New York, NY, November 13, 2018 — I want to thank the World Innovation Summit for Health and the Qatar Foundation for inviting me to speak here today. We are meeting at a time of extraordinary innovation in healthcare for those who can afford it, but unspeakable human suffering for those left behind. None are as left behind as those trapped in war and conflict, so the theme of this conference, “Health Care in Conflict Settings,” could hardly be more timely.
More people are fleeing from conflict than at any point since World War II. Yet instead of rising to meet these needs, there is a political backlash against some of the most fundamental notions that underpin international responsibility for the victims of war. None are more at risk than young children, too many of whom are dying of preventable causes in fragile contexts. They are my focus today – not just what ails them, but a creative intervention that could save millions of lives.
I run an NGO called the International Rescue Committee – the IRC – which was founded in 1933 by Albert Einstein to support refugees fleeing the persecution and violence of World War II. Today we work in over 40 countries supporting people whose lives have been shattered by conflict and helping them rebuild their lives, whether they’re in a warzone like Yemen, where I visited in September, a refugee-hosting country like Jordan or Uganda, or a resettlement country like Germany. With more than 68 million people displaced and 135 million in need of humanitarian aid, we are unfortunately in a growth industry.
What we see every day in the countries we work in, in the communities we work with, tells us three important things about the world today. First, states that have been shattered by violence, conflict, and fragility are falling further behind the rest of the world. At the UN General Assembly in New York this year, I heard unending praise for the Sustainable Development Goals, otherwise known as the SDGs, which are the guiding framework for global progress on everything from poverty to global warming to gender equality to education, and of course health. The motto of the SDGs is to “leave no one behind.” Yet on nearly every indicator we see a growing gap between poor, but stable states and states affected by conflict and fragility.
60 percent of low and middle income countries have either met the target of reducing child deaths by two-thirds or are projected to do so by 2030. That progress is remarkable and should be commended. But just 30 percent of fragile states have met or are on track to meet this same target. Similarly, low and middle income stable states have made much more progress in eliminating hunger.
Nearly 40 percent of low- and middle- income countries have either met or are on track to meet the target of zero hunger, or to get more than halfway there. But not a single fragile state has met their end-hunger target, and only four of them – an abysmal 7 percent of all fragile states – are on track to meet this goal by 2030.
Children born today in sub-Saharan Africa, where many of these fragile countries are, have a 14-fold higher risk of dying than children born in high income countries.
Second, this is not a minor issue affecting just a handful of unlucky countries. The future of global poverty looks more like Yemen or Nigeria than it does like India. By 2030, 85 percent of the world’s extremely poor will live in these fragile and conflict-affected states.
Third, this is not a problem that shows any signs of going away soon. Annually, the number of conflicts we see around the world at any given moment is 65 percent higher today than it was a decade ago. Many of these conflicts are civil wars, which tend to last longer than interstate warfare and are much more likely to relapse. Combine that with the increasing inability of global diplomats to resolve these wars, and you have the recipe for a world in which a select set of countries are stuck in perpetual conflict, unable to break the cycle of violence, and as a result unable to improve living standards for their people.
One of the most critical areas where fragile states are falling behind stable states is on child survival. Today one in thirteen children live in a high-intensity conflict zone – that’s a 75 percent increase from the 1990s. And if you look at demographic trends, most of the world’s children are being born in sub-Saharan Africa, the Middle East, and South Asia, some of the world’s most conflict-ridden areas, so the number of children affected by conflict is only likely to increase.
By 2030, an estimated 70 percent of under-five deaths – 2.4 million children per year – are projected to occur in fragile and conflict-affected states. That is a travesty that every single one of us is responsible for addressing.
But when you start looking at the way these children are dying in places like Nigeria or Yemen, the bombs and guns are actually only a small piece of the problem. Although the most immediate impacts of conflict are direct injury and deaths, the majority of civilians die from the indirect effects of conflict. Diseases break out so easily during conflict due to the breakdown of basic infrastructure such as water and sanitation facilities, a lack of access to health services, forced displacement, and overcrowded and unsanitary living conditions. It is not a coincidence that recent Cholera and Ebola outbreaks have occurred in fragile countries like Yemen and the Democratic Republic of Congo, whose health systems were severely weakened by conflict.
Children born in these environments are particularly at risk of death from infectious diseases like pneumonia and are highly vulnerable to becoming malnourished. In fact, nearly 50 percent of child deaths are driven by malnutrition. Every ten minutes in Yemen a child under the age of five dies from preventable causes, and the single largest driver of child death there is malnutrition.
