‘Leaving no-one behind’ is a potentially radical message at the heart of the Sustainable Development Goals (SDGs) but has been ill-defined in many sectors, including nutrition. The slogan suggests that we must pay attention to the needs of poorest, the marginalised, the most in need, the politically excluded: those who have been long been left behind in terms of the human and sustainable development goals of the SDGs.
We (IDS fellows Jody Harris and Nicholas Nisbett, together with Phillip Baker of Deakin University, Australia), were authors of the framing chapter of this year’s Global Nutrition Report, which focuses on equity and different forms of malnutrition as a means of understanding what leaving no-one behind means for nutrition, in practice.
From inequality to inequity
The report as ever is a treasure trove of data on different forms of malnutrition and the ways in which this affects countries and populations differently. But this year’s focus on equity gives a better sense than ever of who is being left behind in terms of malnutrition. We need to pay attention not only to unequal nutrition outcomes, but also to have a stronger focus on how these differ by wealth, gender, ethnicity, disability and so on and then unearth the deeper drivers: the entrenched inequities behind the more observable inequalities.
A focus on inequity in nutrition is particularly important as new forms of malnutrition (such as obesity) combine with old (such as undernutrition or micronutrient deficiencies) in many places and form the basis of vulnerability to illness, disease, further forms of poverty. But, in a vicious cycle, those who are likely to be malnourished are those who are the most marginalised and vulnerable in the first place. This is especially pertinent as we face the Covid-19 crisis, which seems to be hitting the poorest and those with obesity and related NCDs hardest and in some countries, including the UK, these inequalities appear to be divided along lines of ethnicity, suggesting broader inequities at play.
Inequity as unfair and avoidable power imbalances
‘Mainstream’ public health nutrition – ie that promoted by many international agencies and researchers – has long focused on inequalities in nutrition outcomes, typically using standard social stratifiers like wealth quintile or gender, and less commonly other stratifiers such as ethnicity. Much less attention has been paid to the deeper causes of these inequalities, that we term inequity.
In framing nutrition equity we follow the Commission on the Social Determinants of Health: Inequity highlights preventable disease as unfair, and differences in nutrition outcomes as the result of poor political and policy choices that could have been avoided through reasonable action. But we also draw on wider development and critical social science and epidemiology to highlight broader processes of injustice, discrimination, marginality – these deeper processes are what differentiates inequality (observed differences across different social strata) from inequity (the processes that create these disparities). These are all aspects of the substantial power imbalances that shape and are at the heart of food and health systems.
Action on inequity
This year’s GNR argues that redressing these power imbalances to get to the root causes of malnutrition in all its forms requires dedicated action. This means practical action on food and health systems in support of marginalised groups. It also means work on the social and political processes of injustice and exclusion that create systematic inequities within these systems.
On food systems, the commercial drivers – in particular food industry marketing and lobbying for nutrient-poor and ultra-processed foods high in sugar, fats and salts – have been a pernicious influence and are directly linked to the obesity crisis. The report calls, therefore, for stronger action to rectify imbalances in food systems via regulatory and policy frameworks to ensure access to healthy food for all.
Likewise on health systems – and as the Covid-19 crisis has once again demonstrated – people’s access to universal health care is a right that many countries are failing to realise. The report calls for work to strengthen health systems with a specific focus on reaching marginalised communities with proven methods of support for their nutritional needs.
Our chapter outlines further measures needed to understand how such injustices have come about, and continue to come about, because of the way in which people are experiencing discrimination such as ongoing racism or gender oppression at the heart of food and health systems. Rights and equity-based approaches – first to understand issues in context, then to frame appropriate responses – are the only way to deal with these types of political inequities that fundamentally drive malnutrition and the inequalities in outcomes we continue to see. With injustice at the heart of the Covid-19 crisis and the crisis only likely to exacerbate nutritional inequities in the short term, such actions are urgent and overdue.