Abstract
I
The World Bank, as you may know, is the world's largest source of multilateral development finance for developing countries, investing in everything from agriculture to urban development, water, health, macro- and fiscal management, clean energy, and education—virtually the entire span of development sectors in virtually every developing country in the world. So we put a heavy emphasis on finding those investments that are going to be most transformational for countries and help them both to eliminate extreme poverty, which is a goal that we have set for ourselves, by the year 2030, and to boost what we called shared prosperity, which is to lift up the bottom 40% of the income distribution in every country and to help them do better and have better life prospects.
We know that neither of these goals is going to be attainable unless we can ensure that pregnant mothers and young children get the right nutrition at the right time because this sets so much of the trajectory of their lives, both of the children and their families, and that it's very difficult to change course if the right building blocks are not in place from the outset. We think that undernutrition is therefore one of the most serious and still underattended global development challenges—not just a health challenge, not just a nutrition challenge, but a true development challenge!
We have 162 million people worldwide under the age of 5 years who are chronically malnourished, stunted. And as you know, if you reach the age of 2 years and you don't have the proper trajectory, it's very, very difficult to regain that later in childhood, let alone later in life. Six million of these children die every year.
Now, the good news is that number is half of what it was a generation ago, in 1990. And this represents an extraordinary and truly historic achievement. Never before in human history has the number of children dying in childhood declined for so many years in a row, perhaps ever at all. And remember, the population has increased dramatically since 1990 globally, but the number of child deaths is down by half. So, 6 million a year is still 6 million too many, but we have made tremendous progress in the last 25 years. If we want to continue and finish the job so nobody dies in childhood, we have to tackle undernutrition because it's now responsible for 45% of those deaths that still happen every year.
We also know that children who are iodine-deficient are losing up to 13 IQ points, which is nearly a full standard deviation, and they're getting 1 year less of schooling on average around the world. This has lifelong implications for children, their development, and their families' development. Those who are deficient in vitamin A are 22% more likely to die. These are life-changing events that happen very early in a child's life and that need to be addressed as early as possible.
Obviously, the most damaging and irreversible impact happens in the first 1,000 days of a child's existence, from gestation to the second birthday, which is why we're putting so much emphasis on that first 1,000 days now. This could drive a vicious cycle across generations, where undernourished mothers give birth to undernourished girls, who then grow up to be undernourished women themselves, and the cycle turns its way down through the generations.
But this is often expressed in the terms that I just did it, which is the irrevocable losses. On the flip side of this, of course, is if you're able to achieve nutrition at that level, the gains are equally irrevocable. A child who grows another 4 cm or attains an extra 10 IQ points or develops a stronger immune system or is more able to cognitively and emotionally adapt and connect to others is never going to lose those skills or those attributes. These are truly one-shot lifelong benefits that carry on much farther than any other investment that we can think of.
Many development investments are reversible. You build a road, and you actually have to rebuild it every 3 years because the maintenance just to keep roads up is an extraordinary continuous undertaking. You do something wonderful with the economy, and next year there's a hurricane or oil prices spike or drop or something happens, and all those gains can quickly be swept away.
The gains from early childhood nutrition are forever. And to a large extent, many of them are free because they have come prepackaged in this unbelievable intervention called breastfeeding. This is, of course, what defines us as a mammalian species. And the proof of this is in the lifelong impacts. Children who escape undernutrition are much more likely to survive and stay in school, and they're much more likely to escape poverty—about 33% more likely on average. And their wages are anywhere from 5% to 50% higher than their peers who were not able to escape. And these data are from very rigorous longitudinal studies. These studies have been done over decades now with fairly substantial cohorts and very robustly tested, and the impact, correlations, and causations are very strongly established.
Women who escape undernutrition in particular are about 10% more likely to own their own businesses, and that's today. Of course, as we hope more opportunities open up for women in the future, we would expect to see this effect grow. Entire countries in Africa and Asia are losing anywhere up to 10–11% of their Gross Domestic Product to undernutrition alone and can obviously reverse this by making the proper investments and the necessary social changes.
There are many good success stories in how to solve malnutrition. Countries as widely diverse as Senegal, Brazil, Peru, and Thailand and the state of Maharashtra in India have shown that we can stop undernutrition and save lives and build futures. If we can get good early childhood nutrition programs in place, we can lock in human capital for life and all the potential that comes with it.
