7. Zero Hunger

Sustainable Development Goal 2: Zero Hunger aims to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture.

In this episode of Healthy Cities in the SDG Era, Dr. Erica Di Ruggiero will speak with two experts about the relationship between poverty and hunger, or insecure access to food, within both Canadian and global contexts. Discussions will also focus on underlying issues of systemic racism and social inequities, that lead to a disproportionate prevalence of hunger and food security amongst different social groups.

Dr. Valerie Tarasuk is a Professor in the Department of Nutritional Sciences, cross-appointed to the Dalla Lana School of Public Health. Her primary research focus is household food insecurity. She has led several tri-council research grants to elucidate the scope, nature, and health implications of this problem in Canada, assess the effectiveness of community responses, and determine how public policies and programs impact food insecurity prevalence and severity. In 2011, she led the establishment of PROOF, an interdisciplinary research program working to identify effective policy approaches and mobilize knowledge to reduce household food insecurity in Canada.

Allison Daniel is a PhD Candidate in Nutritional Sciences (in the Faculty of Medicine) and a student in the Collaborative Specialization in Global Health. Her research focuses on children with severe acute malnutrition requiring inpatient admission in Blantyre, Malawi. More specifically, she is interested in the pathways from maternal factors and care practices to child outcomes including development and nutritional status in severely malnourished children. 

CREDITS: This podcast is co-hosted by Dr. Erica Di Ruggiero, Director of the Centre for Global Health, and Ophelia Michaelides, Manager of the Centre for Global Health, at the Dalla Lana School of Public Health, University of Toronto, and produced by Elizabeth Loftus. Audio editing is by Anwaar Baobeid. Music is produced by Julien Fortier and Patrick May. It is made with the support of the School of Cities at the University of Toronto. 

Transcript

Erica Di Ruggiero [00:00:07] Hello. I'm Erica Di Ruggiero and this is Healthy Cities in the SDG era, a podcast about the Sustainable Development Goals and how research conducted by faculty and students at the University of Toronto is helping to achieve them. We're recording from Toronto or Tkaronto, which for thousands of years has been the traditional land of the Huron Wendat, the Seneca and the Mississaugas  of the Credit. Today, this meeting place is still the home to many indigenous peoples from across Turtle Island and we are grateful to have the opportunity to work on this land. In this episode, we'll look into SDG 2 Zero Hunger, which aims to end hunger, achieve food security, and improve nutrition and promote sustainable agriculture. SDG two's targets encompass ending hunger and ensuring access to safe, nutritious and sufficient food all year to all people; ending all forms of malnutrition, doubling agricultural productivity and incomes of small scale food producers, and also ensuring sustainable food production systems. According to the Secretary General on progress towards the Sustainable Development Goals, an estimated 2 billion people, or 25.9% of the world's population were affected by moderate or severe food insecurity in 2019, which was an increase from 22.4% in 2015. Notably, this figure is from before the COVID 19 pandemic, which may have pushed upwards of 132 million people into chronic hunger in 2020. In Canada, food insecurity is measured as "inadequate or uncertain access to food because of financial constraints." Over 4.4 million Canadians are living in food insecure households, according to the most recent national estimate from the 2017/2018 Canadian Community Health Survey. This is the highest national estimate Canada has seen, indicating that current policy and program approaches to address food insecurity are not working. There are many aspects to consider when thinking about hunger and its connections to food and nutrition issues. And in this episode, we'll focus on two our first discussion with Dr. Valerie Tarasuk. We'll look at food insecurity in the Canadian context, then we'll zoom out to consider malnutrition in a more global context. In our discussion with Allison Daniel about her research on children with severe acute malnutrition requiring inpatient admission in Blantyre, Malawi. Dr. Valerie Tarasuk is a professor in the Department of Nutritional Sciences who is Cros appointed to the Dalla Lana School of Public Health. Her primary research focus is household food insecurity. She has led several Tri Council research grants to elucidate the scope, nature and health implications of this problem in Canada. To assess the effectiveness of community responses. And to determine how public policies and programs impact food insecurity, prevalence and severity. In 2011, she led the establishment of Proof, an interdisciplinary research program working to identify effective policy approaches and to mobilize knowledge to reduce household food insecurity in Canada. It's really my pleasure to have Valerie Tarasuk on the program, a leading expert in food insecurity, and that's exactly what she's going to be talking to us about today. Welcome to the program, Valerie. 

Valerie Tarasuk [00:03:43] Thank you. 

Erica Di Ruggiero [00:03:44] So I want to start off with, I think, a really big question, but a very important one, and that is what is food insecurity? 

Valerie Tarasuk [00:03:53] Well, it's a good question. It's an it is an important question in this area. The way that it is measured and monitored in Canada, the thing that we're actually talking about concretely when we talk about food insecurity in Canada is inadequate or insecure access to food because of financial constraints. So people basically not being able to afford enough food for themselves in their families or at least not able to be confident that they can afford enough to eat. 

Erica Di Ruggiero [00:04:20] Yeah, but are there other sort of competing definitions of food insecurity that you think are distracting us from, you know, that fundamental framing that you've just outlined for us? 

