2013 January Column
Kumasi, Ghana. As I write this, my country of Ghana has been electing a new president and government for the next four years. I was up all night to follow the results of the elections, like so many Ghanaians – while drafting this column at the same time! This month for the beginning of a new year I mostly summarise what I wrote last year, hopefully as a guide to this year. As usual, I start with a picture; this one above is of the Gulf of Guinea taken from the shores of Korle-Gonno, a suburb of Accra, where I grew up. I recently visited this place and it brought back some fond memories.
The need for stability
John Dramani Mahama, Ghanaian president since last July since the death
of John Atta Mills, and his life story. He has now been elected president
In sub-Saharan Africa our very existence is determined by the extent of political stability. Countries in all stages of economic and other development that are making good progress are doing so because of long periods of stability and good governance. Without stability and peace, even if there are policies, effective implementation is not likely. There can be no reliable rule of law without stability. So often instead chaos ensues, as in many countries especially in Africa. Without stability there will be no investment, and so populations and communities cannot improve their livelihoods. Countries just go back and forth, they take two steps forward and take five steps backward , where there is no political stability.
Neighbour countries of Ghana include Liberia, Sierra Leone, Mali and Côte d'Ivoire, which are or have been unstable due to wars and conflicts over the years. So in Ghana we are well aware of the cost of instability. But even with stability, there is the need for good governance and good leadership.
Nutrition and stability
Politics, in any sense of the word, is bound up with the basic and underlying as well as the immediate causes of states of nutrition. We know that the main preventable immediate causes of undernutrition are inadequate diets and infections. Underlying these immediate causes are poor maternal and child care practices, food insecurity and inappropriate environmental health and sanitation. Such healthy environments are the prerequisites for any immediate causes to be resolved. Ghana has come a long way forward: anything that destabilises our country will jeopardise what we've worked so hard to achieve. In countries like mine, professionals in the health, education, social security, and community professions – in fact all of civil society – take a close and keen interest in politics.
Maternal deaths in Ghana
Zero tolerance for death in childbirth
Above are some of the mothers of Africa, with their children. Rates of death
of children at or after birth remain very high in many sub-Saharan countries
Beginning my 2012 columns in February, I presented Ghana's zero tolerance for maternal deaths initiative by the then First Lady Mrs Naadu Mills. She said that the rate at which women were dying during childbirth, at about 350 per 100,000 births in Ghana, was unacceptable. She said 'no woman should die while giving life'. She called on chief executives at all levels to draw up comprehensive programmes to reduce maternal mortality within their jurisdiction. Community social mobilisation to ensure political commitment and to bring about societal change was one commitment.
Lessons from recent history
Pictured above is a midwife in Queensland, Australia, visiting an expectant mother in the back country. Good practice needs to adapt to circumstances
In March I looked at the direct causes of maternal death and also their underlying causes. For every woman who dies, approximately 30 more suffer injuries, infection and disabilities in pregnancy or childbirth. In 2000, compared with high-income countries where woman have a mere 1 in 4000 risk of dying during childbirth, in sub-Saharan Africa the figure was 1 in 16. Africa has the highest maternal mortality rate in the world. The immediate causes of maternal mortality in lower-income countries include unsafe abortions, haemorrhage, sepsis, obstructed labour, and eclampsia and. In Africa and other countries where malaria is endemic and also high HIV prevalence, anaemia and HIV both increase the risk for maternal and infant mortality. Underlying these direct causes are poor governance, poor access to health care, poor nutrition, low status of women, and poor education.
I also summarised UNICEFs view that four types of intervention are vital. These are helping to improve emergency obstetric care; laying the foundations for good prenatal care; helping to prevent mother-to-child HIV; and education most of all for girls.
A lesson from history (see the picture above) is that good practice does not have to include sophisticated birthing equipment, the presence of physicians, or even social class generally. Maternal mortality is reduced by care from by trained and skilled birth attendants who provide care during delivery, while preventing and treating fever.
International Women's Day
Above are Cameroonian women in their International Women's Day special
fabric during a march-pass to commemorate the 2012 IWD celebrations
In April I commemorated International Women's Day. The celebrations emphasised the responsibilities and roles rural women can and will play, when empowered, in ending undernutrition and poverty, two key targets of the Millennium Development Goals. Michelle Bachelet, former president of Chile, now executive director of the UN initiative for gender equality and the empowerment of women, said: 'No enduring solution to the major global challenges – from climate change to political and economic instability – can be solved without the full empowerment and participation of women across the world'.
