News Flash 416: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 416

Weekly Snapshot of Public Health Challenges


International Debates: What Does the 2020 Seventy-third World Health Assembly Mean For Socio-economic Survival of Countries, Food Security, and International Cooperation in the COVID-19 Pandemic by Michael Ssemakula 

Q&A: Germany’s Björn Kümmel on WHO financing  

When the market becomes deadly – How pressures towards privatisation of health and long-term care put Europe on a poor footing for a pandemic.  NEW REPORT FROM CORPORATE EUROPE OBSERVATORY  

Coronavirus disease (COVID-19) Weekly Update 

COVID-19 Infection Provides Temporary Immunity, Though Not From Transmission, Says Study  

COVID’s led to ‘massive’ income and productivity losses, UN labour estimates show 

Q&A: COVID-19 a ‘pivot point’ for pharma policy 

The Contagion of Capital: Financialized Capitalism, COVID-19, and the Great Divide by John Bellamy Foster, R. Jamil Jonna and Brett Clark (Jan 01, 2021)

How President Joe Biden could use the Defense Production Act to increase vaccine production – Marketplace 

Clarification of Comirnaty dosage interval  

The European Commission says Covid-19 vaccines should be global public goods, but do their agreements with pharma reflect this? 

Vaccini. Il silenzio sulla licenza obbligatoria 

GAVI seeks political support for COVAX as rich nations strike fresh vaccine deals 

GSK, PATH, Bharat Biotech sign pact for malaria vaccine 

Ending NTDs: together towards 2030 

WHO 2030 NTDs Roadmap: how science and partnerships can support the fight to end neglected diseases 

Overcoming neglect: Finding ways to manage and control NTDs 

WHO highlights progress in accelerating access to hepatitis C diagnostics and treatment in low- and middle-income countries 

Important Advances in HIV Prevention Unveiled: New PrEP Formulas & Broadly Neutralizing Antibodies 

Messages for World Leprosy Day 2021 

MPP welcomes findings of 2021 Access to Medicine Index: more pharmaceutical companies include access plans for LMICs 

Newly Launched: 2021- Year of Equitable Research Partnerships by Daniele Dionisio

OXFAM report: The Inequality Virus. Bringing together a world torn apart by coronavirus through a fair, just and sustainable economy 

Billionaire wealth soars as 255 million of world’s jobs lost in pandemic  

The Struggle to End Female Genital Mutilation: A Dark Secret No More 

Donors back tech over aid to feed hungry world 

Locust invasion spawns new food threat 

Inland Transit Applications: Improved Welfare at Affordable Prices or Increased Traffic and Air Pollution – Case of Iran by DJavad Ghoddoosi-Nejad

Climate change: Biggest global poll supports ‘global emergency’  

EU food safety agency presents plan for integrated risk assessments for pollinators  

Kerry: US will make up for 4 years of lost action on climate 

Biden signs orders to curb climate change, announces April climate summit 

Helping poorest tackle climate crisis will boost global growth, says IMF head 





Inland Transit Applications: Improved Welfare at Affordable Prices or Increased Traffic and Air Pollution – Case of Iran

How to counter air pollution from motorized inland transportation in Iran? Some reflections in the Letter here

By DJavad Ghoddoosi-Nejad

 Assistant Professor in Health Services Management

Birjand University of Medical Sciences – BUMS, Iran

co-authored by Dr Ali Naghizadeh and Dr Morteza Arab Zozani

Inland Transit Applications: Improved Welfare at Affordable Prices or Increased Traffic and Air Pollution

Case of Iran


Dear Editor,

One of Today’s modern society features is using benefits of social mass-media and Internet-based businesses and mobile applications, especially mobile apps for ease of inland transportation (1).

While people’s welfare has improved because of affordable private taxies, in terms of high traffic of single-headed cars or cars with two passengers -including driver- and an increased demand for such services, this issue can be considered in some ways (2).

From air pollution point of view, traffic of private taxies has increased inside big cities and this issue can be a threat for air pollution, especially in cold seasons and air inversion (3). Although because of nature of these apps, return trips to base- of traditional car agencies- have eliminated (4), but still increased demand for such services which has expanded to food deliveries and motorcycles that play more important role in air pollution can be a threat for air pollution in megacities (2,3).

Thus in Iran cars which register for Snapp and such organization are old and out of date, they pollute the air more than up-to-date cars, so using fuel efficient cars, including electric vehicles (5) or using shared services – renting a car by several passengers who share a same destination fully or partially- can be an appropriate solution for decreasing air pollution in order to optimize people’s welfare and minimize effect of this service on air pollution.

Also developing electronic services for banking (6) and public services (7) can eliminate unnecessary traffic and decrease demand of people for attending at facilities like banks or public organizations. In this regards the attention of relevant authorities and the development of intersectional cooperation for the management and control of air pollution is essential.



  • Cherry MA. Are Uber and Transportation Network Companies the Future of Transportation (Law) and Employment (Law). Tex. A&M L. Rev.. 2016;4:173.
  • Kitchel AS. The Uber Effect: How Transportation Networking Companies Impact Automotive Fuel Consumption.
  • Simon Wang SY, Hipps LE, Chung OY, Gillies RR, Martin R. Long-Term Winter Inversion Properties in a Mountain Valley of the Western United States and Implications on Air Quality. Journal of Applied Meteorology and Climatology. 2015 Dec;54(12):2339-52.
  • Chow VT, Sung KW, Meng HM, Wong KH, Leung GK, Kuo YH, Tsoi KK. Utilizing Real-Time Travel Information, Mobile Applications and Wearable Devices for Smart Public Transportation. InCloud Computing and Big Data (CCBD), 2016 7th International Conference on 2016 Nov 16 (pp. 138-144). IEEE.
  • Nikolaeva A, Adey P, Cresswell T, Lee JY, Novoa A, Temenos C. A new politics of mobility: Commoning movement, meaning and practice in Amsterdam and Santiago.
  • Mattila M, Hanin A. The real value of electronic banking. InProceedings of the 2000 Academy of Marketing Science (AMS) Annual Conference 2015 (pp. 398-402). Springer, Cham.
  • Moreira AC, Zimmermann RA. Electronic government: Challenges for public services consumer behaviour and value creation. InHandbook of research on managing and influencing consumer behavior 2015 (pp. 211-236). IGI Global.

Newly Launched: 2021- Year of Equitable Research Partnerships

2021-Year of Equitable Research Partnerships is being featured here as a newly launched campaign by the Research Fairness Initiative partner organization, with the ultimate aim to help reverse persistant evidence that within scientific collaboration between high and low-middle income countries there are issues of power imbalance and inequitable sharing of benefits and resources

by  Daniele Dionisio

PEAH – Policies for Equitable Access to Health

Newly Launched

2021- Year of Equitable Research Partnerships


PEAH is proud to stand in support of 2021-Year of Equitable Research Partnerships as a new project promoted and carried out by the Research Fairness Initiative – RFI partner organization.  As such, PEAH aligns with what highlighted by Kirsty Kaiser, Implementation Manager, RFI South Africa:

“International collaboration in science and education is essential to international development and, as we have seen since the start of the COVD-19 pandemic, the key to finding solutions to globally relevant issues. Unfortunately, there is still evidence that within scientific collaboration between high and low-middle income countries there are issues of power imbalance and inequitable sharing of benefits and resources, despite the many calls for more equitable practices to become the norm. Most notably, a key example of one of these issues is related to vaccine access and the impact of COVID-19 on under-developed health systems within LMICs.

We have decided to promote 2021 as the Year of Equitable Research Partnerships – in line with our  Research Fairness Initiative – which has to date been adopted by 11 research stakeholders across the globe and is gaining traction as a key tool for improving the equitability of research partnerships for funders, organisations and institutions who are taking part in scientific collaboration. In addition to our own work, we are aware of a number of other organisations who are working in this important area and have created a webpage where we list some of the key tools and guidelines we know of that are being used in the work towards more fair research partnerships” .


While taking momentum triggered by this project into most account, PEAH calls on its readership and partners to back the campaign and publish the information on their websites and in newsletters - given the relevance of this issue in the broader context of COVID-19, and research in general. We feel that the scope and aims of the project could benefit from increased visibility and are doing our best to disseminate as widely as possible. 

International Debates: What Does the 2020 Seventy-third World Health Assembly Mean For Socio-economic Survival of Countries, Food Security, and International Cooperation in the COVID-19 Pandemic

The Corona Virus outbreak has underpinned unprecedented economic instability and global food supply disruptions – essentially in Africa. This has put global cooperation (aid, partnerships and concession finance) on test after the economic downturn in the world economy performance. This article provides a discourse on damaging interruptions caused by the pandemic on socio-economic survival of countries and food security. It further demystifies the gaps therein interventions (in line with IHR core principles) presented by WHO member states and UN agencies at seventy-third World Health Assembly – which PHM closely followed through its WHO Watch program

By Michael Ssemakula

Alliance of Women Advocating for Change (AWAC) & People’s Health Movement (PHM)

International Debates: What Does the 2020 Seventy-third World Health Assembly Mean For Socio-economic Survival of Countries, Food Security, and International Cooperation in the COVID-19 Pandemic


COVID-19 novel virus globally was an exceptional disruption –across the world. No government knew the burden the pandemic would have on the humanity, food security and the economic system infrastructure across the continents. The diverse strategic economic emergency and recovery plans have been forthrightly fronted on mechanisms through which governments and region blocs can contain and mitigate the severely damaging impact of the pandemic on their economies –after the dramatic dynamics the pandemic has posed to their economies, and healthcare systems. The potential impact of COVID-19 to local and global food systems (their capability to provide safe, affordable, nutritious food and sufficient incomes for people working in food and agriculture sectors) and broad spectrum of the economies is unimaginable. This acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally at an exponential rate. Worldwide, more than 96,727,446 million cases have been reported, 25,233,609 million of these, are active cases of the disease, over 2,068,303 million are deaths –as per the statistics of Worldometer website of the 2nd day of January 2021. However, there is still a concern of why there are still so few COVID-19 cases reported in Africa compared to other WHO regions. This question largely remained unanswered in the previous virtual held World Health Assembly. The People’s Health Movement for several years has implemented a ‘WHO watch programme’ to follow and provide information, analysis and critical commentary for people on the global health debates taking place at the World Health Organisation (WHO).

In its Global Health Watch activities, PHM follows range of WHO engagements, including the World Health Assembly (WHA) and the WHO Executive Board (EB) and at regional level in the WHO Regional Committees, such as the one for the AFRO region. The analysis that PHM does sightsees how far these international processes and resolutions respond to the local, regional and global contexts and priorities and how far member states and other relevant stakeholders implement, comply with and are publicly accountable for the resolutions made to deliver on the national and global health goals.

Information transparency: where the world fell off the International Health Regulation core principles?

