
We can anticipate continuation of the faster, bigger, cheaper trend. These will have some spin-off for
nutrition through better information exchange. Data-mining has been discussed above and will expand in
ease and power. A major recent jump in capability is a quantum leap in the quality of web-based education.
Having coordinated a project to develop a web based certificate in applied nutrition, I know that the quality
of most web courses is below that of a classroom course – about at the level of the first word processors
developed by a single person over a summer and at a cost in the thousands of dollars. A current word
processing package costs in the billions, and the wait for a next generation web course was ended about
2002, when a consortium of universities in the US released the Nutrition in Medicine teaching modules.
Designed for medical students with an enormous subsidy from the NIH, it is simply stunning, raising the bar
for web courses to way above the quality of a classroom course. The price is well within the budget of
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someone teaching a nutrition course, or a university planning buy a site license. Other initiatives in digital
include the use of cell phones as terminals for instruction, eHealth, and Tele-medicine. Currently primitive,
we can predict astonishing advances in the ensuing decades.
Increased energy cost, followed by a trend toward unlimited low-cost energy
Since we are looking ahead almost a hundred years, we can predict that the scale-up of green energy
sources will achieve economies of scale that were just not possible for a non-renewable source. Stretching a
little one can imagine a practicable, even portable, energy source. Given the disappointment at the Pons and
Fleischman announcement of cold-fusion, the term has been abandoned and replaced with low-energy
nuclear reactions (LENR). A preliminary report of new evidence at the 2009 meeting of the American
Chemical Society met some of the objections to the Pons-Fleishman reports, and this area is again
undergoing expansion. This would have enormous implications for nutrition, especially in areas with a short
growing season. In the developed world, there is already a striking proliferation of greenhouses. With
inexpensive energy, greenhouses become feasible even in the developing world and colder climates. Year
round inexpensive local food then becomes something to take for granted.
New distribution of economic power and alliances of nations
The emerging nations of Asia and Latin America, will grow strongly in the next 2 decades. It is
estimated that by 2020, India and China together will control 65% of the world's economy, with China
overtaking the USA as the wold's largest economy in 2032. By 2050, China will be 20% larger than the US,
and the emerging Asian nations will match the economic strength of the US and EU combined. Decisions
previously made by smaller groups of nations will be broadened. The G20 consists of Argentina, Australia,
Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Mexico, Russia, Saudi Arabia,
South Africa, South Korea, Turkey, United Kingdom, USA and EU (G8 nations italicized). The G20
currently comprises 85% of the global GDP. It recently flexed its muscles by announcing that it will take
over from the G8 (the nations italicized above). This reflects the fact that more than half the economic
growth within the G20 will come from nations not currently represented on the G8. This move will likely
trigger democratization of the World Bank, WTO, IMF and even the (tightly restricted) OECD. All of these
are discussing expanding their membership. The increasing economic power of the emerging nations is
signaled by the recent decision of the G20 that they will assume the financial decision making role
previously held by the G8.
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These projections expand on previous studies, including those done by Goldman Sachs, PriceWaterhouse, Coopers, and the World Bank,
. http://www.carnegieendowment.org/publications/index.cfm?fa=view&id=24195
Pitfalls, confounders, roadblocks – How unshakeable is our optimism?
There are looming threats, beyond the financial melt-down, which we think expect has reached its
nadir. Even as it passes some reverberations are disturbing: currency uncertainties, inflation, third world
debt and the resulting exposure to IMF & World Bank pressure, large-scale land purchases from vulnerable
nations that may in the long term impair their food self-sufficiency. The "war on terror" is a pretext for some
to grab strategic resources or establish permanent military bases and puppet governments. This leaves the
occupied country (not to mention those in rocket range) little scope to pursue an independent food policy or
development strategy. Finally the fear of global warming is being used as a pretext for large-scale diversion
of food to the production of oil, despite the lack of potential to diminish CO2 emissions. The unfair trade
practices and the ability of the rich to purchase the right to emit CO2 at the expense of the poor are likely to
continue undiminished. Some of the rich nations will use the cost of financial recovery and climate
mitigation as an excuse to default on promised aid. All this is more or less business-as-usual for those of us
from the south. Population growth is also a continuing problem, abetted by nations that ban aid that includes
contraception. There are ways to limit population growth without draconian laws and without risking
accusations of genocide. It remains to be seen whether China & India will be benign powers when they
control much of the world's economy. At the very least, China has experience in bootstrapping itself out of
the extreme poverty and hunger – in the four years between 1981 and 1985 the incidence dropped from 53%
to 18%. In the latest data, the incidence of extreme poverty in China is below is 8%. Also at question is
whether any of the formerly great powers will allow themselves to be eclipsed or will seek military
measures to prevent this. Overall, this seems like a time when the burden of problems borne by the planet is
about what it has been in the past. What is different is we have an unprecedented array of evidence-based
tools and strategies for eliminating global inequities, and a growing number of nations and individuals with
a mind to tackle the problems in the way of solving them.