In Ghana, women were called on to use the opportunities government has given to empower them and their families. In Morocco, the national minister said that the day was an opportunity to highlight Morocco's efforts to empower women. In Malawi several projects have been implemented to improve the lives of women. These include fostering women's skills and understanding in health education, agroforestry techniques, and skills development. In Cameroon (above) the day is colourfully celebrated each year with a march-past and other events including making a special fabric for the occasion, sown into different styled dresses.
There is a long way to go, in the matter of women's rights. Four main aims are yet to be met:
- All women should have equal pay for equal work.
- All girls especially in rural areas should be educated at least at primary level, with targets set for full secondary education.
- Women should be involved in decision making at all levels of government.
- Rural women should be paid for all the types of work that they do, at the very least for work done outside the home.
Undernutrition, overnutrition, HIV/AIDS
Africa's triple disease burden
This small boy fishing on the Volta Lake of Ghana has survived for his first five years. But what can he expect when he is older and when he is a man?
In May I wrote about my hopes for World Nutrition Rio2012, the international congress for which the Association was co-responsible. I was honoured to be invited to be one of the opening and closing plenary speakers, along with Renato Maluf, Philip James and Marion Nestle. In the points I made, I focussed on actions and interventions that would be of significance in translating our knowledge of nutrition, the causes of malnutrition and its consequences into actions that can make a difference across Africa.
These were my suggestions. First, have policies. Effective actions depend on rational policies. There should be national nutrition policies that spell out the what, why, when and how of moving into action. There should be clear policies for prevention and also treatment of undernutrition, and also for prevention and management of diet-related chronic diseases. Second, nutrition should be high on the agenda of African governments. When nutrition is not a priority, governments give it little or no money and cut budgets when times are tough.
Third, opportunities for external funding abound. But external support may well not always be available, usually comes with strings attached, and creates dependency and loss of independence. Thus our governments should provide much more support than what they currently do. And thus, fourth, all-government action is essential. Nutrition programmes should be integrated into existing programmes of all relevant government departments.
African Nutrition Leadership Programme
A future for our continent
Here you see participants in the 2011 African nutrition leadership training.
Inspiring young professionals as leaders is crucial for the future of Africa
In July I asked graduates of the African Nutrition Leadership Programme to say why the programme should continue to receive support.
Robert Ackatia-Armah, Ghana, participated in 2009. He commented 'I think people should know that the programme is a philosophy. It is analogous to building a house. A foundation that is not strong will eventually collapse when it takes the pressure of being over-used. What we have been doing in the last couple of years has been to lay a solid foundation to build nutrition leadership, mentoring, and networking principles for success in nutrition programming, government and management.
Joyceline Kaganda, Tanzania, who also participated in 2009, said: 'I really appreciate that I got a chance to attend the course. I learned a lot that has helped me change my thinking in accommodating, compromising and making decisions. I am happy to share with you my recent appointment as director of nutrition education and training at the Tanzania Food and Nutrition Centre. I remember during the interview, many questions were directly linked to what I learned with the programme: issues like team building, networking, collaborating, advocacy and so on. It is my wish that such courses be also conducted in Tanzania'.
Anselimo Makokha, Kenya, participated in 2004. 'Some of the very important ways in which the programme impacted on me are not easily tangible. The issue of embracing integrity in our daily interactions with others – superiors, colleagues, students – is one very strong value that is reflected in some of us. To me, though intangible, these are valuable lessons that I carried from the training I hope many others will benefit from this training'.
Alex Mokori, Uganda. 'I left the programme more motivated to take charge of leadership in all ways possible. I have mentored a team of 28 young nutritionists from Kyambogo University in Kampala, and they are ready to go out there and make a difference in the nutrition landscape. One of our 2011 declarations was to use research and advocacy to improve the situation in Africa; I am glad to be part of the dedicated team in Uganda that has driven the nutrition advocacy agenda forward'.