Transparency in information flow is fundamentally among the imperative points of emphasis that can’t be overlooked. Many countries are still silent about accountability on how they’re controlling the crisis –essentially their transparency regarding information (data to prevent spread of infodemics in communities, and for effective control of the virus), respect of human rights law in regards to the lockdowns and  compliance with International Health Regulation (2005) on achieving international public health security. Through a letter from Trump’s Administration, United States made a pronouncement during the recent concluded WHA73 against the approach WHO handled the COVID-19 crisis. The letter cited how WHO was soundless and a playbook on China’s act of undermining the IHR by not sharing accurate and timely data, samples, isolates and withholding vital information about the virus and their origins through censoring its media and denying international access to its scientists and facilities –which also prompted several member states in WHA73 to call for an impartial, independent and comprehensive review on how WHO managed the crisis through the COVID-19 Response resolution.  From our close watch of the WHA73, this is inadequate, globally there should be a standard review for all countries’ response to the pandemic basing on the principles of International Health Regulation (2005), International Human Rights Principles and Charter of the United Nations, there is so much information gap concerning the coronavirus transmissions and its mortalities especially in Africa and countries with autocratic regimes that may keep this information away from the public domain.

Effective Economic recovery plans and food security: How the interventions to address the two issues remained a wishful thinking at the Assembly?

At the WHA73 WHO watch, we critically observed that the interventions that country governments and institutions are using in response to coronavirus may possess both positive and detrimental negative consequences on economies’ performance, food security, nutrition, food systems policies and welfare inequality more broadly. Without satisfactory coordinated policy responses, equitable and gender-responsive plans and resources, countries may find it challenging in this highly liberalized and globalized world to enhance an egalitarian redemption for all income clusters in their society, as whereas recovering faster as planned. The new international economic order desired during the 1978 Alma-Ata declaration (to promote health for all) did not only aim to address inequalities between groups within nations and between nations of back-in-day but also envisioned the implications that would rise from one-sided policies and interventions that would detrimentally affect people’s welfare and underpin inequality. This is what countries are prospectively likely to face during the COVID-19 economic emergency response plans and credits that may benefit disproportionately the populations within nations and among nations.

In the 73rd World Health Assembly, WHO member States, cited that, the unprecedented disruptions connected to the pandemic and the various responses to this pandemic had adversely affected their countries and marginalized groups –especially those from poor contexts with less power and resources to adapt to volatile crisis events. Not only vulnerable populations and communities have had difficulty in accessing adequate food for survival and adequate nutrition, but many also depend upon the food-system’s stability for their living as source of their income like farmers and agricultural products traders in sub-Saharan Africa and Asian continent. Shocks to the food supply chain have disrupted flow of production and trade, which can have volatile market effects and implications on both food prices and agro-food-based incomes due to the fluctuations in the elasticities of demand and supply for Agricultural sector products and foods. The World Food Program envisages, 265 million people in low and middle-income countries will be in acute food insecurity by the end of 2020 if an action is not taken. The majority of the African countries have inadequate mechanisms to launch substantial stimulus packages as an intervention applied in rich countries such as Canada, US, Germany and UK, which have all launched stimulus grants amounting to more than $5trillion, low-income African nations look to donors largely to multilateral and bilateral agencies for help.

The Coronavirus pandemic now, is not just a disease but also economic devastating challenge ruining the global food security and world economy phenomenally in developing economies. Some populations have little or some no assistance from their governments to cope up with the damaging impact of the virus on their economic wellbeing. Awkwardly food security wasn’t among points of focus in WHA73, only Venezuela and Paraguay that citied out food security concerns and gave a mention of how their populations found it challenging to continue farm production activities. Globally, many people are struggling to cater and feed their families due to the shutdown of the countries which is underpinning a fall in the economic, agricultural activities and welfare standards. This is limiting people’s ability to access nutritious foods in different ways, including through reduced income and increased job insecurity as countries have imposed lockdowns to stop importation and further community transmission of Coronavirus cases. Countries are yet to design sound food security and agricultural policies, emergency food reliefs and contingency plans (in line with the resolutions WHA53.15 and WHA63.3 on advancing food safety initiatives) which are vital for safety and availability of nutritious foods to prevent impending global food insecurity and shocks in the food supply chains.

Economies’ survival in lockdowns, concessional finance and global cooperation

At the World Health Assembly 73, member states gave account of different interventions including the nationwide lockdowns which were applied as a mechanism to curb community transmission of the virus. Implications of the lockdowns on the world’s developing economies seem have tremendously started biting characterized by massive job layoffs, fall in (investment confidence, investment multipliers, export and savings multipliers), consumption affordability and National income or gross domestic product multipliers. The IMF predicts that the sub-Saharan Africa’s economy will shrink by 1.6%, and the real per capita income falling by 3.9% the lowest since 1970.  It is estimated that the COVID-19 related disruptions will lower sub-Saharan Africa’s GDP growth in 2020 to between 1.5 percent and 2.5 percent, down from the projected 3.6 percent pre-COVID-19 projections. Under a scenario where African governments quickly take the appropriate steps to contain the spread of the virus and global conditions stabilize, the regional GDP growth will decline by around 1 percentage point, to 2.5 percent .

Evidence is emerging on the substantial impact and social-economic damage of lockdowns for countries across continents, predominantly for the most deprived households, the large number of workers in informal sector employment, the smaller scale business initiatives with short of cash savings, low economies of scale, high debt outflows and widening inequality. In Zimbabwe, for instance, an analysis in April found out 34% of companies with zero production, and 52% operating at 30-60% of pre-lockdown capacity levels, with revenue losses of between 45% and 100%. Countries like Mauritius have lost 5% of their GDP growth due to the border closures. 70million jobs in the aviation industry are likely to be lost as many companies have grounded their planes. Countries in East Africa may lose up 4 billion USDs in their exports to countries like China.

The enormous challenge posed to developing countries, is how far can they sustain the lockdowns, where is the praxis and tradeoff between the health protection agenda and economy redemption in medium term? Many countries are struggling to make tight decisions –to or not to lift their lockdown restrictions as they move into the “new normal” of physical distancing in diverse life spheres. In many African countries, nationwide partial/full lockdowns have now been stretched and have continued a month or beyond. Their impact raise queries on their sustainability.

With countries stumbling about their economies’ survival many have resorted to borrowing and seeking assistance through international cooperation (rich countries, multilateral and bilateral agencies, region blocs (through Official Development Assistance) and philanthropic foundations)). At the opening of this year’s World Health Assembly, the UN secretary general –Antonio Guterres called for;

“….increase the resources available to support developing countries. Calls for WB, IMF and International Financial Institutions’ assistance in dealing with COVID-19.  We must be able to create more inclusive and more egalitarian economies and stronger society

This is an enabler to allow member states progressively put into effect their interventions to contain and avert the economic impact of COVID-19 –and allow a scaled up health spending (in health workforce, sensitization, medical supplies (through ACT accelerator that aim to increase availability of diagnostics, therapeutics and vaccines to increase testing, detecting, and treating of Corona virus patients)) and investment into economic emergency and recovery plans such as stimulus grants for private sector, unemployment benefits and relaxed monetary and fiscal measures (like reduction in taxes).

The pandemic has established a change in the development, health and humanitarian cooperation paradigm –from the old and orthodox tradition development economics model (that –aid should be from self-proclaimed “developed” countries to developing/emerging economies) to now a new model of global public investment to promote global public goods for health –thus remodeling the terrain of global cooperation. The statements made by member states at the WHA73 demonstrated how countries were working in unison to address the pandemic through the “principle of solidarity and spirit of unity” –ie European commission highlighted in its statement during the Assembly that it had raised USD 8 billion to support vaccine development which will be  universal to all not a luxury to few but a universal good. In the recent past, on 13th March China sent a plane load of experts and medical supplies to Italy, including masks and respirators. Italy is among the richest countries (with average income, US$34,480); despite rapid advance over the past decades, China is still much poorer (average income, US$9,770).

From the member states’ submissions at WHA73 which were virtually presented, it’s unfortunate that several countries, essentially from the developing contexts, have not established yet the disease underlying dynamics of COVID-19 and the potential implications of the multiple policy decisions, programs and economic recovery plans. Many governments have negotiated and some received the emergency credit from the International Monitory Fund (IMF) Rapid Credit Facility to support their Balance of Payment, Central Banks, health spending (through Covid-19 response), social protection, National Development Banks and private sector interventions, without evidence, clear strategies and plans to inform any economic recovery response. This will not only escalate the developing countries’ and emerging economies’ public debts, but the entire global debt will shot up. The enormous pile of the global debt may grow unabated: last trimester of 2019, it reached 253 trillion dollars and today amounts to 322% of the planet’s GDP. This affects more the developing countries as more of them allocate a big proportion of their financial year budgets to servicing their public debts

Credit finance and public debts vs continuous public health provision

The IMF is one of the institutions moving swiftly to provide comprehensive funding to its member countries, by leveraging $1 trillion lending capacity through Rapid Credit Facility (RCF); for example, IMF Executive Board Approved  US$491.5 million and US$ 739 Million Disbursement to Uganda and Kenya respectively to address the COVID-19 Pandemic (for Balance of Payment and Budget Support). Further extended rapid debt service relief to help 25 poorest and most vulnerable countries, 19 of which are in Africa through the Catastrophe Containment and Relief Trust (CCRF). This provided grants to the poorest and most vulnerable members to cover their IMF debt obligations for an initial phase over the next six months and will help them channel more of their scarce financial resources towards vital COVID-19 emergency medical and other relief efforts.

This is a phenomenal intervention for economies’ restoration essentially from the loaming global/country level economic recessions, but we are strongly concerned about the severity of the deepening national debts that the Rapid Credit Facility may cause to countries across continents especially from developing contexts –which was not talked about by the IMF and World Bank or delegates representing WHO regions during the WHA73. The escalation of the public debts of economically struggling and highly indebted countries may equally pose disastrous implications such as inequality in access to the crucial services of the social sectors of the countries like health –as governments may divert resources to paying debts than investing into human health and leave this to the private sector, (PHM notes in the People’s charter for Health that inequality is one of the root causes of ill-health and deaths of poor and marginalized people). We are extremely worried that this may be a conduit to a fall in the welfare of the poorest populations thus underpinning poor health outcomes on the set of global health goals, human security and Universal Health Coverage. There should be a transparent and accountability mechanism made by member state governments on the impact of these credit emergency funds to the public, country finance authorities, IMF and WB (as the funds disbursement bodies). Member states should further be guided on how to use the emergency COVID-19 funding as an essential tandem to enable needed assistance reach the most vulnerable people –but also avert misuse and escalation of public debts and their associated implications on the countries’ future social sector budgets. As noted in the EU proposal in OP1 “Calls for intensified international cooperation and solidarity to collectively contain, mitigate and defeat the COVID-19 pandemic, including coordinated mobilization and use of financial resources”, the distortion of the country level (both current and future) welfare and programmes should be averted even through this emergency assistance and credits offered through international cooperation –this should also aim at assisting countries to establish IHR core capacities. IHR core capacities are intrinsically tied to health system strengthening and explicitly should be recognized as global public health goods.