Concluding thoughts in a perspective for the end of the 21st century
Hunger is as old as humanity, but the current scale and severity are unique. The response at the start of
this century is an unprecedented commitment to action. Secular trends over decades or centuries predict that
extreme poverty, hunger, and malnutrition will be dealt with decisively over a time-horizon of 25-40 years.
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There is danger in naivety. Warfare is almost as old as poverty and there are no signs of its disappearing..
Those with wealth and political or military power will continue to tilt the rules in their favor. The players
will change, but armed conflict and exploitation will continued unabated. There will be pockets and flareups of extreme need and suffering.
Through the ups and downs, the challenges to the poor and the rich are old ones, to exercise forbearance.
The rich are challenged to forbear from taking an unfair advantage where they have the power to do so, to
avoid the myopia that what is good for our nation is good for the world, and to see the global, good as the
rising tide that lifts all. The poor nations will be challenged to exercise forbearance as they ascend the ladder
of development. The sudden attainment of power brings many temptations. It seems safe to assume that both
rich and poor will repeatedly fail these challenges. Yet perhaps it is allowable to hope that China, India,
Brazil, South Africa all of whom are well acquainted with poverty, will remember from where they came
and deal more gently with the vulnerable than did the recent imperial or colonial powers. Having seen these
nations bootstrap their way out of poverty, the developing nations – for better or for worse – will look to
them as role-models.
There are compelling reasons for optimism, impatience, and indignation. There is optimism that from the
perspective of centuries the trend toward alleviation of hunger, malnutrition and poverty is robust and
formidable. There is impatience that the pace is so slow. There have been repeated defaults and delays,
Milestones have been missed rescheduled and missed again, while those who defaulted almost seem to be
deliberately dragging their feet. There is indignation that millions will die undeserved, miserable, and
unnecessary deaths because the world has not given the issue of hunger the priority it deserves. The UN’s
Ban Ki-Moon's declaration at the end of the 2009 Rome Food Summit sums up the sentiment: "Today, more
than one billion people are hungry. Six million children die of hunger every year – 17,000 every day. Urgent
action is critical. In 2050, the world will need to feed 2 billion more mouths – 9.1 billion in all". The hungry
are aware that there is no worldwide shortage of food. The cost of an adequate diet for all is for less than
one nation spends on warfare in a month. To focus finally on the practical, here are Ban Ki-moon's closing
words: "Our job is not just to feed the hungry but to empower the hungry to feed themselves ... The smallholder farmers are the heart and soul of food security and poverty reduction. A major goal is to provide
them with seeds and land and offer them access to better markets and fairer trade"[73].