To do this, we need to provide key health services. We need to enable and empower parents to care well for their young infants and to understand the full benefits of proper breastfeeding, good nutrition, checkups, growth monitoring, and the full range of services, and of course we really need to emphasize continually this very simple and very powerful intervention, breastfeeding.
It's odd to call it an intervention. This is probably the second most natural behavior of the species, and yet in today's modern world this is one of those fantastic things we did for half a million years that has begun to fall off our behavior set because of all the mixed blessings of modernity.
You know all this, but it bears repeating. This is a natural, renewable food source that needs no packaging, no transportation, no storage, no cooking, and no refrigeration. It goes with you, and it is environmentally friendly. It is a win–win for the health of the mother and the child. It creates lower infant mortality, creates benefits for maternal health. It reduces the lifelong risk of noncommunicable chronic diseases for the child, and of course it promotes all that tremendous emotional bonding that comes with breastfeeding. It's a win–win for the child's education because it helps ensure a healthy brain development, longer school attendance, and higher IQ. Again, all of this has been demonstrated through a series of studies. And it has a very, very high rate of return as a pure financial investment. Forget all the humanitarian and emotional arguments, which are very powerful and compelling. Just in sheer, raw bottom-line economic terms, this may be the single most effective investment a country can make in any sector for any reason!
And wonderfully, it also reduces inequity. This ensures that all children, irrespective of their gender, whether they are from a rich country or a poor one, can get the best possible start in life and start from a very even basis. So I sometimes joke that if breastfeeding did not exist and somebody invented it today, he or she would really be eligible for a joint Nobel Prize in Medicine and Economics for all these reasons.
So what do we need to do to get this at the level it needs to be? First, obviously, governments need to invest in breastfeeding programs. They have to ensure that health and undernutrition budgets in particular include support for breastfeeding, and not just financial support, but the kind of social change and norm-setting that is required.
People tend to do what the people around them do, and one problem we had is, as this has fallen off as the normative behavior, it's more and more difficult just to go in and target isolated individuals. A pamphlet, a speech alone is never enough. You really need social change that enables everybody to see that all the other women do it, and so there must be something good about this.
Obviously, we need to prioritize and finance creating breastfeeding-friendly settings—workplaces, health facilities, public places, etc. And again, this should not just be through the health sector, but through other sectors that influence things like this—workplace policies, social protection programs, anything that links people to services and to either public or private spaces can be adapted for this.
Laws need to be adopted in some places to protect breastfeeding. Obviously, the adoption of the International Code of Marketing of Breast Milk Substitutes, maternity protection laws, and safe spaces for breastfeeding are other things that can enable this to become or resume being the norm that it was for so long.
Employers can take a lead in providing support to breastfeeding mothers: policies to support breastfeeding women, providing designated private spaces for breastfeeding and expressing, allowing flexible scheduling to come back to work and to support milk expression during work.
I was once walking through a building about 15, 20 years ago, when this great changeover was happening, and I happened to see a memo that said, “Please note that effective immediately Room 5276 is no longer the designated smoking room. Smokers are asked to please go outside and smoke in front of the building.” There was a little line of asterisks, and then underneath it said, “We are pleased to announce that Room 5276 is now designated the official nursing room.” I said, “God, I hope they cleared out the secondhand smoke before they did that.” But at least the spirit was in the right direction.
So on the World Bank's part, we are influential in helping countries think through their challenges and make and assign priorities for their investments, for their policy attention, and for the bully pulpit of their political leadership. So one thing we've tried to do is to highlight the importance of nutrition overall to virtually all developing countries.
So one thing we have done is to add stunting as an indicator to what we call our corporate scorecard. These are the sort of meta-measures by which we are ultimately holding ourselves accountable, the goals that we're really aiming toward, as opposed to the sort of year-on-year things that define whether we're delivering with efficiency and met our budget, all of which are important, but they should all be guided by higher-order objectives, and one of them is to reduce stunting worldwide.
So this is something we want to track in its own right, but we also consider it one of the most powerful predictors of whether we will be able to attain the full suite of sustainable development goals that are currently being negotiated in the United Nations system.
In our country operations, we right now have 30 projects that explicitly reference breastfeeding objectives, working in all regions of the world—Timor-Leste to Yemen, Bangladesh, Peru, Niger, the Kyrgyz Republic, and elsewhere. And this work is not only part of our health, nutrition, and population cluster, but also our social protection and labor practice, which has a lot of influence in the programs that bring people to services or influence how they interact in the labor force and in the workplace.