News Flash 415: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 415

Weekly Snapshot of Public Health Challenges


Defending and Reclaiming WHO’s Capacity to Fulfil its Mandate: Suggestions from a Perspective of Language and Power by Judith Richter 

2021: a new year for the WHO 

Webinar registration ‘The Great Take Over: How we fight the Davos capture of global governance’ Jan 26, 2021 04:00 PM in Amsterdam 

Prince Mahidol Award Conference 29 JANUARY – 3 FEBRUARY 2021 (VIRTUAL CONFERENCE) 

Towards a new structural approach to pharmaceutical innovation, intellectual property and public health: If not now, when?  

MPP and the Joint Research Centre of the European Commission partner in the field of intellectual property for COVID-19 and beyond 

New US Chief Medical Advisor Anthony Fauci: Restores Relations With WHO & Reverses Global Health Course 

EB 148: WHO’s COVID-19 Technology Access Pool (C-TAP) comes under scrutiny 

MSF Statement on EB148/8 – Global strategy and plan of action on public health, innovation and intellectual property (GSPOA)  

MSF Statement on EB148/6 – Non communicable diseases 

MSF Statement on EB148/6 – Oral health and noma disease 

Italian regulator AIFA urged to take action over 577 missing clinical trial results 

 COVID-19 and the Plague Cycle 

Coronavirus disease (COVID-19) Weekly Update 

New Year, New Lockdown in the United Kingdom: ‘The Great Deception’ by Ted Schrecker

Virus Mapping, Pandemics Preparedness and One Health: We Need Them All

Lacking Resources & Authority, WHO Was Too Slow To Act Against COVID-19 – Says Independent Review Panel 

Civil society letter to pharmaceutical corporations making COVID-19 vaccines 

Tedros calls out ‘me-first’ approach to COVID-19 vaccines: ‘This is wrong’ 

WHO Director General Rebukes Countries For Vaccine Hoarding At Opening Of WHO Executive Board – A Look At What Else Is In Store 

Covid19 Vaccine Governance: Sidelining Multilateralism  

COVID-19 Vaccines: How and When Will Lower-Income Countries Get Access?  

Global regulators highlight key role of healthcare professionals in fostering confidence in COVID-19 vaccines 

Interim Results of a Phase 1–2a Trial of Ad26.COV2.S Covid-19 Vaccine 

La campagna vaccinale  

Health Research and Development Investment in Kenya 

Nourishing India – What Needs to Be Done by Veena S Rao 

Landlocked Lesotho faces food crisis amid Covid border closures 

Human Rights Reader 560 

UN: World facing ‘catastrophic’ temperature rise this century 

Don’t Trade Off Climate Mitigation and Development 

Shift to renewables ‘significantly decreased’ emissions, EU agency says 








Nourishing India – What Needs To Be Done

This paper attempts to explain the dimensions of India’s chronic malnutrition which continues to afflict infants, children, adolescents and adults, and why it is not decreasing faster. It goes into its historic and generational causes, which have made it evolve into a very multi-causal and complex affliction, the causes of which can broadly be categorized as India’s triple deficit, namely, the dietary deficit, the information deficit and the market deficit. The paper explains each of these deficits and their impact on the nutrition/health status of various age groups, and makes a case that India’s chronic undernutrition and micronutrient deficiency can be reduced with much greater speed and sustainability if the triple deficit is addressed through new and innovative interventions

By Veena S Rao

Retired Secretary to Govt of India

Advisor, Karnataka Comprehensive Nutrition Mission

"Views are personal"

Nourishing India – What Needs To Be Done


India has become quite accustomed to being labelled as home to the largest number of malnourished children in the world, or home to the largest number of undernourished persons in the world. Year after year, leading annual publications appear with the same stark statistics. Very little formal comment comes from government, but there do appear very concerned scientific and social commentaries upon the poor health and nutritional status of a large percentage of our people, urging the government for strong action. However, soon, this critical, complex and elusive subject which forms the foundation of our human capital becomes overshadowed by another priority.It is now over a month since the National Family Health Survey 5 (NFHS 5) first phase was published covering 17 States and five UTs.[i] There are ups and downs – infant and child mortality rates, including perinatal and neo natal mortality rates showed substantial improvement, but nutrition indicators and anemia, especially among children and women have deteriorated. Stunting among children below 5 years has indeed increased drastically in several States, including the more progressive ones, such as, Kerala and Goa and in some of the traditionally better nourished North East States, particularly Meghalaya, Nagaland and Tripura. But Manipur and Sikkim have shown a dramatic decline from 28.9% to 23.4% in Manipur and 29.6% to 22.3% in Sikkim. Even Bihar, a difficult State, has shown remarkable improvement in reducing stunting from 48.3% to 42.9% (with rural data better than the urban data) and Assam too has shown slight improvement. In most other States, except for Telangana, where stunting has increased from 28% to 33.10%, the position appears to be more or less static, with a one percent change this way or that.

The percentage of wasted children in most States has also gone up, the highest increase coming from Ladakh from 9.3% to 17.3%, followed by Nagaland from 11.3% to 19.10%, and Jammu & Kashmir from 12.2% to 19%. Both Bihar and Assam see an increase in wasted children, from 20.8% to 22.9% and 17% to 21.7% respectively. Karnataka has shown remarkable improvement bringing the percentage down from 26.10% to 19.5%.

As far as under-weight is concerned, except for improvement in Karnataka, Meghalaya and Sikkim, in other States the percentages have either have either increased or plateaued.

Again, there has been no comment or response from government or any policy making authority, though several articles by eminent public health/policy experts in both mainstream and social media have appeared expressing deep concern. There will, in all probability be further deterioration in nutrition indicators following the COVID 19 pandemic, in the next phase of NFHS 5 which is currently going on, primarily on account of loss of livelihoods, reduced food consumption among the poor, and dislocation of government nutrition programmes.[ii]

For how long have high levels of malnutrition afflicted India’s population? Let me begin by quoting from the concluding paragraph of Chapter 1 of ‘A brief Survey of the State of the Public Health’ – India’s first comprehensive report on nutrition and health – the ‘Report of the Health Survey and Development Committee’, 1946, headed by Sir Joseph Bhore.[iii]

“To sum up, the factors responsible for the low level of ill-health in India include, among others, the prevalence of malnutrition and undernutrition among appreciable sections of the people, the serious inadequacy of existing provision for affording health protection to the community and a group of social causes consisting of poverty and unemployment, illiteracy and ignorance of the hygienic mode of life and certain customs such as early marriage. The cumulative effect of these factors is seen in the incidence of a large amount of preventable morbidity and mortality in the community. The continued prevalence of such conditions for many generations has probably helped to create in the minds of the people an attitude of passive acceptance of the existing state of affairs. This attitude will have to be overcome and their active cooperation enlisted in the campaign against disease, insanitation and undesirable personal and community habits, if any lasting improvement in the public health is to be achieved.”

The author would like to emphasise that these factors continue to persist in India even today, though in lesser degree, particularly the attitude of passive acceptance of an affliction, which they do not understand why they have.

It is also important to revisit the findings of the food surveys conducted between the years 1935 to 1948. These are adequately quoted and form the basis of the recommendations of the First Five Year Plan, (1951-1956), regarding nutrition in Chapter 32, Paras 25 and 26. [iv]

Para 25 reads as follows: “The average diet of an Indian is lopsided primarily because of its extremely high cereal content. The other noticeable feature is that the diet lacks in adequate amounts of protective foods leading to inadequacy and very often to total lack of proteins of good quality. Inadequacy of minerals and most of the important vitamins in more or less varying degrees is the other important feature. It has not been sufficiently realized that the inadequacy of B group of vitamins is of the most serious import in view of the large intake of carbohydrates. Intake of vitamins A and C also is often inadequate”. These surveys have led to the following observations: “It appears that two-thirds of the families did not consume any fruits and nuts at all. About one-third of the families did not consume sugar and jaggery, meat, fish or flesh foods, and a quarter of the family groups did not consume milk and milk products or leafy vegetables. Again, amongst the groups of families consuming particular foodstuffs the intake of leafy vegetables, other vegetables, ghee and vegetable oil and pulses was below the desired or recommended level. Only in about one-fifth of the groups of families surveyed was the intake of pulses and other vegetables up to the recommended level. Though any generalisation on the data presented is not desirable for reasons more than one, yet it may be stated that in about four-fifths of the families surveyed the intake of protective foods was either nil or below standard.

Para 26. “The bulk of the population cannot afford to purchase a satisfactory diet. In terms of average income it would hardly be possible for more than 30 per cent of the population to feed themselves on an adequate scale” (First Five Year Plan, 1951-56 Chapter 32).

The reports and data referred to above clearly establish that India has a long, generational history of chronic malnutrition. Undernutrition and micronutrient deficiency which even today afflict around fifty of our population, is not something that was suddenly acquired because of successive natural calamities, food shortages or war. Clearly, it is one of the outcomes of sustained socio-economic deterioration caused by the increasing poverty in the 19th and 20th centuries under colonial rule, brought about by changed occupations and agricultural patterns enforced by colonialism, and surging illiteracy resulting from depriving the existing and flourishing indigenous system of education of patronage and funds. Reduced incomes, poverty, compounded by rapidly growing illiteracy, poor health care, and lack of opportunity for upward economic or social mobility, created the most fertile environment for chronic malnutrition and micronutrient deficiency among the general population of India, the remnants of which persist even today.

In 1947, independent India was born with a meagre per capita income of Rs 249.6, a literacy rate of 18.33% (with female literacy at 8.86%)[v] male and female life expectancy at 26.91 and 26.56 years respectively, a death rate of 22.8 per 1000, infant mortality rate of 158 per 1000, and maternal mortality at 20 per 1000 live births, with only one third of the population having the income to feed themselves adequately.[vi]

With this background, India’s malnutrition in today’s context, (which refers here to calorie-protein- micronutrient deficiency only) has evolved as an extremely complex biological condition with multiple and heterogeneous causes, multiple manifestations, and an inter-sectoral, inter-generational character. It is the hidden layer of ill-health, poor physical and cognitive growth which leads to poor learning skills in children, and eventually to lesser income earning capacity in adults, and perpetuation of the poverty cycle. 

Poverty is a prominent, but not the sole cause of malnutrition. While all malnourished people may not necessarily be poor, people who are poor would generally be malnourished. The fact that the percentage of people suffering from undernutrition and micronutrient deficiency exceeds the percentage of people below the poverty line clearly establishes that undernutrition has multiple other causes.