Valerie Tarasuk [00:04:31] Well, it's the competing definition, crazily enough, actually isn't about food insecurity. It's food security. Many, many years ago, FAO published this definition. It was, you know, food security is you know, that all people all at all times having access to sufficient, nutritious, safe, culturally- appropriate food. You know, it was a big, broad motherhood statement. And so in the beginning, everybody, including me, thought, well, food insecurity is the opposite of that. Then it's people not having all those conditions. And it's that is a way to think about food insecurity. But then time passed and there was a need to measure this thing and then to operationalize that big construct. And so what we ended up with was this thinking. And I think it's totally appropriate to say, well, if you're going to pinpoint something to track at the level of individuals or households, what's the most important part of that big, big package that we need to trap? And, you know, very quickly, it was, well, the most extreme case. Obviously, you know, the lack of that is someone not having enough to eat. So it got dropped down to this very, very precise concept construct. Right. That is what's being measured not only in Canada but internationally as well, people's inabilities to afford the food that they need. But that's very different than us talking about food safety or culturally appropriate foods or, you know, physical access to foods in the context of, you know, retail issues or rural and remote communities. You know, those are all important issues that the way in which our food system has been altered through this pandemic and issues related to supply chain or food production like those are all really, really important issues. And they fit under the umbrella of food security. But they they're not the same as this thing that we're talking about of food insecurity that is this very, very extreme condition, a very, very problematic thing of people not being some people not being able to afford enough to eat. 

Erica Di Ruggiero [00:06:35] Yeah. And I think you raised some really important points about precision, which of course, matters when you're trying to measure a...construct like that. So maybe to walk us through, you know, how is it measured, maybe using examples from your own research. Beyond the big question that you said that it does try to answer. 

Valerie Tarasuk [00:06:56] So since 2004, Canada has been measuring food insecurity, using an 18 item questionnaire that was developed by the United States Department of Agriculture, and it was developed specifically to measure food insecurity in that country. And it is that 18 item module is a very sophisticated thing. The questions ranged from worrying about running out of food to not having money for more through to some questions about compromises in the quality of food and then compromises in quantity. So the lion's share of the 18 questions focus on, you know, have you cut the size of your meals because you didn't have food or money to buy more? Have you? Have you not eaten? Have you have you gone without eating for whole days? Have you lost weight all because you didn't have food or money to buy food? The questions differentiate between the experiences of. And children and households were both resigned. And that's because of a very heartbreaking body of research that shows that when families are deprived of resources, adults will often deprive themselves of food as a way to free up what they've got for their kids. So this is a gritty thing and it's a very sophisticated, very well validated scale of severity, going from someone with anxiety about food deprivation because of the lack of money for food through to people going whole days without eating. 

Erica Di Ruggiero [00:08:17] Yeah. So I think you've outlined, you know, some of the ways in which the measure and I know you and your team at Proof have really also helped to quantify the relationship between material deprivation, poverty and food insecurity and some of the health implications. You started to allude to some of those. What is your research telling us about, you know, what the situation is like in Canada? 

Valerie Tarasuk [00:08:40] Well, we've got a very serious problem. Our most recent national estimate before the pandemic was 4.4 million Canadians living in food insecure situations. And everything we know about the survey platform on which this thing is measured in Canada, it would tell us we're underestimating. So and 4.4 million was the biggest number we'd ever captured. So the indications were that the problem was getting worse, but also that this problem is festering. So we have a disturbingly large subset of the population that are struggling to afford enough food. That's the story. And you you mentioned it in the context of poverty and low income. And I just want to make a brief comment about that. Sure. These things are absolutely related because the way in which people get food for the most part is to buy it. So your inability to get enough to eat is about not having enough money in your purse. Right. But where food insecurity and value adds, I think, in terms of our thinking about poverty in Canada, is that it's telling us about somebody's experience of deprivation. I mean, by the time somebody is telling us that they don't have enough money to feed themselves and their kids, they're telling us something very important about themselves. And we might learn that by asking their income and comparing it to some income threshold. But we learn something very, very primal when we get that they actually can't afford enough food. And when we scratch the surface, then we see that they also can't actually afford to pay their rent. And if they've got prescription medications, as they're very likely to have, they're probably unable to fill some of those prescriptions because of a lack of money for them. So it's a cascade of events that transpire. We start by identifying someone as vulnerable based on these questions about food, and that works brilliantly in terms of us identifying vulnerability, because it's such a basic, such a, such a such a basic experience, but then it stands out. So, so, okay. So then we ask the question of how does it relate to health? Well, holy does it ever relate to health! In the beginning, we thought we were looking at, you know, this would have associations with diet related conditions like diabetes or high blood pressure or cardiovascular disease. And absolutely, those those conditions are more prevalent among people who are food insecure. And if we take diabetes as an example, they're more likely to not be able to keep their disease under control. But as soon as we opened our minds to the idea that there might be correlates with other conditions, then the whole world opened up because then we realized that food insecurity is very, very strongly associated with mental health problems. And honestly, the associations with mental illness are stronger than those with chronic other chronic conditions. But more recently we've also done work elaborating the associations between food insecurity and infectious diseases. There were [...] for a while there have been Canada looking at food insecurity in relationship to HIV and hepatitis C and so infectious diseases. But I think you can imagine where I'm going with this that I anticipate as time wears on and we get better data, we're going to see that that food insecurity was, you know, how people that were living in food insecure households are probably more at risk of COVID infection. So infectious diseases, chronic diseases, injuries, accidents, we see higher mortality rates, those things, but also sadly, higher rates of suicide among people from food insecure situations. 

