Claudio Schuftan and Radha Holla
A focus on the social determinants of nutrition (including its political determinants) is imperative to revitalize global nutrition policies and embed them well within the human rights framework. Yet due to the increasing influence of private corporations and philanthropies over public policy (especially through various forms of multi-stakeholder initiatives) and policy implementation (particularly through public-private partnerships), these determinants are being ignored. As our analysis will show, the multi-stakeholder Initiative Scaling Up Nutrition (SUN) provides a good example of this as is also featured in Article 4 of this publication. Here, we additionally focus on the neglect of the social determinants of nutrition (SDN) in current global nutrition policy making.
The SDN correspond to the conditions in which people are born, grow, live, work and age, including the nutrition services available to them. These circumstances are shaped by the distribution of wealth, power and resources at global, national and local levels, which are themselves influenced by policy choices.
In 2008, the World Health Organization (WHO) Report of the Commission on the Social Determinants of Health made three overarching recommendations which also apply to the field of nutrition, namely: to improve daily living conditions; to tackle the inequitable distribution of power, money, and resources; and to measure and assess the impact of concerted efforts. These recommendations were also directed to the private sector. Yet these essential measures, as well as the other structural roots of hunger such as income maldistribution, unemployment, lack of access to education, to health services and to sanitation, racial discrimination, and no access to productive resources are rarely, if ever, mentioned by private sector actors who are also, in principle, bound by them.
On the other hand, in the area of nutrition, public private partnerships (PPPs) often end up reinforcing increasingly globalized food chains that contribute to the corporate-led homogenization of diets across the globe with its dire impacts on local food systems and on household food security across population groups. The UN Special Rapporteur on the Right to Food, Olivier De Schutter, has clearly explained the problem of how the private sector tries to use technical solutions for what are fundamentally social problems. (See Box 1)
“Countries committed to really scaling up nutrition should begin by regulating the marketing of commercial infant formula and other breast-milk substitutes, […] and by implementing the full set of WHO recommendations on the marketing of breast-milk substitutes and of foods and non-alcoholic beverages to children […]. This speaks in favor of […] addressing the full range of factors causing malnutrition, rather than narrowly focusing on initiatives that address just the specific needs of a child‘s development […]. [I]nterventions […] targeting pregnant or lactating women and children under two years old, while vital, do not substitute for addressing the structural causes of undernutrition […]. The violations of women‘s rights, gender inequality and the lack of women‘s empowerment are another major factor explaining poor nutritional outcomes.[…]. Nutrition interventions should be but one part of broader-based strategies for the realization of the right to adequate food. […]
The Special Rapporteur [also] sees no reason why the promotion of foods that are known to have detrimental health impacts should be allowed to continue unimpeded: these products reduce the life expectancy, in particular, of the poorest segment of the population who are also the least nutritionally literate [….] [A]n international code of conduct regulating marketing food and beverages in support of national efforts might be desirable in order to take into account the international nature of commercial promotion of energy-dense, micronutrient-poor foods and beverages. […]
[I]t is high time to recognize the real tension that exists between a strategy that promotes processed foods, enriched with nutrients to the point that diets become medicalized, and a strategy that promotes local and regional food systems, as well as a shift towards foods that are less heavily processed and thus more nutritious.”
Corporate control over nutrition through Public Private Partnerships
The private sector and some international NGOs have gained unprecedented influence in global governance while States have seen a clear decline in their influence. The ostensible explanation given for the close interaction with the corporate and private sector is the “scarcity” of public funds. However, this scarcity applies only to funding development as sufficient public funds are made available for corporate bailouts. One key result of this increased influence has been the making of PPPs the number one strategy to manage the health and nutritional needs of the world’s population.
In recent years the United Nations (UN) has emerged as one of the principal proponents of PPPs (more often than not contracted with for profit entities). These PPPs are considered by many to be a necessary and ideal instrument to fund development work. However, a deeper analysis reveals the multiple (sometimes contradictory) agendas and conflicting interests involved.