These can be clubbed as follows:

Physical Causes– such as, poverty, hunger, under-nutrition, calorie-protein-micronutrient deficit in daily diet, infection and disease.

Historic and Socio-economic Causes- such as, generational poverty and low income caused by illiteracy/low literacy and lack of skills; gender discrimination which became embedded in social custom, and lack of information and awareness. 

Behavioural and Socio-cultural – arising out of poverty, gender discrimination, lack of information and awareness and superstition, leading to low status of women; lesser food and health care for the girl child within families; early marriage of girls, early/frequent pregnancies, inadequate weight gain during pregnancy; delayed complementary feeding to infants – in short, negative child care and feeding practices, ignorance and neglect of adolescent and maternal care, lack of knowledge regarding the best balanced diets within scarce family budgets, all cumulatively resulting in the inter-generational cycle of malnutrition.

Governance related Causes – such as, lack of intensive grassroots Information Education and Communication (IEC) programmes which provide families and communities information and awareness regarding the importance of balanced diets within their purchasing power, regarding proper child, adolescent and maternal care; inadequate nutrition/ health interventions and poor coverage at grassroots level for women, adolescents and children, especially in chronic malnutrition areas; coverage gaps in safe drinking water and sanitation programmes; lack of real time, action based nutrition monitoring and surveillance; and lack of accountability of programme managers regarding persisting poor nutritional indicators among communities. (There is not merely a lack of clarity, but even lack of demand for accountability as to who exactly in the governmental system, should be held accountable for the continuing high rates of malnutrition in India, particularly increased wasting among children, as reported in National Family Health Survey 4 (NFHS 4) 2015-2016.

Critical interventions to address these heterogeneous, root causes at the programmatic level can be clubbed as follows: [vii]

  • Specifically targeting the inter-generational cycle of malnutrition by simultaneous addressing the nutritional needs of infants, children, adolescent girls and pregnant and nursing mothers.
  • Bridging the calorie-protein micronutrient deficit in the daily diets among the inter-generational target groups by providing appropriate energy dense fortified supplementation for consumption.
  • Bridging the Information Gap through a sustained, multi-layered general public awareness campaign, most importantly through interpersonal communication to reach the general public, especially in households, regarding proper nutritional practices within existing family budgets, and proper child, adolescent and maternal care, and for creating demand for on-going government programmes.
  • Accelerating, integrating and tightly monitoring multi-sectoral ongoing programmes that have impact on malnutrition, such as, Immunization and Vitamin A Supplementation, Anaemia Control, Water and Sanitation, etc. and achieving convergence between the ongoing programmes so that they operate simultaneously, and filling programmatic gaps. Involvement of the community, Non-Governmental Organizations (NGOs), women’s self-help groups (SHGs – village organizations for women) and village panchayats (elected village councils) for intensifying demand creation and increasing programme coverage.
  • Real time monitoring of the beneficiaries’ nutrition indicators, particularly regarding underweight, stunting and wasting of children, body mass index of adolescent girls, pregnancy weight gain, and incidence of low birth weight babies

India’s malnutrition and the Triple Deficit

The author believes that India’s chronic undernutrition and micronutrient deficiency is perpetuated by three deficits – the dietary deficit, the information deficit and the market deficit.

Dietary deficit, that is, the protein-calorie-micronutrient gap which exists in the daily diets of at least fifty percent of the people, is the most proximate and direct root cause of chronic under nutrition in India.

India is proud of its demographic dividend that 67.3% of its population is between 15-59 years of age, and that this demographic advantage of having a young working population will persist for at least another three decades.[viii] This factor is emphasized at most social and economic fora, and is seen as India’s comparative advantage vis a vis several other industrialized countries.

However, a critical factor which has not yet been stated or acknowledged in contemporary public policy debate or in nutrition/health focused debate is that the potential of at least fifty percent of our demographic dividend to access the best opportunities to rise above poverty and contribute to the economic growth is severely handicapped on account of under-nutrition, poor health and morbidity, because of generational and routine dietary deficit within their daily diets.

What exactly is Dietary Deficit, and what impact does it have on the lives of children, women, adolescents and adults?

According to the FAO publication ‘Undernourishment around the world, Depth of hunger: how hungry are the hungry?[ix], the depth of hunger, or food deficit, is measured by comparing the average amount of dietary energy that undernourished people get from the foods they eat with the minimum amount of dietary energy they need to maintain body weight and undertake light activity. The greater the deficit, the greater the susceptibility to nutrition-related health risks. A weak, sickly person cannot fulfil his or her individual potential. A nation of weak, sickly people cannot advance.

The diets of most of the 800 million chronically hungry people lack 100-400 kilocalories per day. Most of these people are not dying of starvation. Often they are thin but not emaciated. The presence of chronic hunger is not always apparent because the body compensates for an inadequate diet by slowing down physical activity and, in the case of children, growth. In addition to increasing susceptibility to disease, chronic hunger means that children may be listless and unable to concentrate in school, mothers may give birth to underweight babies and adults may lack the energy to fulfill their potential.’

The World Bank adds that “the depth of hunger is low when it is less than 200 kilocalories per person per day, and high when it is higher than 300 kilocalories per person per day.” [x]

Impact of Dietary Deficit, Hunger and Undernutrition

On pregnant women and new-borns

An undernourished and anaemic pregnant woman, whose diet before or during pregnancy is inadequate, and has gained inadequate weight during pregnancy carries undernutrition to the womb. This will result in growth retardation of the foetus and the infant will be born of low birth weight. Low birth weight increases neonatal and infant morbidity and mortality, retards emotional and intellectual development and leads to permanently stunted height.[xi]

As per the National Institute of Nutrition (NIN) publication, Dietary Guidelines for Indians – A Manual, “composition of breast-milk depends to some extent on maternal nutrition[xii]. Though in general, even the undernourished mothers can successfully breast-feed, in the case of severe malnutrition, both the quality and quantity of breast-milk may be affected, particularly the fat content. Concentration of water-soluble vitamins as well as fat soluble vitamin A (beta-carotene) is influenced by the quality of the maternal diet.” This could also explain the high rate of undernutrition, wasting and stunting of children below 6 months as shown in Tables 2 to 4 below. 

On children of six months to 2 years 

Undernutrition and anaemia among this age group results in slower physical and cognitive growth, inability to achieve their complete physical and cognitive potential, lower immunity and higher infections, and permanent stunting.  Scientific evidence establishes that inadequate nutrition among infants below three years, which is a period of rapid growth of their brain cells, can result in slower and lesser development of cognitive ability.

On school going children and adolescents

Undernutrition, anaemia and micronutrient deficiency among this age group again results in slower growth, reduced ability to learn, play and do physical work. This translates into lower educational achievement as they grow, school dropouts, lesser ability to acquire professional skills and lower income generation capacity as they enter the work force. Additionally, undernourished adolescent girls will become undernourished and anaemic mothers, thereby perpetuating the intergenerational cycle of undernutrition and poverty.

On Adults

Dietary deficit, chronic energy deficiency (CED) and anaemia in adults results in reduced energy to work and earn, thereby making upward mobility difficult and confining them in the poverty trap. The body of such adults suffering from undernutrition and CED becomes programmed to function in scarcity, creating a negative balance where muscles don’t build and existing muscles become thinner. This adversely affects the protective mechanisms of the body and reduces immunity and life expectancy.

Data on India’s Dietary Deficit 

Let us look at some data which measures the extent of dietary deficit among the population. Below is some of the data published over the last decade regarding the calorie-protein- micronutrient deficit that afflicts the diets of various age groups of India’s population.

Findings of the National Nutrition Monitoring Bureau (NNMB) 3rd Repeat Survey (2012)[xiii] 

Findings of the National Nutrition Monitoring Bureau (NNMB) Report 2017[xiv]

The primary objective of the NNMB Technical Report 27 was to assess the diet and nutritional status of the urban population. This would also include as a secondary objective an assessment of the current status of food and nutrient intake among different age/sex/physiological groups of the urban population in the 16 NNMB States. 

Findings of National Family Health Survey (NFHS 4), 2015-16[xv]  The most graphic indicator of a severe and chronic dietary deficit among mothers and children is given in the Tables below based on data from NFHS 4.

The Tables inform that only 8.7% breastfed children and 14.3% non-breastfed children between 6 to 23 months received an adequate diet. This is the most direct evidence of dietary deficit among infants from 6 months to 2 years. This is an extremely serious indicator which is the source of under-nutrition in the life cycle of India’s afflicted population.

The data goes on to give some more disturbing figures, namely, that 17.78% children below 6 months are stunted, 21.57% children are underweight and 28% are wasted. This data is presumably related to low birth weight (20% NFHS 4) and is a direct indicator of an unacceptably high dietary deficit during pregnancy resulting in poor maternal nutritional status and inadequate pregnancy weight gain. Even more disturbing is that the percentage of children aged 6-8 months receiving solid/semisolid food and breastmilk in India has decreased from 52.6% in NFHS-3 (2005-06) to 42.7% in NFHS-4 (2015-16).

A Feasibility Study of Introducing Low-Cost Fortified Energy Food in India conducted by Karnataka Comprehensive Nutrition Mission (KCNM) in 2018 through KPMG confirms that the dietary intake of calories, protein, fat, calcium and iron is inadequate indicating a minimum gap of 30% in dietary intake in comparison to the recommended dietary allowance, among households earning less than Rs 60,000 per month, particularly among those earning below Rs 30,000/- per month.[xvi]

The study was spread across five states — Karnataka, Odisha, Uttar Pradesh, Gujarat and Maharashtra. Empirical evidence for the study was captured from stakeholder groups on the demand side covering households, doctors, nutritionists and frontline workers (ASHAs-Accredited Social Health Activists and AWWs-Anganwadi Workers/Childcare Centre Workers) as well as on the supply side covering manufacturers, distributors and points of sale such as kirana (general) stores, village haats (weekly markets) and pharmacies to assess the feasibility.

The study observed that 70% of the respondent group subsists on diets consisting mostly of plant-based foods, with low nutrient bio-availability, making access to Fortified Energy Food essential to meet the RDA requirements in the diet. The study also gave a firm finding that there is a direct correlation between high incidence of low weight, stunting and wasting among children; low body mass index and stunting among adolescents, and lack of low-cost Fortified Energy Food in the market. 

Bridging the Dietary Deficit – How do we do it?

Addressing the wide calorie-protein-micronutrient gap that exists in around 50% of India’s population, as is indicated in the data provided above, should be stated as a high priority for the Government, if India is serious about reducing undernutrition and micronutrient deficiency. This is also help in achieving the objective of the Poshan Abhiyaan,[xvii] (Nutrition Mission announced by Government of India in December 2017) and for achieving Sustainable Development Goal 2 which aims to “end all forms of hunger and malnutrition by 2030, making sure all people – especially children – have sufficient and nutritious food all year.”

