The slowdown in eradicating hunger
by Richard Horton
Editor, The Lancet Health Journal
In 2015, the UN set the goal to eradicate hunger and malnutrition and to ensure nutritious food for all (Sustainable Development Goal 2) by 2030.
On July 18, the Food and Agriculture Organization (FAO) and UN partners published their annual report The State of Food Security and Nutrition in the World. Following the trend from the two previous reports, the results point to the unlikelihood of achieving this goal.
Previously, FAO used prevalence of undernourishment as the main indicator of hunger, with severe insecurity as a complementary indicator. Despite progress made in previous decades, since 2015 the prevalence of undernourishment has plateaued (at about 10·8% with highest prevalence in sub-Saharan Africa and Asia) and the estimated number of people with hunger has slightly increased (to 821·6 million from 811·7 million in 2017).
Meanwhile, obesity is rising worldwide. This year, the report added a new indicator—prevalence of moderate or severe food insecurity. Data from direct individual surveys show when people had to reduce the quantity or quality of food because of economic reasons (moderate insecurity) or had gone hungry (severe insecurity). The report estimated that 2 billion people do not have regular access to nutritious and sufficient food.
The report reflects on how economic slowdowns have contributed to an increase in hunger and malnutrition, showing that, between 2011 and 2017, 84% of countries (most in Africa and Asia) where undernourishment increased had an economic slowdown or downturn.
Greater income inequalities were also associated with an increased likelihood of severe food insecurity.
Although we welcome the monitoring of the food insecurity and nutrition problem, which is key to assess progress, monitoring on its own is not enough to address the situation. If the policies implemented are not effective, then we must call for stronger political commitment and international cooperation to solve the roots of the problem: poverty and inequality.
Global health''s indifference to poverty must end, by Richard Horton
Global health thrives on fashion. During the era of the Millennium Development Goals (MDGs, 2000–15), that fashion was poverty. The manifesto for the MDGs was the Commission on Macroeconomics and Health, chaired by Jeff Sachs and published in 2001. The Commission concluded that “The linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood.”
Sachs argued that the poor were more susceptible to disease and less likely to seek medical care, even when that care was urgently needed. Poverty lay at the root of all evils. Attacking poverty was the path to development progress.
The Commission proposed that defeating disease was central to eradicating extreme poverty. But although Sustainable Development Goal 1 reiterates the importance of ending poverty in all its forms everywhere, in health we no longer make poverty foundational to our concerns.
Fashions have changed. Now we are mobilised by universal health coverage, global health security, and a climate emergency. These issues are rightly important. Perhaps the fact that since 1990 over 1 billion people have been taken out of extreme poverty means that global health activists see poverty as old news. Yet beating poverty remains a prerequisite for flourishing and sustainable lives.
Disappointingly, global health and its leaders have judged poverty to be yesterday''s idea. This attitude of indifference, for that is what it is, is indefensible.
Earlier this month, UNDP and the Oxford Poverty and Human Development Initiative published new research showing that 1·3 billion people in 101 countries are “multidimensionally poor”.
Poverty in their Multidimensional Poverty Index means deprivations in standard of living (assets, housing, electricity, drinking water, sanitation, and cooking fuel), health (nutrition and child mortality), and education (years of schooling and school attendance). Their findings should shock us all.
Poverty is everywhere. Two-thirds of the poor live in middle-income countries. Children are more likely than adults to be poor and deprived across all indicators. Half of those multidimensionally poor are under 18 years of age and a third are under 10 years.
Within countries, there are great variations in poverty, ranging (in the case of Uganda''s provinces, for example) between 6% and 96%.
Within regions too—the incidence of poverty is 92% in South Sudan and 15% in Gabon. These findings have been given almost no serious attention by global health leaders.
In 2018, the World Bank published its view on trends in global poverty (Piecing Together the Poverty Puzzle). The Bank concluded that “the fight against extreme poverty is far from over”.
Extreme poverty is increasingly becoming the defining challenge of one region—sub-Saharan Africa, where the total numbers of poor people are rising, from 278 million in 1990 to 413 million in 2015. Of the world''s 28 poorest nations, 27 are in sub-Saharan Africa.
The Bank describes a “bifurcated world”, where one in four people in Africa live in extreme poverty. India is currently the nation with the highest number of poor people—176 million. But Nigeria will soon overtake India.
By 2030, the Bank predicts that as many as 87% of those living in extreme poverty will be living in sub-Saharan Africa, where there are especially troubling risks to confront—fragile and conflict-afflicted settings, droughts, and epidemics. The Bank calls for “transformational change”. But the difficult truth is that no-one is listening.
Poverty is not only a curse for the poorest nations in the world. There is endemic poverty in supposedly rich countries too. Persistent poverty affects one in five children up to age 14 years in the UK, poverty that is linked to worse physical and mental health.
And one must not forget that poverty in rich and poor nations alike is gendered. Women lose more life-years to poverty than men. Ending poverty must return as a political objective for global health.
Health professionals are uniquely placed to draw attention to the acute personal consequences of poverty. We can be powerful advocates for action. Poverty is not an economic state. It is an insidious disease of the human soul. Poverty consumes lives, eroding mental resources, diminishing cognitive capacities, and destroying life possibilities.