So if we want to tackle child mortality, especially in fragile contexts, we need to tackle acute malnutrition – and right now we’re failing to do so. This is why the IRC has invested in an innovative new approach to tackle acute malnutrition, and why I am standing before you today.
As you know, acute malnutrition is a condition that occurs when children are low weight for their height or lose their muscle mass. It takes two forms – severe and moderate – but the underlying health challenge is the same, the difference being simply how malnourished a child is. For children, being malnourished can be a death sentence – when severely malnourished, their risk for death increases nearly tenfold.
When I was in northeastern Nigeria last year, I visited an IRC-run malnutrition stabilization center in Borno State, where nearly 2 million people have been displaced by the fighting between the government and Boko Haram. Every bed in the center was full, and when you spend time with the children who have just arrived, you see how close they are to death. They do not have enough energy to move, to smile, to cry – every calorie of energy in their body is dedicated to keeping them alive. Even more painful than seeing the children in the center was knowing that for every child we could treat there were ten more children in need and unreached.
Even for the children who manage to survive, their lives are forever shaped by the damage caused at an early age by malnutrition. Acute malnutrition at such a young, critical age can permanently impair long-term cognitive and physical development. Additionally, malnutrition increases the risk for infection due to impaired functioning of the immune system, which can compound these cognitive and physical development problems. So this isn’t just about the health and safety of children right now, this is about preventing malnutrition from robbing children the opportunity to live full, healthy, productive lives.
Global acute malnutrition rates are dire and have largely been stagnant, which highlights how little success the world has had in combating this scourge. In 2017, 51 million children suffered from acute malnutrition, driven in part by a record four countries facing famine-like conditions. The burden of acute malnutrition is most significant in fragile and conflict affected states. 18 fragile states have acute malnutrition rates above the public health emergency threshold of 10 percent. In places like South Sudan, Somalia, and Yemen, acute malnutrition is over 15 percent.
This isn’t just an issue of poverty or global food supply. Famine and acute malnutrition today is a political problem as much as a health problem and that’s why it’s so prevalent in conflict settings. In Nigeria, it is not poverty that is causing malnutrition – it’s the way the conflict has cut off farmers and herders from their land and livestock, the way the conflict has prevented farmers from being able to bring their food to market.
In Yemen, where I visited in September, conflict has created a perfect storm of conditions that drive staggering rates of acute malnutrition. According to WHO, 1.8 million children under the age of 5 years are acutely malnourished including 500,000 suffering from severe acute malnutrition. Conflict has disrupted food production, destroyed critical health infrastructure, and made access to clean water, medicine, and food itself more difficult. The situation is exacerbated by the fact that the war has cut off vitals ports of entry for food and medical imports in Hodeidah and Sana’a.
The continued high rate of acute malnutrition in conflict settings is all the more unacceptable since we already have an incredibly effective treatment. Ready to Use Food, such as the brand PlumpyNut, can take a child from death’s door to near-certain survival in just four to six weeks of treatment. This product is simple – essentially, it is peanut butter fortified by additional calories and critical nutrients, delivered in a ready-to-eat packet. This product allows children to be treated at home instead of staying in hospitals and treatment centers. And yet shockingly between 80 to 90 percent of all children with acute malnutrition around the world have no access to treatment at all. If 9 out of 10 planes failed to land at Hamad International Airport here in Doha, it would be a public scandal. Our failure here should be a scandal, too.
We have a clear and proven solution on the one hand and a community in desperate need on the other. So why can’t we bring the solution to those who need it?
The problem is three-fold: an artificially fragmented approach to treatment, a system that brings patients to treatment instead of the other way around, and a lack of investment in nutrition. But these problems are soluble, and every single person in this room can help save the lives of these children.
According to the World Bank, meeting the World Health Assembly target for acute malnutrition in low and middle income countries would require treating an additional 91 million severely malnourished children in the next 10 years. This would prevent 860,000 deaths in children under five years of age over the course a decade. 49% of those lives saved would be in sub-Saharan Africa.
We believe this is achievable. Expanding treatment promises not only to save lives, but to improve long-term health outcomes for affected children, and would allow them to better learn in school and be more economically productive unhindered by the long-term effects of malnutrition.
We can do this through two simple tools: first, a combined and simplified malnutrition treatment protocol; and second, community health workers supported by a new training curriculum that allows them to treat children with acute malnutrition in their home and communities without requiring a visit to a health facility.