Article 47 of the Constitution of India under the Directive Principles of State Policy casts a constitutional responsibility on Government in this regard:

“Duty of the State to raise the level of nutrition and the standard of living and to improve public health – The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall endeavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health.”

The author believes that there are three minimum essential interventions through which India can start bridging the calorie-protein-micronutrient gap. Each intervention carries its own impact individually, and the collective impact of all three can create a significant improvement in the dietary intake of the people within a short period of time and improve their nutritional status: 

A. Bridging the Dietary Deficit by IEC, Behaviour Change and Government Programmes

Bridging the dietary gap can be achieved to a considerable extent through a national Information Education and Communication (IEC) and nutrition awareness campaign, which should be multi-layered and should focus on bringing about behaviour change at the household and grassroots level for educating mothers, families and communities about the importance of simple, basic and essential nutritional practices, mainly:

-balanced diets with locally available, affordable foods within their resources

-proper birth weight of infant, the required weight gain during pregnancy and how to achieve it through additional dietary intake

-exclusive breast feeding for 6 months and starting adequate and appropriate complementary feeding after 6 months

-hygiene, sanitation, safe drinking water and its storage

-complete immunization of children and diarrhoea management

-proper nutritional care of adolescents and nursing mothers

-prevention of anaemia among children, women, adolescents and adults

-breaking the inter-generational cycle of malnutrition.

Such a grassroots behavior change campaign would provide simple but critical information at the household level and would bring about the required behaviour change in families in the remotest habitations of India. This grassroots IEC strategy has been successfully applied and field tested in the World Bank funded Karnataka Inter-Sectoral Nutrition Pilot Projects led by the KCNM, and implemented in two most backward areas of Karnataka State – Chincholli and Devadurga Blocks of Kalaburgi and Raichur Districts. The strategy resulted in positive behaviour change and considerably improved the nutritional status of the beneficiaries.[xviii]

Unfortunately, in spite of a wide information/awareness deficit which exists at household level, especially among lower income families, which is also a major cause for the dietary deficit, India has no comprehensive national or state IEC programme at village level that directly targets households to bring about the required behaviour change. IEC and behaviour change have been highlighted in all our early Five Year Plans, but somehow, successive governments have not been able to make it happen.

India has a vast pool of human resources, particularly women, available at the village level, such as, SHG women, village panchayat women members, NGO field workers, CSR (Corporate Social Responsibility) field workers. The author believes that they can be mobilized, trained, and provided proper IEC material, for conducting the grassroots IEC programme as village nutrition volunteers, (VNVs) and monitoring the results. Such an IEC programme will complement and strengthen the existing government programmes, particularly the Integrated Child Development Services (ICDS), through using existing women SHG resources and would not require any further recruitment by Government.

This experiment of VNVs being agents of behaviour change at the household level through a simple, sound and multi-layered IEC campaign has been tested in the Karnataka Multi-sectoral Nutrition Pilot Projects and has proved successful in bringing about the required behavior change and resulting in improved nutritional status.[xix] The first year of this project focused only on IEC at family and community level, mainly through inter-personal counseling, without any dietary supplementation.[xx] According to data for this period, there was a decrease in undernutrition among all age groups by around 30%. Positive behavior change and higher nutritional and health awareness at household level has been validated in the Impact Assessment conducted by the National Institute of Nutrition.[xxi]

However, it would be important to note that the extent of the dietary gap that is bridged by IEC is to a large extent related to cash availability in the family. In families with higher expendable incomes, IEC provides information and enables the family to bridge the dietary gap through higher spending on locally available nutritious and protective foods. In families with lesser income, the effect of IEC on improving nutritional status, though substantial, is limited by purchasing power, particularly in an inequitable market situation where no low-cost protective or fortified energy-protein foods are available.

What also becomes quite clear is that the existing supplementary nutrition programmes in India, mainly the Integrated Child Development Services programme, (ICDS) which was announced in 1975 to directly address dietary deficit among children below 6 years, and pregnant and lactating mothers, has not been successful in completely addressing the protein-calorie-micronutrient deficit. The programme appears to have turned stagnant with decreasing coverage, particularly for nutrition interventions, as the tables below clearly indicate.

As per the Annual Report of the Ministry of Women and Child Development 2019-20, the coverage under ICDS and trends since March 2013 are in the Table placed below[xxii]

NFHS 4 2015-16: Findings regarding the utilization of ICDS services in respect of supplementary nutrition and THR (Take Home Ration) are in the Box below: [xxiii]

The above data indicates that supplementary nutrition coverage by the ICDS programme is grossly inadequate. This can perhaps be explained by several reports which appear periodically in newspapers all over the country about the poor quality of THR, and therefore it is not consumed by the beneficiaries.

B. Bridging the Dietary Deficit by making accessible low-cost nutritious blended food to all sections of the population in the open market.

One of the major contributing factors of undernutrition and calorie-protein-micronutrient deficiency among large sections of India’s population, especially the poorest 30-40 percent, is that there is presently a complete vacuum in the market for low cost, fortified energy foods for lower income families, who are most vulnerable to malnutrition.

The daily diets of the poorest families are meagre and can at best qualify as subsistence diets. For lack of money and knowledge, the families are not able to provide the balanced nutrition required for healthy growth of children and adolescents during rapid growth periods, for women during pregnancy and lactation, for all age groups of both genders during or after illness, and complementary food for infants after 6 months of age. The nutritional status of adolescent girls and boys are also be a cause for serious concern. Forty seven percent of adolescent girls aged 15–19, the future mothers, are underweight, with a body mass index of less than 18.5, as per the UNICEF State of the World Children Report 2011[xxiv]

At the macro level, even though the per capita income has more than quadrupled in the last decade, the vast dietary deficit remains in terms of protein, calorie and micronutrients among around 50% of our population of both sexes and all age groups, despite the ICDS and Midday Meal Programme having been in operation for more than the last four and two decades respectively.

In spite of the policy prescriptions contained in the National Nutrition Policy 1993 and the National Plan of Nutrition 1995, sadly, the Indian market today is completely inequitable regarding the availability of low-cost energy food for the lower income vulnerable groups. While there is abundance of high-cost ready to eat fortified nutritious food available for all age groups for the affluent, there is a complete absence in the market of affordable, low-cost energy food for the lower income families. The Feasibility Study conducted through KPMG in 2018 under the Karnataka Multi-sectoral Nutrition Pilot Projects,[xxv] calculates a market demand of 42 million tons of low-cost energy food per year, but strangely, no private entrepreneurs want to enter this field. One wonders why, in spite of the specific mandate of the National Nutrition Policy 1983 and the National Plan of Action on Nutrition 1995.

The Global Nutrition Report 2020[xxvi] in its Spotlight Section emphasizes that the high cost of nutritious foods for populations most at risk of undernutrition is a major barrier to resolving undernutrition and warrants urgent policy attention.

The incidence of severe child malnutrition and wasting and its improvement was an indicator which was rigorously monitored by the author on a real time basis in the Karnataka Multi-sectoral Nutrition Pilot Projects It was seen that all cases of severely malnourished/wasted children were from households where both parents were engaged in construction or agricultural labour. The infants were left under the care of elder siblings or grandparents, and apart from some roti, (flat bread made from wheat) rice and pulses, which the infants could not eat, there was no other food in the house. And there was no low-cost children’s food available in the market.

Availability of affordable, fortified energy food in the market assumes even greater importance during the COVID 19 pandemic – lockdown and post lockdown. Reports from the field categorically inform that poor rural families are on a survival diet of rice and wheat given under PDS (Public Distribution System which gives subsidized food grains to low-income families), and sometimes some dal. In many villages, even now there is no milk or any other food for children. A study done by Azim Premji University confirms this.[xxvii] In these circumstances, it is inevitable that there will be a further deterioration in the dietary gap of the poorest sections of our population, a surge in underweight, stunting and wasting among children, poor maternal weight gain and low birth weight babies, higher anemia among children, women adolescents and adults, and lower adolescent BMI (Body Mass Index) during lockdown and post lockdown period. 

What India should do

The dietary deficit which is prevalent in varying degrees among the population, as shown in Boxes 1, 2, 3, 4 above, has not yet been acknowledged or articulated by the Government and policy makers as one of the major root causes of chronic and persistent under nutrition and micro nutrient deficiency in India. The Poshan Abhiyaan announced in December 2017 does not contain any reference to it. Neither does the Niti Aayog publication ‘Nourishing India: National Nutrition Strategy, Government of India.’[xxviii] Unless this dietary gap is bridged, large sections of India’s population, particularly the present and future demographic dividend, will forever be deprived of achieving their full physical and cognitive potential. Children’s literacy and numeracy skills will suffer, employability and upward mobility of adolescents and adults in the emerging world economy will remain elusive, and they will remain confined within the poverty trap. Cumulatively, this will result in an appreciable loss of GDP (Gross Domestic Product) to the nation through lost Disability-Adjusted Life Years (DALY) something that has been calculated in numerous studies over the last few decades. The mindset of policy makers and programmers, down to field workers and families, that subsistence/survival diet equals food security must change.

The political executive and policy makers must also note that unlike in the case of outbreak of infectious diseases for which there is an immediate public demand for government intervention, in the case of malnutrition, which is neither visible nor infectious, there will not be any popular demand from the community to address it, as they lack awareness and information regarding their own affliction or its causes. All they know is that they are poor, get tired easily, and their children fall ill often. Hence, in the Indian context it becomes the responsibility of the government/civil society to first provide information and awareness to the community about malnutrition and its causes, and then implement programmes to address those causes.

Government could start showing its seriousness by examining the present nutrition related programmes, and why they are not able to reduce malnutrition faster; whether they are adequate, or require a complete overhaul; should additional interventions be introduced in pockets of chronic malnutrition in every State, which are identified as Aspiration Districts and High Burden Districts – surely, there should be different norms and more intensive interventions in addition to ICDS for these chronically malnourished pockets with the poorest indicators; how does the government plan to address adolescent malnutrition (our future demographic dividend) which is as alarming as child malnutrition, for which we have no clear strategy in place yet. And finally, government must inform us whether the National Nutrition Policy 1993[xxix] is still alive or not, and whether there are any plans to update it, and prioritize interventions in accordance with latest surveys and research findings.

Acknowledging the dietary deficit should be of top priority, because only after there is acknowledgement of it, can discussions take place and a policy be formulated and put in place to address it. The discussions should include the very vital question, whether our present interventions are addressing the root causes of malnutrition in India, what the author has described as the Three Deficits. Clearly, data indicates that India’s current interventions are not able to bridge them, and unless this is done, rapid improvement in its nutritional indicators will not happen.

What is urgently required is a robust grassroots communication strategy to target the information deficit, better coverage by government programmes to address the dietary deficit, and proactive engagement with the food industry, private, cooperative and government, to bridge the market deficit. Public health experts and policy makers are also aware that unless the dietary deficit is addressed, the impact of other nutrition and health interventions will remain sub-optimal.

