#FutureFortified Global Summit on Food Fortification
September 10, 2015
Thank you, Jay, for that generous introduction.
I’d like to extend a special “thank you” to President Kikwete and the government of Tanzania for co-hosting the first-ever Global Summit on Food Fortification. My gratitude also goes to GAIN for their role as co-host of this important gathering.
I am excited to be here, and to be joined by my peers from the Lead Group of the Scaling Up Nutrition Movement. It is an honor to have been asked to address you today on behalf of the Bill & Melinda Gates Foundation.
I’d like to start by asking a very old and difficult question: Why do children die?
Human beings have sought to answer that for as long as anyone can remember.
Unraveling the tragedy of why children in poor countries have had their futures stolen from them in such staggering numbers has led scientists, scholars, and physicians alike to explore the causes of child mortality.
That question helped set in motion my own career in medicine and public health. And it led me – and many others – to ask another question: What can we do about it?
This line of inquiry has helped us make big strides to improve global health. One powerful indicator of that progress is the reduction in child mortality. Since 1990, the child mortality rate has been cut in half – the result of ambitious goals, innovation, and commitment.
Yet, despite this progress, the world is not improving fast enough. More than 6 million children died in 2013. Appallingly, over half of those deaths were from preventable causes.
The underlying causes of child mortality are complex and interlinked—and, in many cases, hidden.
If a four-year-old girl in Tanzania or Malawi or India dies of tuberculosis or pneumonia, is that disease truly what claimed her life?
We have discovered that poor nutrition is often the handmaiden of child mortality. We know that undernutrition is a primary factor in 45% of the deaths of children under age five.
We also now understand the particular importance that micronutrients play in the diets of children and women of reproductive age. Children who don’t get enough of the right micronutrients can suffer from impaired mental development, blindness, stunting, and diminished resistance to disease. Micronutrient deficiencies endanger expectant mothers during pregnancy and during childbirth.
An estimated 450,000 children die each year due to causes associated with zinc deficiency alone. Iron deficiency undermines the health of 40% of women in developing countries. Iron-deficiency anemia has also been linked to premature births and low birth-weight babies.
Worldwide, more than 2 billion people are deficient in essential vitamins and minerals—accounting for nearly 10% of the global health burden.
This burden is especially acute in many parts of Africa and South Asia. Nearly half a million children die in Sub-Saharan Africa each year from common diseases because they aren’t protected by sufficient vitamin A. In Southeast Asia, 600 million people suffer from iron deficiency anemia—those most affected are adolescent girls, women of reproductive age, and young children.
The economic toll of micronutrient deficiency also undermines the potential for prosperity in developing nations.
Countries may lose between 2-3% of their Gross Domestic Product as a result of iron, iodine, and zinc deficiencies.
In Uganda, for example, micronutrient deficiency contributes to an estimated $310 million in lost productivity.
Clearly, millions of women and children are not getting the nutrition they need, and the consequences for families, communities, and entire nations is devastating – but we have a powerful solution at our disposal: food fortification.
The methods we use today to fortify food are made possible through advances in science, technology, and industry. But the idea that a good diet is often the best medicine goes back a long way.
The predecessors of today’s nutritionists might have recommended that we all eat a much higher quantity of seaweed and onions due to their curative properties.
As far back as 2700 BCE, Chinese medical texts reported that burnt seaweed was an effective treatment for goiter, a condition that results in swelling of the neck. And according to the Egyptian Ebers papyrus, which dates back to 1500 BCE, onions cure scurvy.
Of course, what these ancient healers didn’t know was that it’s actually the vitamin C in the onions – and the iodine in seaweed – that produces the health benefits.
Our understanding of the importance of micronutrients has advanced significantly since then. So much so that industrialized nations began deliberately fortifying staple foods and condiments nearly a century ago to address public-health problems rooted in nutrient deficiencies.
Iodized salt is the best known and most widely adopted strategy to tackle micronutrient deficiency. It was first introduced on a wide scale in the 1920s. In addition to preventing goiter, iodine is essential for healthy brain development – in utero and throughout early childhood. Yet, despite its proven benefits, iodine intake is insufficient in three of every 10 households worldwide.
In addition to iodized salt, we now have a growing suite of complementary interventions to reduce micronutrient deficiencies – including vitamin and mineral supplementation programs; biofortification of staple crops; and food fortification.
Today, food fortification comes in many forms: soy sauce with added iron; Vitamin A-fortified cooking oil and sugar; and flour enriched with iron, zinc, folate, and B vitamins.
Without a doubt, it is one of the most cost-effective weapons we have for fighting malnutrition.
The Copenhagen Consensus Center concluded that the annual cost of increasing iodized salt access to reach 80% of the population of South Asia and Sub-Saharan Africa would cost just 5 cents per person treated, or $19 million in total. But the benefits from that investment would be worth as much as $570 million in health-care savings and increased productivity.
The health imperative and the economic benefits are clear, which is why some of the Gates Foundation’s earliest nutrition investments were in food fortification. But even our resources can deliver only a small fraction of what’s needed.
The challenge now is to build on what we’ve learned to get fortified food to the people who need it the most across Africa and South Asia. We need the help of everyone in this room to make that happen.
There is already some good progress happening across Africa, including right here in Tanzania.
Through President Kikwete’s commitment and leadership, Tanzania launched its national food fortification program in 2011. Today, it is reaching millions of Tanzanians with fortified wheat flour and edible cooking oil.