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Appendix The eight
MDGs and the roles of
nutrition Adapted from
[74]4. Reduce by two
thirds the under 5 mortality
rate
5. Reduce by two thirds the
maternal health
6. Combat serious
infectious diseases
7. Global partnership for
development
8. Mitigate impact of
global warming
Delivery of a live healthy child is dependent, above all, on a well-nourished
mother. Protein & folic acid are critical here
Malnutrition accentuates all major risk factors for maternal mortality. NB
protein, iron, iodine, vitamin A & calcium intake
Malnutrition aggravates infections, weakening defense systems. Loss of
immune competence increases transmission/mortality in HIV, malaria,
tuberculosis
Agricultural and economic development leads to improved nutritional status
Climatic deterioration directly impacts food production
From our tiny perch at the start of the 21st century, it is difficult to see beyond the three global
earthquakes of this first decade: a security meltdown "the war on terror", an economic meltdown, and a
climatic meltdown. For a perspective on the 21st century, these events may be seen as distractions created by
special interest groups to manipulate us to enrich them. In any event, they will be dwarfed by tectonic shifts
that have their origins long before, and will continue long after the earthquakes. First, an economic
blossoming in the developing countries, second, an explosion in communications technology as changemaking as Gutenberg, and third the drive toward a world in which advances since the industrial revolution
are shared more equitably, more profound in its consequences than the abolition of slavery.
The war-torn nations pose a thorny problem. There seems no way to provide aid, not way to provide
sustenance or reconstruction to the non-combatants. Each side opposes aid that could help their adversaries.
Perhaps with a new president in the central country, the NATO nations will turn their minds to peace.
However, the war machine vociferously demands to be fed, so one cannot be recklessly optimistic. Speaking
with an eye to the nutrition of the civilian populous, here is something to think about for the rest of this
century. Could not the NATO nations delegate the task of peacekeeping in African nations to Africans
(NATO would provide the funds), and in the Arab nations to Arabs? For relief work, and capacity building
could they not fund relief workers from among the people in distress? When the "peacekeepers" must look
to the locals like robots from outer space, bristling with every lethal toy, should one not expect violence to
escalate? @@need a better idea@@
As predicted above, the MDGs will be achieved around the middle of the 21st century. For most of
the LMICs this will occur largely through their own ascent of the ladder of development, combined with
ongoing contributions of the G20, Grameen-type credit and social businesses, and nation to nation economic
page 39 of 47
partnerships. The nations at risk and those that will need help in the struggle will be those in the Sahel and
the war-torn nations of Africa and the Middle East. The world has become conscious of Africa. The MDGs
provide a network of strategies and Africa-specific enterprises like the Millennium Villages, the Africa
Development Bank, Bill & Melinda Gates Foundation and others, contribute the means for sustainable
development. As the Asian nations in turn emerge from poverty in the second decade, this will free
resources to flow to where they are most needed. Hopefully the BRIC nations will become significant
contributors to the MDGs, but even if they do not, India and China have strong strategic reasons to be on
good terms with Africa. South Africa is an exception among the African states, its GDP per capita is
predicted to grow 7-fold, from $5521 in 2009 to $37525 by 2050. Since the transition to majority rule,
South Africa has maintained a helpful stance toward other African states and the African Union. It has the
location and capacity to become a major participant in the development of Africa as a whole, and hopefully
it will seize the opportunity to commit itself to the MDGs for Africa.
Toward the MDGs awareness & successively more realistic remedies → a solid plan, problems & promise
In discussing solutions to hunger relation we need to be clear on poverty & its origins, & true needs of the
poor
Water, PEM, micronutrients
Before we suggest grounds for optimism grounds for impatience: melt-down is an enormous setback – 6-10
years
As predicted above, the MDGs will be achieved around the middle of the 21st century. For most of
the LMICs this will occur largely through their own ascent of the ladder of development, combined with
ongoing contributions of the G20, Grameen-type credit and social businesses, and nation to nation economic
partnerships. The nations at risk and those that will need help in the struggle will be those in the Sahel and
the war-torn nations of Africa and the Middle East. The world has become conscious of Africa. The MDGs
provide a network of strategies and Africa-specific enterprises like the Millennium Villages, the Africa
Development Bank, Bill & Melinda Gates Foundation and others, contribute the means for sustainable
development. As the Asian nations in turn emerge from poverty in the second decade, this will free
resources to flow to where they are most needed. Hopefully the BRIC nations will become significant
contributors to the MDGs, but even if they do not, India and China have strong strategic reasons to be on
good terms with Africa. South Africa is an exception among the African states, its GDP per capita is
page 40 of 47
predicted to grow 7-fold, from $5521 in 2009 to $37525 by 2050. Since the transition to majority rule,
South Africa has maintained a helpful stance toward other African states and the African Union. It has the
location and capacity to become a major participant in the development of Africa as a whole, and hopefully
it will seize the opportunity to commit itself to the MDGs for Africa.