Bridging the dietary and information deficit and increasing/ improving nutritional intake of the population, as suggested above, does not require heavy financial investment from government. It can be done by intelligently and innovatively creating an implementation model by using existing financial allocations from ongoing national programmes covering women SHGs, panchayats, livelihoods, skill development etc. and piloting it in a few chronic pockets of malnutrition, the Aspiration Districts, which require additional and more intensive interventions. This is exactly the kind of convergence that the Poshan Abhiyaan seeks to achieve.

The COVID 19 pandemic and its unpredictable duration and disruption of existing nutrition programmes and supply chains has created a further nutritional crisis, the ramifications of which are already being manifested. It is now timely and appropriate for government to engage with the food processing sectors and in accordance with the National Plan of Action on Nutrition 1993, incentivize startups for producing low cost energy food for the open market.

It is also important that government partners and stakeholders, domain experts, national and international agencies, donors and philanthropies working in this field, must also acknowledge this serious dietary deficit when they are preparing their India strategy and plans, and integrate interventions to address this in a holistic framework within their mandate, whether it is food fortification or hand washing. This will only enable them to enhance the outcomes that they are working towards within their mandates. Calories, protein and micronutrients, which are fundamental to nutritional status for any strategy, have no substitute.

Raising the diet of our people from subsistence level to higher levels of nourishment through overcoming the triple deficit is the only way we can improve nutritional indicators of our population – children, adolescents and adults. The government must show its seriousness and start addressing this issue urgently through new ideas and innovation



[i] National Family Health Survey 5,



[iv] (First Five Year Plan, 1951-56)

[v] (Data from National Commission on Population),

[vi] (First Five Year Plan, 1951-56)

[vii] Karnataka Comprehensive Nutrition Mission- Strategy Paper

[viii] – Page 12

[ix] Undernourishment around the world, Depth of hunger: how hungry are the hungry?


[xi] ‘Undernutrition in Adults and Children: causes, consequences and what we can do’ by  Ann Burgess MPH* Nutrition Consultant and Dr Louis Danga MBBS** Paediatric Registrar, Juba Teaching Hospital


[xiii]  NNMB 3rd Repeat Survey, 2012 covering rural household in the States of Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, Madhya Pradesh, Orissa, West Bengal and Uttar Pradesh. The average family size was 4.9. The average monthly per capita income (PCI) was Rs.1,356/- at the current rupee value

[xiv] NNMB Technical Report Number 27, 2017, A Brief NNMB Urban Report covering urban households in the States of Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh,West Bengal, Assam, Andaman and Nicobar Islands, Bihar, Rajasthan, Puducherry and New Delhi. The average family size was 4.3. The average monthly per capita income (PCI) was Rs. 4,941/- 

[xv] NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16 Page no: 299- 303

[xvi] A Feasibility Study of Introducing Low Cost Fortified Energy Food in India through Private Sector Participation


[xviii] Karnataka Multi- Sectoral Nutrition Pilot Project- A unique communication strategy

[xix] How nutritional volunteer workers have taken the lead in tackling high rates of childhood malnutrition in India – The BMJ


[xxi] Impact Evaluation of Karnataka Multi-Sectoral Nutrition Pilot Project

ICMR- Indian Council of Medical Research, NIN- National Institute of Nutrition- 2019

[xxii] Annual Report 2019-20, MINISTRY OF WOMEN AND CHILD DEVELOPMENT,Government of India. Page no: 30

[xxiii] NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16- Page No: 260

[xxiv] State of the World Children Report 2011 – Page 21-


[xxvi] Page 84-85





New Year, New Lockdown in the United Kingdom: ‘The Great Deception’

This analysis was originally posted by Prof. Ted Schrecker of the United Kingdom’s Newcastle University in his blog on that institution’s web site.  It has been very slightly modified for a broader audience

By Ted Schrecker

Professor of Global Health Policy, Newcastle University

New Year, New Lockdown in the United Kingdom: ‘The Great Deception’



Predictably, the New Year started in the United Kingdom with new lockdowns.  Given the negligent and cavalier stance of the Conservative central government towards basic public health principles since the start of the pandemic, and the consequent peril to the National Health Service (NHS), this was inevitable, although one may argue with some of the specifics.  It is important to remember, though, that both the parlous state of the NHS and the neglect and defunding of public health infrastructure are consequences of a homicidal decade of Conservative austerity, correctly described in 2017 by the editor of The Lancet, Richard Horton, as ‘a political choice that deepens the already open and bloody wounds of the poor and precarious’.

One of the knock-on effects is that we are now living in a police state – so far, a non-violent one, but violence is not a necessary element of the definition.  Hyperbole, you say?  Well, what else would you call a polity in which the decision about what constitutes a ‘reasonable excuse’ for leaving home is decided, in the first instance, by police, who will be defended by Cabinet ministers?   I wish politicians and self-styled progressive colleagues alike would stop dissembling on this point.  They might well defend the situation as necessary, but they should stop lying about its nature.  Presumably some of these fines and arrests will be successfully contested by those with the time and money to do so, should government eventually permit courts to resume routine operation, which is far from certain.

Speaking of lies, porkies* of Trumpian proportions have been emanating from central government.  We are told that, if we obey the rules and all goes well with vaccination, restrictions might be eased in ‘tulip season’ (May, in these parts) or ‘spring’ (technically, before 21 June).  If any reader believes that, then I can offer a really good deal on some oceanfront property in the Canadian province of Saskatchewan.  (Spoiler alert: there isn’t any.)  Given the government’s record of destroying any public health initiative it touches, the UK will be doing well to be out of the worst of lockdown by September.  In fact, more severe restrictions are threatened.

It will be disturbing to see the manifestations of burnout by the end of a summer without holidays (I quote from the government guidance: ‘holidays in the UK and abroad are not allowed’).  Some of us would in theory have the attractive option of sitting on the local seafront and reading once the weather warms up … except that under current guidance this would not count as exercise, one of the ‘reasonable excuses’ to leave home, so would be a crime.  Such constraints weigh most heavily, of course, on those without gardens of their own or with caring responsibilities.  The incidence of deaths of despair is likely to soar, as is the number of employers using depression and anxiety as a pretext for forced redundancies.

All this means that the chance of a post-Soviet style economic and health collapse in the UK, lasting for a generation or longer, are considerably greater than they were when I first raised the possibility last summer.  It could be, of course, that vaccination will proceed more quickly and effectively than expected (pigs might fly, too) or that some other remarkable advance in prevention will be found.  Unfortunately, it is much more likely that the United Kingdom is over as a desirable place to live and work, for a very long time, except for those living in gated communities or behind castle walls.

The ways in which the pandemic is magnifying inequality – on which I will expand in a subsequent posting, based on material from the postgraduate course in Advanced Social Determinants of Health that I lead – continue to be given limited attention.  Most of the ‘experts’ calling for even stricter lockdowns probably have gardens of their own, job security, and substantial savings, unlike many other Britons; they have generally been silent on inequality issues.  Still less often have they taken up Horton’s pre-pandemic injunction that: ‘The task of health professionals is to resist and to oppose the egregious economics of our times’.  One wishes that members of the government’s Scientific Advisory Group on Emergencies had to disclose their households’ incomes and net worth, along with their professorial titles and British Empire honours, as part of their declaration of interests.

Here is a thought experiment, keeping in mind two propositions.  First, people working in front-line occupations (think essential retail like supermarkets, delivery, driving those buses that continue to operate, Amazon warehouses, meat packing, care homes) cannot work from home, and especially if on zero-hours contracts or without union protection cannot afford to self-isolate after a positive test or if symptomatic.  (The jobs of many others, working in the sector broadly described as hospitality, have vanished under lockdown, possibly never to return.)  Second, as of 25 September almost nine out of ten deaths from Covid-19 involved people 65 or older (more recent figures are maddeningly hard to find on official web sites).  Most of these represented an actuarial boon for the UK treasury, no longer paying state pension, and many for defined-contribution pension plans.

Now, if you wanted to design a pandemic response that pretended good intentions whilst concealing a subtextual agenda of culling the working class (potential claimants of state benefits, after all, and therefore intrinsically suspect for Conservatives) and the elderly, the current UK response is what it would look like.  The UK is hardly unique in this regard, but along with Canada and its charnel house care homes and even more calamitous vaccine rollout it is an especially egregious case.  Implications for other jurisdictions are not hard to infer.

The title of this post refers to what I consider the greatest song by Irish troubadour Van Morrison, ‘The Great Deception’.  Part of the refrain goes like this:

‘I can’t stand it / Can’t stand it nohow / Livin’ in this / World of lies’.


* For those outside the UK: short for porky pies, rhyming slang for lies.

Defending and Reclaiming WHO’s Capacity to Fulfil its Mandate

This article highlights key touchstones for reflections on WHO’s role in the international health arena and raises a number of possibilities, relating to language, propaganda even, and power, which could contribute to reclaiming WHO’s capacity to unequivocally work for peoples’ health

Defending and Reclaiming WHO’s Capacity to Fulfil its Mandate 

Suggestions from a Perspective of Language and Power

By Judith Richter[i]

Independent Scholar


Another ‘reform’ of WHO?

2021 will be a decisive year for the World Health Organization, the highest health authority of this world, whose decisions we must be able to trust as the discussions about its role in the public management of the Covid-19 pandemic has shown.

When President Trump started threatening WHO with the withdrawal of the United States funding, the government of Germany said that, even if the Democratic Party were to win and reinstate US-membership of WHO, there would still be a need to discuss reforming WHO. The problem is that WHO has been reformed under neoliberal ideology for over 20 years and unfortunately, WHO Member-states, as well as senior WHO officials, have not always played a constructive role in the reform of this UN agency. [ii]

In this short text, I raise a number of possibilities, relating to language, propaganda even, and power, which could contribute to reclaiming WHO’s capacity to unequivocally work for peoples’ health.

But before that, let us look at key touchstones for reflections on WHO’s role in the international health arena:

Remember WHO’s constitutional mandate and core-functions

WHO’s objective to work for the “attainment by all peoples of the highest possible level of health” (Article 1) where health is understood as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity….” (preamble)

WHO’s constitutional function to “act as the directing and co-ordinating authority on international health work.” (Article 2a)

WHO’s role as regulatory and standard setting body in international health matters. (Articles 2k and 2u)

WHO’s duty to “assist in developing an informed public opinion among all peoples on matters of health.” (Article 2r)

And “generally, to take all the necessary action to attain the objectives of the Organization.” (v)

The people involved in establishing this UN specialized agency after the second World War also stressed:

“Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people”; and

“Governments have the responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” (Preamble) [iii]

Harmful changes

But governments have often hindered efforts undertaken in the interests of their people due to the rise of neoliberal ideology. Harmful changes resulting from the neoliberal restructuring of WHO and the international health arena include:

1) a gradual narrowing and re-definition of the role of WHO in the international public health arena – more or less reducing WHO’s role to that of a broker of public-private partnerships and part of a global ‘multi-stakeholder governance’ system.