PPPs have further reinforced selective programs by focusing on non-sustainable technocentric and market-based solutions to single issues while not addressing the social determinants of health and nutrition. PPPs have shown to be incapable of promoting and supporting horizontally-integrated sector-wide approaches with an explicit commitment to strengthening local service delivery systems and to respond to locally determined needs. The necessity of building new alliances with civil society, with people’s organizations and with social movements in fostering the right to nutrition reasserts the central place democratic participation should have in decision-making in the provision of all social services. Because the partner supplying the finance in these projects tends to have a disproportionate amount of power in decision making, democratic participation cannot be guaranteed in the PPP model. Another basic flaw is that PPPs often focus on piecemeal technical and market-driven solutions that provide clear benefits for participating corporations, but questionable benefits for target populations while ignoring the social roots of their problems, as is clearly evident in the SUN Initiative. (Also see Article 4 of this publication)
Box 2: The Scaling Up Nutrition Initiative (SUN)
Article 4 of the SUN purports that the Initiative seeks “to promote targeted action and investment to improve nutrition for mothers and children in the 1,000-day period from pregnancy to age 2, when better nutrition can have a life-changing impact on a child‘s future, in addition to encouraging governments to adopt national plans to scale up nutrition in their various sectoral policies”. While this is a laudable goal, the methods chosen by SUN to meet this goal are controversial. In 2010, SUN identified several interventions including breastfeeding, introduction of complementary feeding after six months of age, improved hygiene practices, improved agricultural practices, micronutrient supplementation and other as having a direct impact on the nutritional status. SUN’s Framework for Action spells out that $2.9 billion will be spent on the promotion of good nutritional practices while $6.2 billion will be spent on preventing and treating malnutrition with special foods.
“SUN includes the establishment of PPPs linking business, civil society and government at the country level for meeting the goal of improved nutrition. Private-sector interventions include the production of fortified food products, the promotion of nutritionally healthy behaviors allowing women to ensure good nutrition for themselves and their children, ensuring that lower-income groups can access nutritionally valuable products, and building local capacity through the transfer of knowledge and technology”.
The Special Rapporteur on the Right to Food, while welcoming the progress made through SUN, has called for an explicit alignment of its initiatives with human rights, including the right to food. (See Box 1)
Some of the partnerships in SUN are supported by the Global Alliance for Improved Nutrition (GAIN). GAIN, a PPP itself, was launched at the 2002 special session of the General Assembly on Children. Initially, it invested in large-scale staple food fortification. GAIN provides technical assistance to multi-national, regional or national manufacturers allowing, as they claim, for these enterprises “to procure high quality vitamin and mineral premixes at the best price, combined with a revolving fund mechanism which provides the requisite financing to assist partners in purchasing premixes”. GAIN has established links with 600 companies across 36 large projects in more than 25 countries to improve access to missing micronutrients in diets. According to GAIN promoters, it reaches nearly 400 million people with nutritionally enhanced food products indicating that market-based solutions can play an important role in sustainable improvements in food quality for low-income populations.
One reason companies partner with GAIN is to reach potential customers who are too poor to constitute a solvent market in the short term. Where things go wrong in what GAIN actually ends up doing is precisely due to these partnerships. GAIN’s Business Alliance includes corporations such as Unilever, Ajinomoto, Britannia, Cargill, The Coca Cola Company, DSM, Danone, MARS, PepsiCo, Kraft Foods, and Bel, many of which have been indicted by people’s organizations with human rights violations, including violation of international laws and codes and thus contributing to malnutrition. In GAIN, the role of the governments is to buy these enriched products year after year to feed their malnourished. In doing so, they spend their limited health and nutrition budget on products, rather than investing in long-term solutions like diversification of agriculture and diets, family farms, and in tackling the SDN. For instance, ready-to-use therapeutic foods (RUTF), fortificants, and infant formulas are too often used inappropriately and can increase health and nutritional problems, both for over- and under-nutrition. RUTF should only be used in the treatment of severe-acute malnutrition, when other solutions cannot be applied; never to be used for prevention. , Furthermore, the marketing and consumption of these substitutes or of related products, in place of a freshly cooked nutritionally balanced meal, contributes to major public health problems.
Good nutrition is about accessing a healthy diet that includes a wide range of fruits and vegetables which, in most cases, are more expensive than (fast) foods rich in oils, salt, sugars and fats. Any society where a healthy diet is more expensive than an unhealthy diet is a society that must mend its food system. This is even more imperative where the poorest are too poor to feed themselves in a manner not detrimental to their health.