Transnational industry. Coca-Cola
Nutritionists as advocates
Pictured above are advertisements showing Aftican athletes and women
drinking Coca-Cola. They push for the products to be drunk every day
In August, I wrote about need for more advocacy by nutritionists in Ghana. This followed advertisements by the transnational corporation Coca-Cola. Several comments from colleagues in Ghana condemned this practice:
Abizari Abdul-Razak. 'In the last few weeks I have, with a lot of disdain, heard and seen adverts from the Coca-Cola company promoting the consumption of Coca- Cola with meals. The promotion is dubbed: "Liven up your meal time with Coca-Cola"... The promotion of such unhealthy behaviour is the last thing we need. One of our objectives in the Ghana Nutrition Society, as stated in our constitution, is: "To be a strong advocate of nutrition issues and place at the disposal of the general public our expertise as nutritionists". Well, I think this is the opportunity for us to demonstrate our commitment to that objective. Remember there is no civil society for nutrition in Ghana. We cannot look behind us, we are the backstoppers! The objective of this mail is to start a discussion among us which I hope will generate enough heat to move us into action'.
Paul Aryee. 'I have been equally appalled with this and other disdainful advertisements by transnational, rich and powerful corporations who are mainly interested in the profits accruing to them from such careless and ill-thought pronouncements in our media. The Coca-Cola advertisement is not the only one. There is this other one that encourages mothers and parents to spread hard and highly saturated fat (in the form of Blue Band margarine), daily, "for growth". Well, it should have said for obesity and heart attacks in later life. The use of powerful marketing approaches to sell ill-health to our people should prompt us to come out with the appropriate strategies to counter such anti-nutritional propaganda. You can also have your say on this matter my friends!'
Kingsley Pereko who is a lecturer in the medical school of the University of Cape Coast, wrote in response :'Dear Abizari. This is a good start. I believe there are many others out there that we could take on if we mean to be real advocates of nutrition. We are also part of a civil society and our voices could raise a change. I ask that you extend this campaign not only among the association but you could put it up on the social media to get the support of the masses to overturn this unfortunate situation'.
Scaling Up Nutrition
Transforming Africa's nutrition landscape
In November 2012 in writing about the Nutrition Congress of Africa, I focussed on the opening speech by Anna Lartey, president-elect of the International Union of Nutritional Sciences. She stated that to live a life without malnutrition is a fundamental human right. The persistence of malnutrition, especially among children and mothers, in this world of plenty is immoral, she said.
Presenting on the role of the Scaling Up Nutrition (SUN), Jane Badham said that the Millennium Development Goals cannot be achieved without a global coordinated action on nutrition with special focus on mothers and young children. Leadership must come from the countries themselves, and external support must add value and be demand-driven. Ongoing initiatives to improve nutrition should be linked together for greater coherence, efficiency and impact. Beatrice Kawana of Zambia said that her country joined SUN in 2011. Since then there has been a high level international food and nutrition consultative forum, the development of a national food and nutrition strategic plan, and the establishment of a multi-stakeholder platform for nutrition.
This new year
My best wishes
So what do I hope for in 2013 – and beyond? I can summarise this in one phrase: 'to be fruitful'. Let us be results-oriented in our actions. Sound programmes initiated in 2012, and before then, should continue. We know the problems already. Both under and overnutrition are significant in Africa. We know what we are dealing with.
The good news is that we know well what actions can work. These include extended exclusive breastfeeding, appropriate complementary feeding, increased consumption of fruits, vegetables, and foods high in dietary fibre; and reducing energy intake to prevent obesity and its associated complications. Maternal education is still important to delay the age at which women give birth in Africa, to help child spacing. Managing severe malnutrition is needed. There is no need to revisit these necessary policies and actions. They just need to be scaled up.
So to go back to where I started this month: political stability and good governance underlie good practice in nutrition. We need these in Africa. Scientists and health professionals are citizens too and should be involved in seeking these. Nutrition is in the limelight globally and opportunities abound.
Acknowledgement and request
Conflicting or competing interests: I am associated with the African Graduate Nutrition Students Network. I do not regard this as a competing interest. This column has been reviewed by Geoffrey Cannon.
Readers may make use of the material in this column if acknowledgement is given to the Association, and WN is cited. Please cite as: Annan R. The need for stability. [Column]. January 2013. Obtainable at www.wphna.org.
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