2) the weaving of opaque webs of influence between mega-philanthropies, transnational corporations, WHO (and other UN agencies), government institutions, academics, and a number of public-interest-Non-State actors (PINGOs and civil society organizations and networks) which influence our health policies more than we think.

3) the framing of a neoliberal multi-stakeholder/partnership narrative, including the redefinition of key-political and legal terms, in a way that prevents open and informed discussions and decisions and undermines WHO’s mandate to safeguard international public interests.

4) the rise of a culture of secrecy and censorship which has gradually seeped into all spheres.

Language and power

But we are not powerless in the face of these changes. Insights from language (including propaganda) as power can help us to question these harmful redefinitions and narratives (the storylines which may shape politics and our lives). This is an entirely cost free endeavour which will allow all relevant public actors to truly work towards Health for All.

More clarity in language is an indispensable ingredient in discussions on how to undo harmful neoliberal restructuring of WHO and other UN agencies and problematic public-private webs of influence. I suggest undoing harmful language changes through three strategies:

  • Identifying and rejecting ‘dangerous non-sense’ in neoliberal narratives and terminology
  • “Calling a Spade, a Spade” and replacing problematic terms by less-value laden terms
  • Recovering, and further clarifying, key legal concepts – correct WHO’s misconception and popular misunderstandings of conflict of interest.

I elaborate on these three strategies below: 

  1. Identify and reject dangerous ‘non-sense’ in neoliberal narratives and terminology

Nobody needs to be an academic expert to identify when they see ‘non-sense’. But many may be intimidated by the volumes of official and academic writing which asserts:

In complex situations ‘all stakeholders’ need to work together in ‘partnership’

This, and similar, sentences are presented as an ‘imperative’.

However are simply non-sense, but dangerous non-sense! It is time to reject it!

This alleged ‘imperative’ is part of neoliberal reframing of narratives and key concepts.

Of course, it would be ideal if all societal actors worked harmoniously together when there is an important societal problem. But we all know that this does not correspond to reality, especially when one of these ‘partners’ or ‘stakeholders’ is a powerful for-profit actor who is invited into various fora, on the neoliberal principle of ‘trust’ associated with these arrangements.  French popular wisdom warns “you do not invite the wolf into the sheep pen.” And literature in political science, as well as literature on conflicts of interest in public service, or conflicts of interest in medicine, is full of examples why corporations should not be part of certain decision-making processes. [iv]

Yet the above empty slogan has given rise to plutocratic ‘governance’ (decision-making) systems with totalitarian features. In other words, systems where money, not people (interests), rule (often through manipulation) and where critics are sidelined and silenced.

The draft concept paper underlying WHO’s current Global Work Plan (GWP) is based on such a partnership view. If one undertakes a simple analysis of its discourse by asking “What is said? How is it said? And “What is left out?”, a key suggestion in this document was for WHO to become a humble broker of multi-stakeholder partnerships and part of what was presented as a harmonious, evolving, system of multi-stakeholder governance in health. WHO’s regulatory function of corporate practices – which is distinct from standard setting function – seems to have been lost.[v]

Networks challenging the above imperative and insisting on questioning partnership-approaches, and such as the International Action Network on Infant Feeding (IBFAN), are being discredited and defunded on the grounds that they are not joining the “narrative of the 21st century”.[vi]

Critics have often failed to deconstruct – to fully take apart – such non-sensical terms and narratives. It is not enough, for example, to state that there is a need to consider power differences between business- and civil society- ‘stakeholders’ because this does not challenge the idea that social actors, simply because they have an interest ‘at stake’, are legitimate stakeholders in public affairs; it implicitly reinforces the stakeholder discourse. Calling all kind of societal actors ‘stakeholders’ or ‘partners’ contributes to blurring of fundamental differences between actors in terms of power, interests, and legitimate societal roles and has favoured the rise of public-private hybrids which have acted as Trojan horses for business interests.[vii]

Remember: People are human rights holders whose rights UN agencies are meant to protect, promote, and respect.[viii] Transnational corporations (TNCs) are artificial legal entities whose key driver is profit-making for shareholders. Their power – including that of political lobbying against transnational public-interest regulation – should be kept in check by our governments and the intergovernmental system.

Dangerous ‘non-sense’ is also the more recent redefinition of key concepts such as ‘civil society’ to include transnational corporations (TNCs) and their associations, and of ‘academia’ to include (e.g. corporate-funded) think tanks.

Public-interest actors can of course, where appropriate, interact with business actors. For example, under the late Dr. Halfdan Mahler, WHO cooperated with pharmaceutical companies in its Tropical Disease Research Programme (TDR). At the same time, Dr Mahler did his best to work for transnational regulation of harmful business practices and of the products of pharmaceutical, food, tobacco, and alcohol companies, and towards systems that provide access to Health for All, including access to affordable essential medicines.[ix]

Times have changed. Today there is a need to:

  • re-establish a clear separation of spheres, and an ‘arms-lengths’ distance between public-interest actors and big business actors as well as hyper rich funders and their mega-foundations
  • protect sensitive public interest inside information from firms and associated actors instead of inviting them into fora where they do not belong and giving them roles that are inappropriate
  • allow for public scrutiny
  • and protect whistleblowers – persons who report wrongdoing in the international public interest – and listen carefully to them, instead of sidelining, silencing, or persecuting them.[x]
  1. “Call a spade a spade” – Be specific and replace problematic terms by less-value laden terms

The following terms should never be used without reflection. They should be replaced by terms which do not promote undue influences by giant firms and wealthy funders. These terms include:

  • Partners, partnership, in particular public-private partnership (PPP);[xi]
  • Stakeholder, multi-stakeholder-anything: such as MS-partnership (MSPs), MS-dialogue, MS-platform, MS-governance;
  • Governance.

In fact, PPPs and MS-anythings usually denote public-private hybrids and hybridization (PPHs) – the blurring of boundaries between private/business sphere and the public sphere. They introduce, and legitimize, undue influence of big corporations and mega-funders. Since the introduction of the term governance in the international arena, and the link with a redefined “stakeholder” term, the term multi-stakeholder governance simply means inviting corporations and big funders into decision-making.

This is why health activists working for Health for All, which includes appropriate health care systems accessible to all, and regulation of harmful practices of transnational corporations, have called neoliberal PPPs and MS-arrangements Trojan horses.

Scholars such as Susan George, who has long worked against the seizing of power by corporations, advocates abandoning the terms stakeholder and governance in public discourse. She stresses: “Non-native English speakers… don’t necessarily realize that in English a stake is always concerned with money, property or a bet of some kind. In the days of the American frontier, a pioneer moving West could lay, or ‘stake’ a claim to land, marking it physically with posts – or stakes at the corners…” [xii]

Two further  reflections may help to undo the power of the multi-stakeholder governance notion:

I would like to remind people that the term stakeholder has been redefined in a Novartis-sponsored publication from then UN Secretary General Kofi Annan’s definition of stakeholders as: “those individuals and groups that have an interest, or take an interest, in the behaviour of a company… and who therefore establish what the social responsibility of a company entails” to a definition of stakeholders as “those who have an interest in a particular decision, either as individuals or as representatives of a group. This includes people who influence a decision, or can influence it, as well as those affected by it.”[xiii]

It is also useful to remember that the term governance comes from the Greek gybernan, which originally means to be at the rudder, to steer a boat. What must be vigorously defended is for our ‘health boat’ to be steered in the public interest, with the aim of achieving Health for All. (according to a map and by actors, which allow to reach Health for All.)

  1. Recover and further clarify key legal concepts – conflict of interest (a conflict within an actor)

The neoliberal restructuring can also be reversed by recovering legal meanings of redefined key-concepts.

For example, the power of the broad stakeholder definition can be undone by pointing out that the law continues to define a stakeholder as “any person/group which can affect/be affected by the actions of a business. It includes employees, customers, suppliers, creditors and even the wider community and competitors.”[xiv]

But most important is to recover the meaning of conflicts of interest. During the last ‘reform’ of WHO under Dr. Margaret Chan, Member States had asked WHO’s Secretariat to clarify the concept of conflict of interest and help distinguish appropriate from inappropriate interactions with corporations and other Non-state actors.

Instead, WHO actively redefined the conflict of interest (COI) concept in a way that makes genuine conflict of interest regulation impossible. In its work, the Secretariat build on, rather than publicly rejected, a misleading COI definition that had been developed in a Gates-funded project for use in the Scaling-Up Nutrition (SUN) initiative, a public-private hybrid of which WHO and UNICEF are part.[xv]

The erroneous conception of conflict of interest, which is used in FENSA, WHO’s Framework of Engagement with Non-state Actors, unduly influences WHO’s relations with TNCs and wealthy funders. Among other things, it does not posit conflicts of interests as conflicts WITHIN an actor, but conflicts BETWEEN actors.[xvi] World expert on conflicts of interest in medicine, Professor Marc Rodwin, warned the agency since its Technical consultation “Addressing and managing conflicts of interest in the planning and delivery of nutrition programmes at country level” in 2015, that wrong conceptions may actually lead to an increase of conflicts of interest, among others by diverting attention from identification and genuine regulation of conflicts of interest to risk assessments. He proposes as most suitable COI definition for WHO engagement with Non-state Actors a conception which takes financial conflicts of interest and loyalty conflicts into account.[xvii] In such a conception it becomes clear that public-private arrangements in which public-interest actors are asked to look for win-win situations for both parties are placing them into a loyalty conflict. Is this why SUN’s Gates-funded project had to redefine conflicts of interest?

Non law-based COI concepts, such as the notion of ‘intellectual conflicts of interest’, risk sidelining critical civil society actors or scientists from public debates. This situation is compounded by a problematic confidentiality clause for WHO experts.

In the medical sphere, it is long known that individual researchers, health professionals, or civil servants, cannot resolve certain conflicts of interest, if their institution is caught in what is called an institutional conflict of interest. If WHO had referred to existing institutional conflict of interest definitions, its leaders could have pointed out to its Member States that they have placed our specialized health agency into a severe institutional conflict of interest – a conflict between its mandate (its ‘primary interest’) and the need to collect funds – by their long-standing refusal to fully fund WHO via assessed contributions (which are the equivalent of taxes).

Some political and legal scientist have gone beyond the institutional conflict of interest frame by developing an institutional corruption/integrity theory. It clearly identifies the risk that public-interest organizations’ mandates can be undermined – and their agendas shifted – depending on where their money comes from.