The first problem is that current standard operating procedures are preventing us from identifying and supporting children who need treatment in an efficient and effective manner. The difference between a child with severe acute malnutrition and moderate acute malnutrition can be small, depending on how closely they sit on the arbitrary dividing line used for classification. But once classified into severe and moderate groups, these children are enrolled into separate programs and treated with different products supported by different agencies. Severely malnourished children receive treatment in clinics with ready-to-use therapeutic food, which is provided with support from UNICEF, while moderate acute malnutrition patients are treated at health facilities with ready-to-use supplementary food – fortified blended flours provided by the World Food Programme.
So two different UN agencies are using two different procurement systems to deliver two different treatments for essentially the same illness.
This fragmented approach results in costly systems in which children rarely get the full benefit of treatment because severe and moderate acute malnutrition therapies are rarely both available in the same place at the same time. Far too often children who are moderately acutely malnourished are left to wait until they become more critically ill before receiving treatment. And when a child with severe acute malnutrition has recovered to the point of qualifying for moderate acute malnutrition, that child may be referred to a different clinic for treatment, or treatment may be stopped altogether. This structure keeps these children caught in a vicious cycle and all too often their health backslides, putting them right back in the severe category, once again on the verge of death.
Here’s our solution. To address this divided approach, the IRC has developed and tested a combined, simplified malnutrition treatment protocol that will allow for the treatment of all children with acute malnutrition. This approach is revolutionary and would enable all children to be treated using a single program and one therapeutic product. Preliminary results from our randomized control trial demonstrate that a combined protocol is indeed safe and effective. Under a combined protocol approach, a child is assessed, and in the event of either severe or moderate malnutrition, is treated until full recovery with ready-to-use food, dosed according to the severity of the malnutrition.
This is a simpler, more effective approach.
Critically, a combined, simplified malnutrition protocol will allow global actors like UNICEF and the World Food Programme to work closely together on delivering care that will save costs, remove logistical barriers, ensure more people can access treatment, and most importantly, save more lives.
Luckily, the WHO already recognizes the importance of reducing duplication and inefficiencies in its work and we welcome the Global Action Plan’s reform efforts in the global community’s approach to health. We believe that the treatment of acute malnutrition must be placed at the heart of this reform agenda and should serve as a true litmus test of the resolve of global institutions to place health outcomes over bureaucratic turf wars.
The second problem is that the current model of care requires parents to take sick children to a health facility for treatment – an impossible task in many conflict environments. In fragile and conflict-affected countries in particular, large segments of the population have limited or no access to health facilities. Sometimes this is caused by a complete breakdown in the government-run health system as in Yemen, sometimes this is because health workers can’t get to the health facilities themselves, and sometimes this is because health facilities are directly targeted for attack as has happened to multiple IRC-run health facilities in Syria. All too frequently, conflict occurs in nations where health facilities are too few to begin with, exacerbating existing access issues. This is true particularly in sub-Saharan African nations affected by conflict, such as South Sudan.
So if you’re a mother in Kivu province in the DRC, and you have a child suffering from acute malnutrition, our current model asks them to trek to the nearest health facility – often hours away by foot through extremely dangerous territory – to get their children treatment. Even worse, there may be no health facility that’s possible to reach.
Compare this approach – bringing the patient to the treatment – to how the global community has so successfully used community health workers to treat diseases like pneumonia or malaria, or to provide immunization services, by bringing the treatment to the patient. In Ethiopia for example, the government has invested in a nation-wide community health worker program that places trained workers at health-posts across the country, which has helped the country reduce child mortality by two-thirds, meeting one of its key Millennium Development Goals three years ahead of schedule.
So the second step to fixing this problem is getting the treatment out of the health facilities and into the communities and homes of those who need it. The IRC has piloted a set of tools and training curriculum that will allow community health workers to treat children with acute malnutrition where they are. The tools and training curriculum enable low-literate community health workers to provide this treatment directly to people who need it – no highly trained doctors from the cities or foreign humanitarian workers needed.
Our tools are cheap, intuitive, and intentionally low-tech. Here is one tool – a simple colored band that measures upper arm circumference that anyone, even a layperson or someone who is illiterate, can use to accurately and consistently diagnose acute malnutrition. We’ve combined that with simple, non-numerical dosing scales that allow these community health workers to provide the required quantity.
Now I wouldn’t come before you today unless I knew this simple treatment worked. We launched a research study in a rural district in South Sudan – the country with the highest rate of acute malnutrition in the world – and found that community health workers were able to successfully treat over 90 percent of children with severe acute malnutrition using these two simple tools we have designed. These results far exceed the global standard for acute malnutrition treatment and were even better than treatment within health facilities.