Erica Di Ruggiero [00:12:22] Yeah. So I think I mean, your points really help to illustrate perhaps one of the myths about food insecurity, which is it's just about food, but it actually is a compass that points to these other determinants, but also many comorbidities related to health, in particular mental health. And so it's a really important to continue to measure it over time, as I'm sure you would agree. 

Valerie Tarasuk [00:12:46] Right. 

Erica Di Ruggiero [00:12:46] Repeatedly, a one time wonder survey is not going to cut it. And we do need to comparative data to be able to tell the story. You know, given the magnitude of the problem that you described just before, you know, COVID hit, you know what what can you say, though, about how food insecurity affects particular households so indigenous and black households. Any data on that particular situation? 

Valerie Tarasuk [00:13:13] Yeah. Yeah. I mean, obviously, people those most at risk of food insecurity are people who are low income, particularly working aged adults and their families. And but on top of that, what we've got in Canada is a very, very unsettling story of higher rates, of food insecurity among households identified as indigenous or black. And that and those those rates, you know, those groups continue to be more likely to report food insecurity even after we take into account things like household income, homeownership, education, household composition, all sorts of other variables. And still ethno-racial identity, you know, is a strong, highly significant predictor of food insecurity. For a long time, I think in Canada, we've been aware of the fact that indigenous peoples were more likely to have health problems and to, you know, to surface in other sorts of measures of socioeconomic disadvantage. It's a relatively new thing in Canada for us, I think, to be talking about black race as another predictor. But food insecurity brings those things together very strongly and from the work that we've done and I mean, we have a paper coming out on black rates of food insecurity in the not too distant future. From the work that we've done, it's really hard to see this as anything other than a story of systemic racism. And for sure there's more work to be done. But it sickens me to the hints you know, our first piece of work on this topic has been very descriptive, and part of the reason for that is that Canada doesn't have a practice yet of oversampling vulnerable groups on surveys. And so while indigenous and black households are way, way, way more at risk of food insecurity, they make up relatively small proportions of the total population. So for us as researchers, they end up being very tiny numbers in these population survey databases. And so so we need more numbers in order to start to unearth the ways in which it looks like public policies are being in equitably administered so that things that we would expect to be universal and to benefit all Canadians equally, because honestly, there is no other explanation than to say that that isn't true. Right. I mean, we would not be seeing these disproportionate rates of food insecurity among indigenous and black households if they had access to the same sorts of social protections that white households in Canada do. That's I mean, I'm seeing that as a hypothesis right now based on fairly crude, crude, descriptive data. But I have to say it because there is no other explanation for what we're seeing. 

Erica Di Ruggiero [00:16:12] Mm hmm. Well, I mean, I think it's also partly the challenge we had here in Canada to actually not collect race-based data, first of all. And secondly, it speaks to mistrust of these populations and the institutions that are responsible for collecting this data. And so we need to signal these problems because the data is incomplete. Right. But it's what you have to work with and you're still seeing a problem here. I think you've alluded to a number of sort of policy implications of this work. So I'd like to shift our conversation to that, if I may. So, you know, if you were to be asked, you know, what are policymakers actually currently doing to address food insecurity in Canada? How might you answer that question? 

Valerie Tarasuk [00:17:01] Well, I might have said nothing. And but then the pandemic hit and now we've actually seen policy that is being rolled out under the guise of addressing food insecurity. But what's happening? What am I talking about? I'm talking about millions of dollars that have been put into food charity operations since the pandemic. In April, we saw the federal government announce $100 million in what it called the emergency food security fund. And then in October, they added another 100 to that pot. And additionally, there was 50 million for something called, I think, surplus food redistribution. And like. So they've been. The numbers are small. This those dollar values are small relative to other government spending on the pandemic, there's no question there. So from that perspective, you could say, well, this is peanuts. Why are we even talking about it? But, you know, symbolically, it's gigantic that we know everything, everything we ever knew about food insecurity and who was most at risk as the pandemic hit. And we saw people in low wage, precarious work tossed out. And, you know, always with that 4.4 million, I should go backwards a little moment here. 