Legal expert and ethicist Jonathan Marks writes in his book The Perils of Partnership that public agencies need not only conflict of interest policies but also “comprehensive counterstrategies to insulate themselves from corporate influence”. And he asserts, “public health needs another paradigm”.[xviii]

Both, institutional conflict of interest, and institutional corruption/integrity, frameworks center on the need to ensure the integrity, independence, and trustworthiness (respectively credibility) of public institutions. This is a complex task. It entails ensuring that they have the capacity and political will to fulfill their public mandates.

WHO’s Framework of Engagement with Non-state actors (FENSA) lists the above three terms under its ‘principles’ of engagement. This triad is further key-touchstone when trying to recover WHO’s capacity to work for peoples’ right to health.

Many of the neoliberal ‘principles’ of engagement need to be questioned. It should be noted that the term ‘trust’ does not figure under FENSA’s principles of engagement. Member States have eliminated during the discussions on earlier drafts. It should therefore also be eliminated from principles of all other ‘engagement’ policies in public health which involve cooperation with private-sector actors.

However, it is important to recognize the limits of WHO’s Secretariat. They are set by funding and Member State willingness to act in the international public interest rather than in their narrow national interests or that of their transnational companies. The United States and EU Member States, for example, have often resisted effective regulation of harmful TNC practices and reshaping of pharmaceutical and health systems policies in the public interest. As we can see right now, China can prevent WHO, and journalists, from undertaking genuine investigations into the origins of the Covid-19 virus[xix]

Full public funding and the recovery of WHO’s mandate

To resolve WHO’s key institutional conflict of interest, to enable it to recover its integrity, independence and trustworthiness, any Member State or civil society actor criticizing WHO’s handling of the world’s health problems, must therefore also call to undo the long-standing ban on raising assessed Member state contributions to WHO, as critics supportive of WHO have said for two decades.

Today, the question is: Will WHO’s Director-General and its high-level officials engage in, and support, efforts to defend the mandate and core-functions of WHO and start extricating our UN specialized agency for health from opaque and inappropriate relations with venture philanthropies and transnational corporations? Otherwise, our tax money contributes to further strengthening public-private, plutocratic, global governance systems in health.



[i] Independent scholar. Author of the books Holding Corporations Accountable and Public-private partnerships and international health policy making: How can public interests be safeguarded? and numerous publications ranging from analysis of corporate lobby against international regulation to work on conflicts of interest regulation and other ways to maintain the integrity of public-health policy making. Declaration of interests: throughout my long career as sociologist, I have never relied on corporate or venture philanthropy funding. This paper was self-funded. Acknowledgments: I thank Alison Katz for language editing and editorial advices.

[ii] Birn, Anne-Emanuelle and Nervi, Laura. “(Re-)Making a People’s WHO,” American Journal of Public Health, 110: 9 (September 2020): e1-e2. (see author’s website for French, Spanish and German versions)

Richter, J. (2012) “WHO reform and public interest safeguards: An historical perspective. Editorial.” Social Medicine 6 (3): 141-150, April 2012 (& Spanish translation)

[iii]; , accessed 12.01.2021

[iv] Since Corona-policies have started impacting peoples’ lives it starts becoming common knowledge that companies which are producing emergency vaccines are not just charitable institutions but have clear financial interests at stake;  unfortunately there is too little research and media coverage examining how concretely the Bill and Melinda Gates foundation and its’ webs of influence have been shaping – and continue shaping – WHO’s and national advices on how to address this latest transmissible health challenge. Is it due to their influence that the current narrative presents widespread vaccination as the light at the end of the tunnel? To what degree was the neglect of low-tech approaches, such as the provision of FFP2/N95 respirators and plexi-shields in shops and offices due to plans elaborated in Gates-corporate-webs of influence?

Most media coverage focusses on debunking wild theories on the role of Bill Gates which circulate in social media, some newspapers present him as a hero in the ‘war on the virus’. Thorough analyses of Gates’s role in shifting and influencing international and national health agenda risk to be sidelined even further sidelined as yet another ‘conspiracy theory.’

[v] Richter, J. (2017) Comments on Draft Concept Note towards WHO’s 13th General Programme of Work, 14 November,

Richter, J in cooperation with Alessia Bigi (2017) “Comment on WHO’s draft 13th General Programme of Work”, IBFAN-GIFA Briefing Paper, 28 November 

[vi] Richter, J (2015) “Conflicts of interest and global health and nutrition governance – The illusion of robust principles,” BMJ RR, 12 Feb.,

[vii] The term stakeholder is not easy to translate into other languages. A German translation as ‘Interessensträger’ (interest-bearer), for example, is problematic. It fails to address the problem of redefinition of the term stakeholder; and this translation does not contribute to undoing the discursive and propagandist power of the term stakeholder in anglo-saxon literature and official documents.

[viii] This was stressed by Nora McKeon in her neglected comment on the FAO HLPE Report on Multi-stakeholder partnerships to finance and improve food security and nutrition in the framework of the 2030 Agenda

[ix] Richter, J. (2001) Holding corporations accountable: corporate conduct, international codes, and citizen action. London & New York: Zed Books


[xi] For a shift in the meaning of partnership, see e.g. Richter, J (2005) Global partnerships and Health for All: Towards an institutional strategy. A discussion paper prepared for WHO’s Department of Government, Civil Society and Private Sector Relations (GPR). Geneva, WHO, 20 pages, 2005

[xii] Susan George (2015) Shadow Sovereigns: How global corporations are seizing power, Polity Press, Cambridge, p. 7-8

[xiii] Hemmati, M. (2002). Multi-stakeholder processes for governance and sustainability: beyond deadlock and conflict. London, Earthscan. Forother references &context of this shift, see Richter, J. (2002). Dialogue or engineering of consent? Opportunities and risks of talking to industry. Geneva, International Baby Food Action Network/Geneva Infant Feeding Association (IBFAN-GIFA), p. 18 ff.

[xiv] It comes from the “Stakeholder theory” which “states that a company owes a responsibility to a wider group of stakeholders, other than just shareholders.” See Corplaw Admin. (2013, July 16). Shareholder and stakeholder theories of corporate governance. Retrieved from Corpolaw:

[xv] Richter, J (2017) “Comments on Draft Approach for the prevention and management of conflicts of interest in the policy development and implementation of nutrition programmes at country level”, WHO online consultation, 29 October 2017,

[xvi] Richter, J. “Time to debate WHO’s understanding of conflicts of interest.” British Medical, Journal (BMJ) rapid response, 22 October 2015,

Many civil society organisations still do not seem to have understood that they replicate this conception in some way.  They still talk about conflicting – and diverging – interests BETWEEN public and for-profit interest actors as conflicts of interest. For a reference concerning Gates and Member State funding and WHO’s institutional conflict of interest, see the section on CoI in :

Birn, A.-E. & J. Richter (2019) U.S. Philanthrocapitalism and the Global Health Agenda: The Rockefeller and Gates Foundations, Past and Present. Health Care under the Knife:  Moving Beyond Capitalism for Our Health. eds. Howard Waitzkin and the Working Group for Health Beyond Capitalism, Monthly Review Press (advance chapter see)

[xvii] Marc A. Rodwin (2020) .WHO’s Attempt to Navigate Commercial Influence and Conflicts of Interest in Nutrition Programs While Engaging With Non-State Actors: Reflections on WHO Guidance for Nation States; Comment on “Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool”, IJPM, September

[xviii] Marks, Jonathan H. (2019) The perils of partnership: industry influence, institutional integrity, and public health, Oxford University Press, New York

[xix] A recent article argues that it may have created during research on vaccines to immunize against harmful corona-viruses – and this “lab-escape theory” does not sound implausible

News Flash 414: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 414

 Weekly Snapshot of Public Health Challenges


2020: a Year in Review through PEAH Contributors’ Takes by Daniele Dionisio

The (Re)Construction of the World: Aid. Solidarity. Politics. Online conference February 12-14, 2021, with Achille Mbembe, Susan Buck-Morss, Rita Segato, Ulrike Herrmann, Sandro Mezzadra, among others 

EU Development Policy in 2021: Greater than the Sum of Its Parts? 

WHO informal consultation (3 December 2020) addressed concerns on price transparency and shortages 

Italy and the Dubious Honor of Chairing the G20 

Africa’s Road to Recovery in 2021 is a Fresh Start

Coronavirus disease (COVID-19) Weekly Update 

Africa: Covid-19 Death Toll Exceeds 74,000 Across Continent 

Rapid Increase In COVID Cases ‘Not Due To The Variant’, WHO Says 

WHO calls for new names for Covid variants to avoid country stigma 

WHO Stresses That China Trip To Investigate SARS-CoV2 Virus Origins is Not About Blame; Urges All Countries to Improve Genome Sequencing Research 

WHO Has ‘Outsourced’ Its Role On Vaccine Access – Civil Society Groups Claim 

Webinar registration: Learning Session: European Citizens’ Initiative & Access to Covid-19 Vaccines Jan 19, 2021 02:00 PM in Brussels 

Ensuring equitable access to vaccines for refugees and migrants during the COVID-19 pandemic 

UK meets £250m match aid target into COVAX, the global vaccines facility 

Poorer countries could start getting COVID vaccines this month-WHO 

Opinion: US development organizations must collaborate on COVID-19 vaccine distribution strategy 

EMA receives application for conditional marketing authorisation of COVID-19 Vaccine AstraZeneca 

Research shows Pfizer vaccine works against mutations | New Mutant Strain | Britain | South Africa 

Arthritis drugs could help save lives of Covid patients, research finds 

How can we overcome pandemic fatigue in 2021? 

Global Funding Across U.S. COVID-19 Supplemental Funding Bills 

UNICEF, WHO, IFRC and MSF announce the establishment of a global Ebola vaccine stockpile 

Implementation of tuberculosis preventive treatment among people living with HIV, South Sudan 

Death on the Central Mediterranean: 2013-2020 

Contributions From APAN During Disasters by Tanushree Mondal

Can the World Tackle the Food Insecurity Crisis in 2021? 

One Planet Summit: no climate fix without biodiversity 

The 2020 China report of the Lancet Countdown on health and climate change 

Countries face emissions ‘cocktail’ from waste burning 

Renewable Energy Transition Key to Addressing Climate Change Challenge








The ISOHA Europe Virtual Conference 2021

A snapshot here on the Europe Virtual Conference 2021 currently being held by the International Student One Health Alliance (ISOHA) as a week-long webinar series from 11-17 January 2021


The ISOHA Europe Virtual Conference 2021


The ISOHA Europe Virtual Conference 2021 currently being held in Romania, Europe, is a week-long webinar series from 11-17 January 2021, featuring speakers from different fields of One Health each evening. The event is attended by 600 registered participants and over 100 attendees live on Zoom each evening.

More information and registration here


Further to the ISOHA announcement, find intro slides below  for the January 16 webinar session held by George Lueddeke Chair, International One Health for One Planet Education Initiative (1 HOPE) – based generally on his recently PEAH published commentary Rebuilding Trust  and Compassion in a Covid-19 World.