Toward the MDGs awareness & successively more realistic remedies → a solid plan, problems & promise
In discussing solutions to hunger relation we need to be clear on poverty & its origins, & true needs of the
poor
Water, PEM, micronutrients
Before we suggest grounds for optimism grounds for impatience: melt-down is an enormous setback – 6-10
years
Preview microcredit, MV concept, wave of impatience – people lead govts (they have to lie)
Enterprise, venture, initiative, project, endeavour, pursuit, assignment, undertaking, task, function, scheme
Preview microcredit, MV concept, wave of impatience – people lead govts (they have to lie)
Enterprise, venture, initiative, project, endeavour, pursuit, assignment, undertaking, task, function, scheme
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======================================
1
Peter Svedberg Poverty and Undernutrition : Theory, Measurement, and Policy, OUP, 2002, 348 p, ISBN : 019-5660919
United Nations Secretary-General and the UN Development Group: http://www.unmillenniumproject.org/goals/index.htm
5
Mark R. Rank, PhD; Thomas A. Hirschl, PhD Estimating the Risk of Food Stamp Use and Impoverishment During
Childhood Arch Pediatr Adolesc Med. 2009;163(11):994-999
6
Paul Collier: The bottom billion
7
GHEC Why is the third world the third world
9
Michael Meacher This war on terrorism is bogus The Guardian, 6 September 2003
32
Frances Moore Lappe
33
Global and regional poverty trends Chapter 1 of Global Economic Prospects 2009 World Bank Data on Poverty and
Inequality
34
FAO The State of Food Insecurity in the World 2009 Chapter 1 Undernourishment around the world
http://www.fao.org/docrep/012/i0876e/i0876e00.htm (download from Corporate Document Repository at
ftp://ftp.fao.org/docrep/fao/012/i0876e/i0876e02.pdf)
35
http://en.wikipedia.org/wiki/Poverty
36
H Rosling Presentation to the US State Department http://www.gapminder.org/videos/ted-us-state-department/
37
Prediction web
38
Trinity College Dublin Trends in Agricultural Aid
http://www.tcd.ie/iiis/policycoherence/index.php/iiis/development_cooperation/trends_in_agricultural_aid
39
Greg Palast Confronting the Globalcrat The Nation December 21/28, 2009
40
The Earth Institute, Columbia University: The Millennium Villages Project Annual Report January 1 – December 31,
2008 http://www.millenniumvillages.org/docs/MVP_Annual_Report_2008.pdf
44
http://www.grameenfoundation.org/
45
http://en.wikipedia.org/wiki/Grameen_family_of_organizations
46
http://www.grameenfoundation.org/our-impact
53
Karen C Lindell, Kelly M Adams, Martin Kohlmeier, and Steven H Zeisel The evolution of Nutrition in Medicine, a
computer curriculum Am J Clin Nutr 2006;83 (suppl): 956S–962S
54
Drucker G. Int Health News. 1988 Summer;9(6):2. ORT 10 years after - 500,000 lives saved each year.
58
http://www.micronutrient.org/English/view.asp?x=554
4
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59
http://www.who.int/vmnis/iodine/status/en/index.html
Yenesew Mengiste and K Tilahun Yield and water-use efficiency of deficit-irrigated maize in a semi-arid region of
Ethiopia. African Journal of Food, Agriculture, Nutrition and Development Volume 9 No. 8 November 2009
66
Business Week Innovation February 22, 2008, 12:05PM EST
http://images.businessweek.com/ss/08/02/0223_paulpolak/index_01.htm
67
http://science.howstuffworks.com/earth/green-technology/sustainable/community/playpump.htm/printable
68
International Food Policy Research Institute. Billions fed http://www.ifpri.org/publication/millions-fed
69
David Whelan, Tatiana Serafin and Cristina von Zeppelin Billion-Dollar Donors, Fprbes Magazine 24th August 2009
http://www.forbes.com/2009/08/24/billion-dollar-donors-gates-business-billionaire-philanthropy.html
70
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64
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