Erica Di Ruggiero [00:18:22] Sure 

Valerie Tarasuk [00:18:25] About two thirds of food insecure households in Canada prior to the pandemic were reliant on employment income. So this was very much a problem of people in the workforce unable to garner sufficient income to make ends meet. And so as the pandemic hit and it hit disproportionately across the workforce, and some people like you and I were easily able to migrate home, never having any interruption in our income or income security through this. People who were always more vulnerable in the workforce were thrown under the bus. And so the it was clear that they would be even more vulnerable to severe food insecurity as a result. And so the federal government announcing that it needed to do something about food insecurity was progress because it recognized this is a problem and it also was effectively acknowledging gaps in its existing [...] and it's existing social safety net. So good, right? But then the way to resolve that, to give money to, you know, ad hoc, voluntary, to charity operations, to end food processing companies, to distribute food, is it's just it's just very, very distressing, right, to see that that's where they've gone. 

Erica Di Ruggiero [00:19:44] Well, I guess one of the big challenge in this field has been, you know, the Band-Aid solutions that are used to address a very complex problem of food insecurity. And so you've just outlined some of the investment strategies which are short term and in response to another crisis called COVID. But if you had your way, what should we be divesting in? In other words, stop doing? And where should we be putting investments to truly tackle this problem head-on? Um...not a new problem, but a problem that's only being further exacerbated by the current pandemic. 

Valerie Tarasuk [00:20:21] Yeah. Yeah. So, I mean, Canada is unique in that for decades now, for decades, we are primary response to food insecurity in Canada has been food banks and other sorts of, you know, community based food programs. And we are unique in our dependance on that response. And I mean, we've moved to a new level with the federal government now turning to food charity as a way to manage food insecurity through the pandemic. So we've just gone to a new place in terms of our our our thinking, our very misguided thinking that somehow we can ensure that no Canadian goes hungry if we just give money to food banks or make donations to them. Where should we be going? I mean, there's a growing body of evidence that says, you know, first and foremost, we need to make sure people have adequate, secure incomes. That's how we protect ourselves from food insecurity. And if, you know, at a at a government level, we want to create strategies to prevent food insecurity. That's what they are, you know, plain and simple. We have a success story in Canada that we've had for as long as we've been looking at food insecurity. And that's what we do as seniors. Many, many years ago, we introduced the old age security and guaranteed income supplement public pensions to insulate seniors from poverty. And those things did a brilliant job of reducing poverty among seniors, and they continue to do that. And when we look at data nationally, and this has been true from the very beginning of food insecurity measurement in this country, we can see that seniors are protected from food insecurity. They're not vulnerable. They have the lowest rate of insecurity in the country. And in fact, when a low income person turns 65, their risk of food insecurity drops by more than half. So we know how to do it, right? We've got a guaranteed annual income for seniors in this country that is indexed to inflation. It's more than double the amount of money anybody on welfare receives. And it works beautifully to insulate that population subset from food insecurity. We need to roll that out, that thinking out in our programs for working age adults. And I know there's a lot of talk and there's been a lot of debate over the last year or two about the idea of a basic income or a guaranteed annual income for other Canadians. And that would be a very big help in dealing with food insecurity in this country, there's no question there. But there's you know, it's a radical idea. And like always with radical ideas, it's taking time to gain any foothold, at least in terms of policy reforms. But if we can have a guaranteed annual income or a basic income for working age adults, then we need to deal with what we've got, which is social assistance. That right now is in most parts of this country, a sentence to food insecurity, because the rates are so, you know, so patently inadequate to to cover the costs of shelter and food. So we've got we've got to deal with that, that we also have this very, very big problem of people in the workforce unable to make ends meet. And so we need to look at other ways to transfer incomes. And in some of this is as simple as ensuring that we've got adequate minimum wages and that we've got people protected from unemployment through broader coverage with employment insurance, or it's new a new a new carnations in the Canada response benefit. So we need those kinds of things. But on top of that, I also think we need to pay attention to the income transfers that we have for families with children, to the mere fact that somebody has a child in their household, someone under the age of 18 in a household is enough to increase the risk of food insecurity in this country like I kid you do not. If we just look at households, just, you know, the population in this country and we say, do you have a child or do you not? And child defined as someone who is under 18 simply know that answer is enough for us to know something about the risk of food insecurity because the presence of children increases risk. Now, that is outrageous, right? That I mean, I should not be able to make that say. 

Erica Di Ruggiero [00:24:32] That's our future generation. Right? That we're putting at risk. 

Valerie Tarasuk [00:24:35] Is absolutely ridiculous. And we've got really, really strong data that we've had since the nineties telling us that children are exposed to severe food insecurity, are indelibly marked by the experience, you know, as young people. 

Erica Di Ruggiero [00:24:48] Their have been experiments with the child tax credit. And but we've also seen provinces try to claw that back, and it's actually gone in the wrong direction. 