The SUN Roadmap, which details the means by which national, regional and international actors will work together to establish and pursue efforts to make nutrition interventions more substantial and effective in countries with a high burden of malnutrition, prioritizes mostly technical interventions, all of which are ‘top-down’. We cannot find anything substantial related to the right to nutrition in the SUN Roadmap. SUN ignores the fact that there are claim holders and duty bearers involved in social interactions, and that it is only their direct engagement that will move the process of realizing this right forward.
However, the most unacceptable component of the SUN initiative is its complete silence on SDN. The proposed ‘pro-poor’ orientation does not address disparity reduction; rather it “targets” the poor. In the absence of any consideration of the SDN, this “nutrition with a human face” victimizes them as if they are responsible for their malnutrition and then throws them a crumb of bread.
People experience poverty and the violation of their right to nutrition differently, according to their gender, age, caste, class and ethnicity. For us, in nutrition work, poverty is multi-dimensional. It relates to powerlessness, to exclusion and thus discrimination, to exploitation, to victimization and to violence. It is also related to migration, to forced displacement, to rising urbanization and to loss of livelihoods. Yet, the SUN Initiative, in its call for nutrition to be placed more at the center of development, refuses to accept this, with all the implications this carries.
Who drives SUN and the global nutrition agenda?
In the past, the UN Standing Committee on Nutrition (SCN) primarily set the global nutrition agenda. In early 2009, the World Bank, together with UN entities such as UNICEF, UNDP, the SCN and donors such as the UK and Canada’s development agencies, the Bill and Melinda Gates Foundation, Save the Children-USA, Hellen Keller International and others developed the Global Action Plan for Scaling Up Nutrition Investments. This plan created space for the private sector to play an increasingly important role in driving the nutrition agenda. It should be remembered that the Gates Foundation owns large amounts of stocks/shares in Coca Cola, Kraft Foods, GlaxoSmithKline, Sanofi Aventis, Johnson and Johnson, Proctor & Gamble, McDonald, and Monsanto.
Donor agencies have consistently tried to steer SCN’s work on nutrition. In 2011, Irish Aid gave SCN 300,000 Euros exclusively for SCN’s work on the SUN Initiative –a sum without which SCN would not have been able to continue functioning. Thus keeping the SUN Initiative alive has been an overarching need for the SCN and a built-in conflict of interest that does not really allow the SCN to take a critical stand on SUN’s shortcomings, as is its mission and mandate.
Though SCN has recognized SUN’s weaknesses (mainly the lack of attention to the human right to nutrition and HR-based approaches and the little clarity of the role and actual behavior of the private sector), it was felt that these weaknesses would be best remedied by SUN participant countries themselves. But this has not happened. The efforts of some civil society individual SCN members to introduce human rights language were vetoed by the donors backing the Initiative, and up to today, attempts to include HR concerns in the Roadmap have had little success.
The limited opposition to the corporate takeover of nutrition, as exemplified by SUN, raises concerns about corporations’ short- and medium-term impact on local nutrition systems. This includes their capacity to achieve measurable and sustainable results, their disregard of the SDN and of the right to nutrition, as well as their contribution to a fragmented, vertical approach in global nutrition governance. A critical reflection and action on the governance role of global PPPs has emerged , , , but added poignancy is sorely needed.
States should protect the right to nutrition by adopting measures that reduce the negative public health impacts of the existing food systems. Moreover, States should take immediate measures to make a progressive transition to more sustainable diets. Some WHO recommendations on this include: Using taxation to encourage healthy diets, revising the existing system of subsidies, and regulating marketing practices.
Much more grassroots activism will also be needed to make sure that global standards are not influenced by corporations trying to assure private profits as they act purportedly in the realm of the public interest. Broadening such an effort has been the guiding principle of the People’s Health Movement (www.phmovement.org ) and of the International Baby Food Action Network (IBFAN) (www.ibfan.org).
Strategies to regain control
Grassroots organizations and people’s movements have identified several strategies for people to regain control over food and nutrition. Here we review just some of the available options presented in no particular order of priority. The list is by no means complete. Many other action points were insinuated in this article’s body and are not repeated here.