The third and final problem is that there is a massive failure to properly invest in treating acute malnutrition, particularly in fragile and conflict contexts. Multilateral financing has played a major role in driving reduced child mortality over the past two decades. The Global Fund to Fight AIDS, TB, and Malaria, along with Gavi, the Vaccine Alliance, are among the specialized funds that have raised billions of dollars aiding the world’s poor in accessing health services. That sort of large, fit-for-purpose multilateral financing is a big part of the reason why child mortality from infectious diseases has declined so dramatically in stable contexts.
According to the World Bank, scaling up the treatment of severe acute malnutrition in low and middle income countries by 2025 requires an additional $9.1 billion dollars in new financing. This means if we want to meet international health goals for reducing acute malnutrition among children, we need to spend nearly a billion dollars per year more than we are currently spending – and that money is simply not going to be possible just through humanitarian budgets alone.
We need to approach this funding gap creatively, by leveraging funding from development donors as well as humanitarian aid; by scaling up private sector investment in responding to the acute malnutrition crisis; and by maximizing the impact of every dollar. We need current donors to expand their commitments to nutrition financing and we need foundations, private sector companies, and donor nations who are not currently investing in nutrition to expand into this critical area. We need multilateral organizations to expand their financing for fragile states’ health systems, including for treatment of acute malnutrition, and to apply the same market-driven financing approaches that resulted in lowered vaccine and drug prices to this critical challenge as well.
Meeting this challenge will require more investment, but by reducing duplication in the UN approach to treatment, creating simpler, cheaper tools for treatment, and deploying community health workers who can provide care at lower cost, we can actually reduce the average cost of treatment per child.
By giving this neglected health issue the attention and resources it deeply needs, the IRC believes the world can improve the health outcomes of the over 50 million children suffering from acute malnutrition every year and save the lives of nearly a million children over the next decade.
We can solve this problem, but the IRC can’t do it alone. We need your help. First, we need the political leaders and government officials in the room to have the commitment and courage to say that we will not leave fragile states behind. The SDGs must not be a rhetorical commitment, but instead must be a challenge to all of us to meet the need where it actually exists, and that increasingly means going into the heart of conflict zones where service delivery is the hardest.
Second, we need the international actors here today from the United Nations system, including UNICEF and the World Food Programme, to begin the process of adopting the combined protocol and the delivery mechanism through community health workers. Additionally, we need WHO leadership to support countries in the development of treatment guidelines. We urge UNICEF and the World Food Programme to publicly declare their support for a common approach for treatment of acute malnutrition using a single product and delivery mechanism.
We’ve seen great interest from each of these actors, but now interest needs to become action. We share a common goal, so let’s make sure we’re actually working together to achieve it. And best of all, it’ll make everyone’s job easier, cheaper, and more impactful.
Third, we need Ministries of Health in countries with high rates of acute malnutrition, particularly in the Sahel and Central and Eastern Africa, to support additional operational research on the combined protocol delivered through community health workers. Those of you in the room from Ministries of Health will be critical for this approach to eventually be adopted at scale.
Fourth, we need the donors and business leaders in this room to provide financing that is fit for purpose. Innovative thinking enabled the creation of multilateral funding institutions like Gavi and the results have been transformative for the health of people in low income countries who otherwise would not have access to life saving interventions. Donor governments and philanthropies have provided the backbone of financing that has enabled these institutions to deliver progress, and we need the same commitment and financing capacity to address this critical issue. We can build the tools, but focused, multisector financing will enable global health and humanitarian actors as a sector to actually treat all the children with malnutrition that need it. And of course, I encourage all of you to directly fund the IRC’s research and implementation.
If we can get these four things from you – political commitment to fragile states, a unified approach by the UN system, Ministry of Health commitment, and fit-for-purpose financing to address child malnutrition – we believe we can drive the next dramatic reductions in child mortality globally. We believe it is possible to go from just 10 percent of children treated for acute malnutrition to 90 percent, and in the process reduce acute malnutrition rates to under 5 percent, meeting the World Health Assembly target for acute malnutrition by 2025. And most importantly we believe we can save the lives of nearly a million children around the world over the next decade in addition to improving the health outcomes of 50 million children per year.
I’m not promising you it will be easy, but I am promising you it is possible to save these children. With one in thirteen children around the world living in a warzone, what other choice do we have but to fight for them?