Valerie Tarasuk [00:24:57] We've got a long and troubled history of recognizing the importance of benefits to it, particularly to low income households with children. But this game playing and show game around who gets what and when they get it. So but but then, you know, with the Liberal government, the Trudeau government, one of its signature initiatives in its first term was to introduce a thing called the Canada Child Benefit, which was beautiful and universal, not something that could be clawed back by the provinces for social assistance recipients, which had happened to that old national child benefit. But, you know, a great idea, right? Okay. So great. And, you know, harmonized some other federal programs that had been in place before the liberals were elected. All fine, but then we did great [...] the Canada Child Benefit a benefit that goes to, I think, over 90% of households with children under the age of 18. So beautiful coverage and it has some kind of sliding scale on it. So the lower income households get more benefit than higher income households. But as I said, it goes to more than 90%. So families with incomes as high as $200,000 are receiving some check from the Canada child benefit every month. Okay. So how come how come I'm still sitting here saying that, you know, the mere fact that someone has a child over the age of 18 in their household is a predictor of food insecurity? And yet the Canada child benefit actually wasn't designed to deal with insecurity as if like, it would make sense to say that. I mean, I say that because this is something that was told to me by one of the architects of the benefit. And then I thought, what if it wasn't supposed to enable families to have enough money to feed their kids? Like what was the like what they had that would have been more important than that one? Like, I mean. Well, it's. 

Erica Di Ruggiero [00:26:42] A political I'm sure it was a political commitment more than as opposed to an evidence based one. Right. 

Valerie Tarasuk [00:26:49] So, I mean, it blows my mind to think that we would have had this gigantic redesign of child benefits in this country, and then we'd have somebody boldly saying, but it's not supposed to do that. And I think, well, okay. So we did an analysis of the Canada Child Benefit's effect on food insecurity, and we can see that it had some effect. Very low income families in Canada had a slight reduction in the probability of being severely food insecure. Now severely food insecure households are households that have told us that they haven't had enough to eat because of lack of money. We're talking about an extreme level of food deprivation, and we saw it diminish somewhat with the introduction of the candidate child benefit. But the benefit has done nothing to change the prevalence of food insecurity among families with children overall. And, you know, so still we've got this issue of having a child being a risk factor. But this is a perfect example of a policy that could so easily be improved to protect families with children for food insecurity. Right. They're already getting the benefit. All we have to do is add more money because that's what it's about, that the transfer payment to low income families is not enough to make a difference, particularly given that those, for the most part, are the same families that are either in the workforce but on low wage jobs with poor benefits, or they're on social assistance with basic incomes that are absolutely inadequate to cover basic needs. So it's the perfect solution as a federal program for this aspect of food insecurity. But, you know, as we've moved it through the pandemic, what have we got now? Hundreds of millions going to foodbanks and what a one time increase to the Canada child benefit back in May or June, I think. But it went to everybody, you know, $300 increment went off for everybody in the country. Well, you know, those people with the incomes of over 200,000, they actually didn't need it. With the incomes below 20,000, they could have used 3000. 

Erica Di Ruggiero [00:28:54] They could have used more. I think it's it's a really good example of maldistribution of resources. Right. And I mean, I think what you're also signaling is a program like this that could be improved was designed in a siloed way. And it needs to also be designed in concert with other policies that, of course, address this very complex problem. You've already alluded to these, but affordable housing, of course, is key. You know, precarious work is, you know, a fundamental driver. And we've only seen that get worse with the pandemic. And you also touch on food banks. So, you know, now I'm going to turn the the story to the other side of the coin, which is we keep investing in solutions that are Band-Aids. And so they do take money out of the system that could be better redirected to more effective policies. We happen to be, as I understand it, it's the 40th anniversary of food banks in Canada. And so, you know, what would you say to that? I mean, it is a strategy that we shouldn't really be investing in as a long term one, but it seems to be the go to strategy. So what are your thoughts on that? I mean, it's emblematic of many strategies that are feel good strategies, but they still subscribe to this charitable model rate of tipping it. 

Valerie Tarasuk [00:30:17] It is very, very concerning. I mean, one thing that that people really need to know is that when I mean, there are two two facts about food banks that that I just wish I could spray paint on the walls. The first one is that most people who are food insecure don't use them. So while the numbers, you know, anytime you hear the numbers of people using food banks are really big and or, you know, the amount of donations is really big. Like you heard these numbers that are tons or hundreds of thousands or whatever and they sound huge. And you think, Oh, that's got to be a gigantic operation. But the truth is that, yes, it's big, but it pales in comparison to the size of the problem of food insecurity. So prior to the pandemic, we were seeing roughly one in four or one in five was the ratio of the proportion of food insecure households that would ever show up in food banks or food charity community food programs. So one in four or five. So the vast majority of the people with the problem, this is not a response for them. And I mean, I can talk more about why that is. But the bottom line is there's you know, these two problems don't actually even converge for the most part, right? The overlap is small. The second thing and then when we look at the people who are food insecure, who do use food banks, what can we say? They are more likely to be severely food insecure that the use of food charity is is an act of desperation. People use food charity as a last resort because for many reasons, among them being that, you know, we're in an affluent society where to go to a charity to receive food, to feed yourself and your children is a deeply, deeply humiliating thing to have to do. And so it's never going to be an appropriate response for a country like ours. We should never think that institutionalizing in a charity as a response to something, some basic need is appropriate. And this is in an affluent society it isn't. And so, you know, we have this low, low utilization. But but when we look at where people go in because they're desperate and then we look at what difference does it make now they've gone? Does using a food bank or a food program of some sort, does it protect them from hunger? No! 