Universal health will never be achieved unless and until poverty is eradicated.
* Multidimensional Poverty Index: http://hdr.undp.org/en/2019-MPI
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Under-reporting poverty does not make it go away
by Sharan Burrow
Inter Press Service, agencies
The World Bank claims poverty is decreasing around the world but UN research shows it depends on what you measure. If we are serious about reducing poverty, we need to start by properly identifying it.
The World Bank has repeatedly claimed that extreme poverty is on the decline. In its Poverty and Shared Prosperity Report, it states that ’the world has made tremendous progress in reducing extreme poverty. The percentage of people living in extreme poverty globally fell to a new low of 10 percent in 2015 — the latest number available — down from 11 percent in 2013, reflecting continued but slowing progress. The number of people living on less than $1.90 a day fell during this period by 68 million to 736 million.’
What are we measuring?
The World Bank’s extreme poverty line of US$1.90 a day is in fact not based on real estimates of people’s cost of living within countries. This explains why it fails to capture the desperation experienced by so many.
As soon as we focus on people’s lived experience, the picture becomes more stark. At a most intuitive level, we know that poverty is determined by a person’s inability to meet their material needs. Perhaps the most basic of these needs is food. The UN’s 2018 figures on hunger show that it is on the rise globally. It estimates that 821 million people are currently going hungry. It is striking then that the World Bank considers millions of those living in hunger as living above its poverty line.
While the World Bank estimates that 400 million people live in extreme poverty in the Asia-Pacific Region, a 2018 report from the UN Economic and Social Commission for Asia-Pacific highlights that 520 million people in the region are undernourished, and 1.2 billion people lack access to basic sanitation.
The World Bank also estimates extreme poverty in Latin America, at 4.1%, to be low, and suggests it has been declining over the last years. Meanwhile, the UN Economic Commission for Latin America and the Caribbean’s (ECLAC) 2018 figures indicate that both poverty (29.6%) and extreme poverty (10.2%) have been increasing since 2012.
ECLAC defines its poverty and extreme poverty lines based on the costs of food and other essential goods and services. While the World Bank claims that extreme poverty has nearly been eradicated in the region, ECLAC figures show that nearly a third of people in Latin America are unable to cover the costs of basic goods and services, and one in 10 cannot even afford the basic costs of food.
So what is the World Bank’s poverty line based on? The US$1 a day indicator was set out in the World Bank’s 1990 World Development Report. While the ‘dollar a day marker’ was easily understandable to the public, it was primarily symbolic and not based on any estimate of the income people would need to live on.
The poverty line has since been updated according to inflation and changes to the consumer price index, and it currently stands at US$1.90 for the poorest countries. The Bank did develop additional poverty lines for lower-middle and upper-middle income countries, at US$3.20 and US$5.50 a day, largely to reflect higher prices in those countries.
The arbitrary nature of the Bank’s approach to poverty measurement has numerous critics and many have identified the need to move towards a basic needs approach. This would define the amount of money needed to cover food, housing, and other essential goods and services, including health and education.
It is estimated that if the Bank were to measure poverty on the basis of needs, international poverty rates would be considerably higher. The Bank has resisted such a call, arguing that the US$1.90 poverty line is valid and meaningful as it corresponds to the median of the national poverty lines of the world’s poorest countries.
What’s really happening is the World Bank validates its poverty line largely on that basis of other World Bank-developed national poverty lines, a flagrant case of partiality and circular logic. Research by Professor Sanjay Reddy showed only 9 of the 87 national poverty lines cited by the Bank have been derived independently.
The Atkinson Commission on Global Poverty, which was set up to advise the Bank on global poverty measurement, set out several recommendations to improve its poverty monitoring and measurement. It recommended that the World Bank partner with other agencies to construct a basic needs estimate of poverty. This is entirely feasible and some regional agencies are already successfully doing it. Nevertheless the Bank argued against it, putting the onus for adopting a more accurate approach on individual countries and preventing the development of internationally comparable estimates.
The Bank’s own Acting Director for Research Francisco Ferreira recently conceded, ‘there is significant room for arbitrary decision making’ in setting the World Bank’s international poverty estimates. He went on to argue that correcting against such arbitrary consequences is unfeasible as the Sustainable Development Goals’ (SDGs) poverty reduction target is based on World Bank poverty measures.
For an international institution to argue that an inaccurate measure should be maintained because the international community is using it, highlights a profound lack of ambition and responsibility taking.
The World Bank, and the greater international community, should not fear changing a measure that is not working. In fact, it is necessary in order to achieve the Bank’s stated goal of poverty reduction.
Under-reporting poverty does not make it go away. Rather, inaccurate indicators make it harder to identify the policies that truly address it, such as raising wages, reducing precarious work, extending social protection coverage and enhancing access to essential public services such as health and education.
It is high time the World Bank moves away from an arbitrary indicator towards one that captures the cost of living, based on the real needs of people.
* Sharan Burrow is General Secretary of the International Trade Union Confederation (ITUC)
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