• Use a SDN approach and the concept of food sovereignty instead of food security; the SDN and food sovereignty are closely related.
• Establish links with groups working to oppose TNCs hegemony and join hands with them in rejecting the corporations executives’ calls for corporate social responsibility
and instead, based on the principles of human rights, demand and monitor corporate social accountability regarding corporate violations on the SDN.
• In the area of international aid, identify local alternatives that can be made by communities themselves, to the single solution of using ready-to-use therapeutic food
(see footnote 8) as is being promoted not just for the treatment of acute, severe malnutrition, but also for its prevention.
• Oppose the use of ready to use supplementary foods (RUSF) for the prevention of severe malnutrition; denounce such attempts, proposing SDN-based policies.
• Work with lawyers and judges on the legal aspects of the Right to Adequate Food and Nutrition on their use of this right in court.
• Insist on claim holder participation in the design, implementation and monitoring of all development projects/programs.
• Denounce PPPs given their inherent clear conflict of interest and their being considered as a prime policy model.
• Create a similar long-term watch dog mechanism as the one used by IBFAN to monitor the junk food and beverages industries.
• Work towards ensuring that the SUN Initiative once and for all handles the issue of conflicts of interest and that policy making on behalf of public health follows the principles
of democratic governance. The reform of SUN also needs to cover human rights principles of accountability, participation, and non-discrimination.
• Also keep pressuring the SUN Initiative to include actions on the SDN and a more decidedly rights -focused approach as its new Roadmap is being prepared; become a SUN watchdog.
• Actively participate in the debate and design of the post-MDGs global strategy for development; critique the fact that goals are easy to set, but the crucially important processes
needed to reach the goals have been neglected.
• Lobby for the UN Special Rapporteur on the Right to Food position to become a permanent position within the UN system to provide a dedicated and progressive focal point for action.
• Transpose into domestic legislation the International Code of Marketing of Breast-milk Substitutes and the subsequent World Health Assembly (WHA) resolutions on the marketing
of breastmilk substitutes and of foods and non-alcoholic beverages to children and ensure that these laws are effectively enforced.
• Impose taxes on soft drinks (sodas), and on junk foods, in order to subsidize access to fruits and vegetables and educational campaigns on healthy diets.
• Review the existing systems of agricultural subsidies taking into account the public health nutrition impacts of current allocations, and use public procurement schemes for
school-feeding programs and for other public institutions to support the provision of locally sourced, nutritious foods, with particular attention to poor producers and consumers.
• Increase support to farmers’ markets and urban and peri-urban agriculture, and ensure appropriate infrastructure to link local producers to the urban consumers.
• Reform the Standing Committee on Nutrition to ensure its public-interest agenda and human rights focus are preserved, as well as to make it representative of UN agencies and of
civil society. The latter’s voice must be heard throughout the United Nations system.
• In the sourcing of foods and in nutrition-based interventions, ensure that local food chains are involved and that living wages are paid to workers and fair prices are paid to farmers
so as to guarantee the right to nutrition of all people affected by and involved in the interventions.
We reiterate, the SUN Team, and claim holders and duty bearers involved in SUN will have to do some hard thinking: Should the SUN Initiative be just improved in its form as a multi-stakeholder initiative with the private sector as a partner, with no conflict of interest safeguards and pretending SUN is a movement? This position should be challenged as a policy paradigm rather than calling for its reform in terms of its implementation. Recasting the SUN agenda by basing all interventions on the human rights principles of accountability, participation, and non-discrimination, and ensuring that these interventions fit under broader national strategies for the realization of the right to nutrition in order to improve countries’ ability to contribute to sustainable, long-term solutions may be an insufficient call to change the SUN’s Roadmap. Such a call does not really correspond with the political analysis FIAN, IBFAN and the People’s Health Movement are making.
More drastic steps are needed to ensure that nutrition interventions strengthen local people’s mobilization and influence, as well as strengthening food systems so as to favor the switch to sustainable diets.
In sum, we need to understand that the two challenges presented in this article will only be addressed if all of us, in all corners of the world, recognize that things will not change if we continue with our every day business as usual. What conclusions you draw from this recognition is up to you. We hope to be able to count on you for what lies ahead.