Erica Di Ruggiero [00:32:36] You know...So it's a mismatch, right? 

Valerie Tarasuk [00:32:39] The amount of assistance that any one person was able to receive from these charities is simply a drop in the bucket of what they need. And it doesn't help them to pay their rent, to put shoes on your kid or, you know, cover their prescription drug costs. If they don't have coverage, it doesn't do any of that. They come out with a couple of bags of groceries that maybe things they normally wouldn't eat because, you know, you take what you get in charity. And so when we look at people who are using you report having used a food bank or other programs and then we follow them. Over time, many of them are likely to still report food deprivation simply because, you know, the assistance isn't even enough to cover off that. So I think I really believe if Canadians just understood better how ineffective it is at even managing hunger, which is what we think it should be doing, that there would be more of an appetite for other kinds of policy responses because this just isn't working. But but the messaging around the donations and the utilization give you the impression that somehow, you know, we've got our finger in the dike here and we can't move it. That fingers vital and you know that we can't change anything like this is just such a such a critical thing for us to be doing. But it's so missing the mark. And as as we continue to rely on it, what have we got? We've got a problem that's festered because we haven't dealt with the root causes. 

Erica Di Ruggiero [00:34:04] Right? Yeah. I mean, it's very difficult to undo things like this. Right. And I mean, a 40th anniversary is very telling. 

Valerie Tarasuk [00:34:13] That's right, that's right. 

Erica Di Ruggiero [00:34:13] When we [...] haven't been able. It's an intractable sort of policy direction in which we continue to be stuck in. But we need transformative change and hopefully the pandemic and other crises we're facing will lead us there. I want to sort of end in giving you a chance to come back to sort of the measurement of the problem of food insecurity. We know that during COVID 19, we've seen disruption to data collection. And so we're going to have some gaps. Right. And these will have implications for current and future public policy responses, which will remain incomplete. Any thoughts on on that reality and what needs to change and what we need to learn from because of these disruptions to data collection? 

Valerie Tarasuk [00:35:01] Yeah. Yeah, it's it's been very problematic for people in the area of food insecurity because. When the pandemic struck, the primary vehicle for measuring and monitoring, it had been the Canadian Community Health Survey, and it was immediately put in a field and went back into the field. You know, six or more months later, it went back in online. But if someone doesn't have enough money to put food on the table, they also don't have enough money for Internet. And that, you know, they may never have had enough money for Internet, but it's to rely on online data collection, as has happened in many domains through the pandemic. Is it just simply means that we've turned out the lights on those who are most vulnerable and going forward? I mean, you know, I know there been a lot of conversations through the pandemic about Internet access. And going forward, that's something that needs to be addressed, I think, in Canada. And and certainly measurement and monitoring of all things related to vulnerable groups has been a casualty of that. But we need to get way smarter in terms of being more responsive. And as I said earlier, I think as we rethink our measurement and monitoring systems more broadly and in Canada, we also, I think, have to open our minds to the idea of oversampling and different kinds of data, vulnerable populations. Because, I mean, through this pandemic, we've also become much, much more attuned to issues of race and the way in which so much in our in our country is racialized. And to move beyond that, we need race based data collection. And there's just no you know, that would go a long way right through helping us to be able to identify where there is real gross negligence in terms of the administrations of policies based on the ethnic racial identity of applicants. And I can't see any other way that that's those kinds of systemic problems in Canada will be exposed until we have better data. 

Erica Di Ruggiero [00:37:13] Yeah, I think, you know, you make an excellent point and I'm really glad you came back to that because I was actually going to ask you to sort of return to that theme because there was a problem before the pandemic. Right. That we weren't necessarily collecting sufficient data from underrepresented groups for all sorts of reasons. But I guess at the end of the day, we really need ongoing data collection, not just to measure the problem, but also to measure the impacts of the proposed solutions that are being put in place. So thank you so much, Val. I know I could spend all day talking about this topic that we share and have a lot of interest in, but we really appreciate your wisdom and for sharing your perspective today on this program. So thanks for making the time. 

Valerie Tarasuk [00:37:55] Well, thank you, Erica. It's been great to talk to you about this. Thanks. 

Erica Di Ruggiero [00:38:06] Allison Daniel is a Ph.D. candidate in Nutritional Sciences, in the Faculty of Medicine and also a student in the Collaborative Specialization in Global Health. Her research focuses on children with severe acute malnutrition, requiring inpatient admission in Blantyre, Malawi. More specifically, she's interested in the pathways from maternal factors and care practices to child outcomes, including development and nutritional status in severely malnourished children. Well, it's my pleasure to have Allison Daniel on the program today. So welcome, Allison. 

Allison Daniel [00:38:40] Thank you so much for having me. 

Erica Di Ruggiero [00:38:42] Yeah, it's a real pleasure. So we're going to be talking about SDG 2, also known as Zero Hunger. And we're delighted to have Allison here, who's going to share with us some of her research and perspectives on the topic. So, as you know, Allison, the W.H.O. or the World Health Organization has estimated that around 45% of deaths among children under the age of five are linked to malnutrition, with the majority of these deaths occurring in low and middle income countries. So I know this is an area that is of great interest to you and you're doing a lot of really important work in there. So but just for our listeners, what do you think are the key determinants of malnutrition? 