Tanzania was able to scale its efforts quickly, in significant part because of a strong partnership between domestic private-sector cooking oil producers, wheat-flour millers, and the National Food Fortification Alliance. While it is too early to know the long-term health outcomes of this program, it already provides a partnership model that other nations can learn from and build on.
There are other good examples of progress elsewhere on the continent. In South Africa, a partnership with GAIN increased access to folate-fortified wheat and maize flour – contributing to a more than 30% decline in brain and spinal birth defects, including a 41% reduction of spina bifida.
In Ethiopia, a national salt-iodization program has substantially increased the number of households with adequately iodized salt.
Given all we have learned from more than a decade of work in the field, we believe there are three keys to expand and sustain food-fortification efforts to reach the most vulnerable populations.
The first key is that governments in high-burden countries must establish an effective regulatory framework. This includes deciding what foods and condiments to fortify, setting fortification standards to achieve public-health outcomes, and ensuring quality control and compliance.
Filling the gaps on data about nutrient deficiency is also essential to understand where undernourished and micronutrient deficient people live; what they are eating; how they get their food; and – crucially – if they have access to fortified food.
Governments must ensure that the efforts of ministries – such as health, commerce and finance – are linked up. This means, for example, that the public-health objectives of fortification programs are understood and made achievable by ministers of finance and trade.
Perhaps most importantly, mandatory regulation sends a clear signal to the private sector that a government intends to make fortification widely available. This is the kind of certainty companies need to commit to fortification.
The second key is that private food producers have to be part of the conversation about standards, and they must take the lead on quality assurance. After all, they are the ones producing fortified food. This includes first and foremost national producers of salt, flours and cooking oil, as well as producers of fortificants and premix.
However, companies can do more than simply join the dialogue. Their commitment and willingness to fortify products can stimulate political action.
In the eight-country West African Economic and Monetary Union, efforts to expand access to fortified foods, including through regional trade, are having an impact. That impact began with an important commitment.
In 2004, a regional association of cooking oil producers made the bold decision to adopt vitamin A fortification as a standard practice.
By last year, more than 80 million people across these eight countries were consuming fortified cooking oil.
These efforts have also sparked action across the Economic Community of West African States. In all, 14 countries in West Africa now have legislation on the books for mandatory food fortification.
The reality is this: Companies need a fair market in order to do business. Without that, they risk being undercut by others who can produce or import a cheaper product – but whose quality of fortification is substandard or altogether absent.
Even when a company desires to contribute to an altruistic goal like public health, it is unlikely they will do so without a genuine market incentive. Without the private sector’s involvement, we will not achieve the kind of magnitude or quality assurance needed for sustainable fortification programs.
The third key is the involvement of development partners – international agencies, NGOs, and the philanthropic sector.
The development sector must step up their support of high-burden countries as they develop national nutrition plans, including food fortification. This means generating evidence for policymakers to make informed decisions. It also means investing in and empowering local partners so that fortification programs are set up to succeed.
If we are to unleash the full potential of food fortification, we must ensure access to everyone, most especially the poorest of the poor who often don’t get their food from the industrial food system. This is a fundamental challenge in food-fortification programs. If the poorest people can’t afford these products, or don’t have access, we risk falling short of global goals.
China’s effort in the early 2000s to launch iron-fortified soy sauce as a method to combat anemia showed promise when it reached nearly 60 million people within two years. However, the program struggled to gain traction among poor and rural farmers, the very population most at risk of iron deficiency. In the time since, through partnership with GAIN, China has expanded the reach of the iron-fortified soy sauce to lower-income populations, bringing this product into seven new provinces.
As I wrap up, I want to go back for just a moment to iodized salt.
Nearly 200 years ago, the French chemist Jean Baptiste Boussingault concluded that iodized salt would be an effective prevention for goiter. Yet, it took nearly 100 years before iodized salt was first introduced on a wide scale – in Switzerland. It took even longer for the United States and Europe – and longer still for developing countries.
Even today, iodine deficiency disorder is still a serious public-health threat for nearly 2 billion people worldwide.
Imagine if a century hadn’t gone by before people gained access to iodized salt. Imagine the reclaimed health and opportunity for millions of women and children.
Now imagine what Boussingault would say if we drag our feet getting today’s array of fortification interventions to the people who need them?
With a growing array of proven, cost-effective food fortification solutions available today, it would be a gross injustice to let a hundred years – or even 10 years – pass, without taking action.
Quite literally, the coins you have in your pocket right now can make the difference between a child’s life never realized and a productive life well-lived.
We are here today because of the urgency of the problem and the feasibility of the solution. To achieve that solution, we need every proven nutrition strategy we’ve got – of which fortification is one.
And we’ll need the commitment and political will of everyone in this room to make a lasting difference. And the time for us to align our efforts is now.
In two weeks, the United Nations will meet in New York City to adopt the Sustainable Development Goals.
To meet the ambitious goal of ending extreme poverty by 2030, development partners, the private sector, and governments must ensure access to the resources and solutions that can help people transform their lives. And we know that safe, nutritious, and sufficient food all year round is an essential building block people need to lift themselves out of poverty.
Yet, we will only succeed in achieving the SDG targets on poverty, hunger, and malnutrition – and feeding a future world population of 9 billion – if we work together to incorporate mandatory large-scale food fortification into national nutrition programs.
It is up to us to build these partnerships. If we do, I believe we can accomplish more in the next 15 years of food fortification than we did in the previous 100 years, bringing us much closer to a world in which we no longer have to ask why children die.
I look forward to working with each of you, and the entire nutrition community, to make this possible.