We have initiatives that are working to strengthen infant and young child funding policies, and we're doing a lot of analytic work, generally in economics, to understand the costs of investing and the benefits of investing, to create the tools so policymakers can understand the cost-effectiveness of nutrition interventions versus the other things they might choose to invest in.
At the end of the day, if you want to persuade policymakers, you have to speak their language, which is usually economics, and you need to be able to justify things on the same basis at which they assess things that they can actually go out and look at. So it can be an uphill battle, but the strength of the evidence is so strong for nutrition that we feel it's a winnable one.
And because we recognize that breastfeeding, which, combined with other interventions such as micronutrient supplements, deworming, and growth monitoring, is so powerful, we are trying to present countries with the knowledge that all of this together is going to be a very, very potent package in driving their economic development.
But, of course, the World Bank is just one actor. We are a trivial share of financial support compared with the countries' own resources and to capital flows around the world. Official development assistance is a very small share of all the money that is at the disposal now of developing countries. This is a good thing. It reflects the growth and prosperity around the world in recent decades, the growth of private foundations, and other organizations interested in this. But it does mean that we need to get more and more organizations engaged, and we really need to be able to fund and support all of this on a massive scale.
So this is why just a few weeks ago, along with the Children's Investment Fund Foundation of the United Kingdom, the UBS Optimus Foundation, which is one of the largest capital management firms on Earth, the United Kingdom Department for International Development, and UNICEF, we've launched the Power of Nutrition. This is a United Kingdom–based charity and fund that is aiming to unlock up to $1 billion in the next 5 years of new private and public financing to help improve child nutrition.
And it's designed in a way that's going to support well-designed country programs—it's not meant to be freestanding or separately owned or operated—and to come under very robust strategies that are going to ensure that things are sustainable, that they're embedded in how the countries are designing and running their own systems, and that brings in expertise from external partners to help make these things as consequential as possible and to have the greatest possible impact.
It's going to use private and philanthropic grants alongside of government funding and finance from the International Development Association, which is the World Bank's fund for the poorest countries, and act as a catalyst to try to significantly increase investments in nutrition and drive large-scale progress in countries. There are thousands of wonderful boutique projects all around the world that have success in a village or a district or something, but the stumbling block has always been getting these things to scale and getting them mainstreamed, getting the knowledge of what's working to enough policymakers that this can really become part and parcel of how they do national practice overall.
It's going to focus on channeling more money to do the things that we know work, and this means following the science as much as possible. This is not meant to be a sort of wildly experimental activity. It's really meant to take what works to scale.
Breastfeeding obviously needs no further justification, but the ways of getting it to work remain very much under study; we need to know what's going to be the most effective way in helping to offset the long trend away from breastfeeding. Regarding micronutrient supplements, we need to learn how to make sure that children are getting vitamin A and iodine and other interventions that we know work, but where we have yet to crack the nut of how to get them to scale.
This Power of Nutrition has actually developed an innovative matching offer that guarantees that every dollar in private funding will be multiplied three or four or five times by matching that's secured from other funders. So it gives private donors an added inducement to put money in, knowing that they're going to be able to leverage much more dollar for dollar, sort of in the way that National Public Radio annoys you by saying, “If you call before 12 o'clock, your money will be doubled,” and so forth. It seems to work for them, so we're hoping it will work for nutrition.
And at the World Bank's part, we are very pleased that one of the mechanisms that will be operating through this partnership is a $55 million multidonor trust fund, and that eligible countries can apply to right now. So this is money that's in the bank that poor countries can start to access. And working with UNICEF, we're proud to be the first implementing partners for this Power of Nutrition initiative.
The first country to benefit has already signed up—this is Tanzania—just at the end of last month, which will receive $20 million through this trust fund in order to scale up what they're already doing with the hope of achieving lasting nationwide impact.
So in short, ending undernutrition is an issue of equity and saving lives and also of boosting economies and prosperity and the prospect for all people around the world. Therefore, it is very close to the core of the World Bank's agenda and mission and is very close to what we are doing in working with countries to try to help them scale up.
There's been a great deal of interest and goodwill around nutrition for a long time. It took a while for it to get outside the confines of the scientific community into the broader public policy community. We're quite confident that its moment has arrived. The creation of this very muscular public–private partnership is, I think, one of the most tangible signs of that. This is real money in international development terms, and it is a broad partnership in terms of the kinds of organizations that are coming to the table and the seriousness with which they undertake things.
So we're very hopeful that the moment is here, and now it's up to us to capitalize on this to make a lasting difference for everybody, starting with this most powerful intervention of all, breastfeeding.