Allison Daniel [00:39:28] I think when we think about determinants of malnutrition, we have to consider a lot of different levels. The first being a population or community level, which can be related to health systems, capacity and access, food security or food insecurity, as well as things like seasonality, which of course are impacted greatly by climate change. When we kind of consider the causes of malnutrition at the child level, it's really important to consider that there are bi directional relationships between things like acute illness and malnutrition. So malnutrition is not simply a lack of food. And I really want to emphasize that point. And there are also a lot of other social factors that are related to risk of malnutrition. Those can be things like a single mother having difficulty caring for a child, other things like neuro disability or other disabilities that a child may have, that puts them at risk of malnutrition. So there really are quite a range of factors to consider when we think about risk for malnutrition as well as risk for mortality from malnutrition. 

Erica Di Ruggiero [00:40:38] Yeah. So I think, you know, that's really very important to highlight those different determinants. And malnutrition of course is not a simple problem with a simple fix. But if you had to sum it up in one sentence, what do you think? Really, what's at the crux of malnutrition? And part of the reason I'm asking is because I'd like to hear from you in a moment about, you know, what kind of interventions we should be designing to address malnutrition. So just from a determinants perspective, what do you think? 

Allison Daniel [00:41:11] Yeah, I mean, that's such a challenging question to answer because I think there are so many cross-cutting issues that that lead to malnutrition. I mean, the biggest one really is poverty itself. I think that would be the biggest determinant. And within that, there are obviously a whole range of factors. But that's quite a hard question to answer. 

Erica Di Ruggiero [00:41:32] No, no, I know, I know. And I think that was part of the reason I asked it, because you've answered it brilliantly, because we too often try to come up with a simple answer to a very complex problem, which really kind of moves me into the next topic I wanted to explore with you, which is really around some of the interventions that need to be designed and evaluated to address this very complex problem. So based on your own research, what have you learned about the design of interventions affecting different outcomes related to malnutrition? I know high mortality rate in this population is a huge concern and of course there are longer term implications of malnutrition...should kids get past the age of five? So would love to hear your thoughts on on the design of interventions there evaluation and also you know any thoughts about the work I know you're doing with the gruesome all out program. 

Allison Daniel [00:42:31] Sure. So just for context, my research focus is really on children with severe malnutrition in addition to an acute illness. So these are very sick children who require hospital admission at a nutritional rehabilitation unit. So this is really a specialized center that provides both clinical care and nutritional care. So one of the things that is is really important in this population is learning how to prevent or sorry, applying interventions to prevent mortality in the inpatient setting, but also the outpatient setting after kids leave hospital. What we've been seeing is that the risk of inpatient mortality is 20 to 30%, and it's actually close to the same level after children leave hospital within the first year after discharge. So I really want to emphasize that, that these kind of post-discharge programs are going to be very important in determining a child's outcome after hospitalization. So my my work has really been around this intervention program called the CUSUMANO Program. It's a counseling program provided by nurses in the hospital setting where they teach mothers about nutrition, wash and also playing and interacting with their children. It was really aimed to improve child development and nutritional status after children have a bout of malnutrition. But based on the results of a trial that we did evaluating this program, it's really not sufficient to improve these long term outcomes, which likely relates to the fact that these children are so vulnerable, again, experiencing a high risk of mortality after leaving the hospital. And therefore, it's very difficult to also impact some of these longer term outcomes, like development and stunting and so on. And we do see that that the use of these outcomes can persist several years after children experience malnutrition with lower grades in school in later ages, for example. 

Erica Di Ruggiero [00:44:40] Yeah. So you can see the multiple ripple effects that malnutrition can have on the health of a child. Maybe I can take you back to something you said. You talked about a bout of malnutrition for for somebody who has no idea what that means. Can you give us an example of what that means? 

Allison Daniel [00:44:59] Yeah. And I think it might be important for me here to actually maybe clarify what I meant by that, because so what I was referring to there was when a child has malnutrition and an acute illness and requires admission to a nutritional rehabilitation unit. But I do want to point out the fact that we've commonly called this severe acute malnutrition, but it's actually not necessarily an acute disorder disease. It's often very persistent over a long period of time. So there is some evolution of the terminology to just be around severe malnutrition or severe wasting, because even if a child recovers from severe malnutrition, they may remain moderately malnourished or or become severely malnourished again. So I think when I said about malnutrition, that might actually not be the appropriate way of framing what this problem really is. 

Erica Di Ruggiero [00:45:55] Mm hmm. No, but I think it just gives you a chance to also unpack this very complex problem a little bit more. So for our listeners who don't necessarily know where the Kusamala program is, can you just tell us a little bit about, you know, the location and just expand on on where we're talking about in the world? 

Allison Daniel [00:46:16] Sure. So I've been based part time at the Moyo Nutritional Rehabilitation Unit in Blantyre, Malawi. So it's one of the largest centers for for malnourished children actually in sub-Saharan Africa. And it's it's it's part of a [...] larger tertiary hospital known as Queen Elizabeth's Central Hospital, which is connected to the University of Malawi College of Medicine. So it's got a really strong research program and also clinical training programs. 

Erica Di Ruggiero [00:46:49] Okay. Well, that's good to know. Thanks for that. But actually, you know, I'm really glad you started to unpack the terminology because language does matter and it kind of helps me, you know, move us or zoom out, I guess, from a local country context to what's really being done globally. So maybe you can just reflect briefly first on what is being done to address and prevent malnutrition and what might be some future policy directions. I know, for example, that you're involved right now with the World Health Organization in helping to draft a global action plan on child wasting. So that might be one area, but I would love to hear your thoughts on what's being done and where policy really needs to go next. 

Allison Daniel [00:47:37] Sure. So one of the things that's happened in the last about 15 years that really revolution revolutionized care of children with malnutrition, is that community based management of acute malnutrition model? So that's quite a mouthful there. But basically one of the things that really impacted how malnourished kids are treated is most children can be managed nutritionally in a community setting, so they can be provided with a therapeutic food to take home. In the past, before that model existed, all severely malnourished children needed to be admitted to a hospital setting, which is not the case anymore. That is only for children who have severe malnutrition and an illness, as I talked about earlier. So that's one of the things that I think is is really quite effective, is that community based program, which also involves a lot of screening in these communities. In terms of moving forward, though, one of the most important things that that these new global guidelines on malnutrition will address is children with moderate malnutrition. This has really been an understudied area and we currently don't have any guidelines yet. We do know that these children are at risk of becoming severely malnourished or contracting an illness or simply being at risk because they they remain moderately malnourished for a very long time. So that's one of the things that these guidelines would really focus on, is how do we manage this huge number of children that experience moderate malnutrition? 

Erica Di Ruggiero [00:49:17] So I guess it really oh, sorry. But it helps to, I guess, try to get ahead of the curve and prevent things from getting to the acute stage. So it sounds like that's a huge area of focus. I wanted to. For people who aren't familiar with W.H.O. guidelines and we know there are many of them for different topics, who are they being directed at or has not been determined yet? Who's the audience for these guidelines? 

Allison Daniel [00:49:44] Yeah, that's a great question. So these are global guidelines, but one of the important things about W.H.O. guidelines is that they should always be considered by individual countries or even regions within those countries and be adapted to those settings. Although the guidelines have a series of recommendations, not all of those will be able to be applied in different contexts. But it really is for governments or ministries of health to use and make their own decisions based on their own populations. 

Erica Di Ruggiero [00:50:17] Okay, that's good to know. And is there a sense of when they might be coming out? I know it's still early days probably and hard to predict, but any thoughts on that? 

Allison Daniel [00:50:26] Yeah, the goal for these guidelines is to release them by the end of 2021. It's a very ambitious goal, but that's that's where we're at right now. 

Erica Di Ruggiero [00:50:34] Okay, that's great. Anything else you wanted to add or share? I know we could talk about this all day because this is a really complex problem that's very much connected to other determinants outside the health sector. But I appreciate you sharing your thoughts. Any last words for our listeners? 

Allison Daniel [00:50:51] I do really want to bring up the point that malnutrition or food insecurity represents a lot more than food itself. And I think that's something to really keep in mind when we're trying to address these major problems at the individual level or at the community or or population level. 

Erica Di Ruggiero [00:51:11] Yeah, no, I think that's a great point. And I think too often we focus on the magic bullet. And think that food is the only solution, but that's a decontextualized solution to a very complex problem. So glad to have had you on the program, Allison. Thanks so much for sharing your thoughts and your experiences and also your research in Malawi. 

Allison Daniel [00:51:32] Thanks so much, Erika, and thanks everyone for listening. 

Erica Di Ruggiero [00:51:42] As highlighted by both discussions in this episode, the global and social determinants and root causes of hunger are extremely complex and context specific. Yet in all cases, hunger in all of its forms is about much more than food itself. Notably, material deprivation and poverty are underlying and significant issues that must be addressed in order to truly tackle the root causes of food insecurity. Beyond this, the issues of systemic racism and health and social inequities to address the disproportionate prevalence of food insecurity among different groups must be prioritized. As previous guests on healthy cities in the era have called for more data on vulnerable groups must be collected on a regular basis in order to design more effective policies to address food insecurity. Healthy cities in the SDG era is made with the support of the School of Cities at the University of Toronto, whose mission is to bring urban focused researchers, educators, students, practitioners and the public together to explore and address complex urban challenges. 

Erica Di Ruggiero [00:52:47] We would love to hear your thoughts on healthy cities in the SDG era. If you enjoyed this episode, please rate, subscribe and share to help others find the series. You can find healthy cities in the SDGs here on Spotify, Apple Podcasts and the line of School of Public Health's YouTube page, as well as our Center for Global Health website. Join us for our next episode where we'll look at SDG 1 No Poverty. Thank you for tuning in and we look forward to speaking soon. Take care.