Innovating to Improve Nutrition Within the Covid-19 Crisis

September 29, 2020

Access to an adequate amount of high-quality food is closely linked to growth, health, and well-being across the life cycle. Prior to the Covid-19 outbreak, several coordinated global efforts had successfully elevated the importance of nutrition within global development agendas. Now the pandemic is exacerbating nutrition challenges in diverse regions, including Latin America and the Caribbean, East Africa, and South Asia, erasing hard-fought gains. Governments, multilateral organizations, and NGOs are finding new ways to improve nutrition and raise the profile of nutrition activities within the health sector while responding to the pandemic.

Prioritization of Nutrition and Health Before the Pandemic

Prior to the outbreak of Covid-19, several coordinated global efforts had successfully raised the visibility and political profile of nutrition within health and development circles. These activities galvanized funding and political commitments from governments and mobilized development assistance efforts aimed at addressing the complex and far-reaching problem of nutrition challenges worldwide.

In 2012, the World Health Assembly endorsed the Global Nutrition Targets within the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition. Key priorities of this plan were the reduction of stunting, anemia, low birth weight, obesity, and wasting. A further priority was increasing the proportion of mothers who exclusively breastfed their infants for six months.

The Sustainable Development Goals (SDGs) also highlighted the relevance of nutrition to health and development. Approved at the UN General Assembly in 2015, Goal 2 envisioned a world with zero hunger. Access to nutritious food is also essential for achieving many of the other 16 Sustainable Development Goals. And access to nutritious food is, in turn, shaped by global commitments related to women’s empowerment, access to safe water and sanitation, and poverty alleviation.

And this year the Nutrition for Growth Summit was intended to celebrate recent achievements and rally the global community in support of sustained attention to nutrition programs. The event was originally scheduled to take place in Tokyo in December, but it has been postponed to 2021 because of the Covid-19 pandemic.

As the pandemic intensifies, the outlook for nutrition is concerning. An increasing number of Covid-19 cases are being reported in the lower- and middle-income countries, where nutrition gains over the past two decades have been most critical.

Worldwide, nearly 1 billion people each year fail to access sufficient quantities or quality of food, vitamins, and minerals to fulfill their daily energy and nutrient needs for optimal health. Children are especially vulnerable. Because of poor nutrition, more than 160 million children under the age of five are stunted (too short for their age) and nearly 50 million more are wasted (underweight for their height). Indeed, nearly half of all deaths annually among children in this age group can be linked to malnutrition.

But young children are not the only ones at risk of poor health and premature death due to poor nutrition. At least 5.7 percent of adolescents worldwide are considered to be underweight. And undernutrition is just part of the equation, with being overweight or obese an increasingly important component of poor health outcomes.

Nutrition is closely linked to economic development as well. In 2019, the United Nations estimated that the global economy experienced $3.5 trillion in annual losses to productivity and health care costs associated with poor nutrition. Conversely, programs that promote access to, and consumption of, high quality food contribute to economic growth, with an estimated $16 return to the local economy for every $1 invested in nutrition activities.

The economic disruptions sparked by the pandemic will have a profound impact on the outlook for global nutrition activities. The most recent World Economic Outlook from the International Monetary Fund anticipates a 4.9 percent decrease in economic growth by the end of 2020. The World Bank expects increases in global poverty for the first time since 1998, thanks to curtailed trade and transportation, shelter-in-place orders, the collapse in oil prices, and shocks to the health system. With the pandemic pushing an estimated 71 to 100 million additional people worldwide into extreme poverty, defined as living on $1.90 or less a day, the number of families facing nutrition and health challenges is sure to increase as well.

While responding to the pandemic, health facilities have been struggling to provide routine services, including antenatal care, micronutrient supplementation, and treatment of diarrhea in children. Health services have become more expensive because of the need to provide personal protective gear and rearrange clinics to provide adequate spacing for social distancing and a higher level of infection prevention and control. At the same time, families have been reluctant to bring children to health facilities for routine services out of fear of being exposed to Covid-19. As a result, nutrition programs may be falling through the cracks at the precise moment they are most needed.

An indigenous Wichi woman breastfeeds her son in northern Argentina where inadequate access to safe drinking water and nutritious food has contributed to child mortality. | RONALDO SCHEMIDT/AFP via Getty Images

An indigenous Wichi woman breastfeeds her son in northern Argentina where where inadequate access to safe drinking water and nutritious food has contributed to child mortality. | RONALDO SCHEMIDT/AFP via Getty Images

A recent study suggests that 6.7 million more children will face wasting in 2020 than in previous years, with a projected 128,605 additional nutrition-related deaths among children under the age of five. These are sobering numbers, but Oxfam warns that by the end of 2020, hunger could kill more people worldwide than Covid-19 each day. Yet in a recent update to its Global Humanitarian Response Plan for Covid-19, the United Nations Office for the Coordination of Humanitarian Affairs reports that only $5 million out of a requested $245 million to support nutrition programs globally had been raised.

Nutrition and Covid-19: A Dynamic Relationship

As with any emerging disease, scientific understanding about Covid-19 is developing quickly. How a person’s nutritional status affects their risk of being infected with SARS-CoV-2, the virus that causes Covid-19, or how it may affect the person’s response to treatment or recovery from infection is not yet entirely clear.

However, it has become apparent that poor nutritional status is a risk factor for more severe infection outcomes. This is partially because poor diet is associated with compromised immunity. Being overweight or obese also appears to make people more likely to experience Covid-19 complications.

Some work has posited that nutritional supplementation with critical minerals and vitamins may help protect those infected with the coronavirus from the most debilitating symptoms and health outcomes.

However, the impact of Covid-19 on the health and nutrition outlook for vulnerable populations is more far-reaching than the risks of infection for those with low nutritional status. Several additional aspects of the social and economic impacts of the pandemic are making food security a serious problem and thus intensifying the potential for a global nutrition crisis.

Hoarding and shelter-in-place orders have limited many people’s access to food choices outside the home. At the same time, high levels of stress and anxiety have led some groups to be more sedentary or choose less nutritious food than they might otherwise.

As governments divert resources to outbreak response, social services and safety nets, such as school nutrition programs, have been scaled down or stopped entirely. This further reduces the access of poor communities to quality food, including fresh vegetables and animal proteins.

One result has been greater dependence of populations across world regions on cereal staples such as corn, rice, wheat, and cassava.

A woman works with her child on her back in a vegetable patch in Tokomadji, Mauritania in July 2020. | Raphael Pouget/UNICEF

A woman works with her child on her back in a vegetable patch in Tokomadji, Mauritania in July 2020. | Raphael Pouget/UNICEF

Border closures have also prevented the seasonal migration of agricultural workers in some areas, and the breakdown of internal transportation routes has meant that some perishable items, such as milk and meat products, may not make it to market in acceptable condition. Humanitarian assistance programs that normally provide nutrition services have also reported difficulties gaining access to the populations they serve during the Covid-19 outbreak in diverse regions, including Syria and West Africa.

Within this context, several world regions are facing specific nutrition challenges.

Nutrition in Latin America and the Caribbean

The region of Latin America and Caribbean has been particularly hard hit by Covid-19. More than 4.5 million cases have been reported in Brazil alone, with high rates of mortality in Mexico, Peru, Colombia, Chile, and Bolivia.

In May, the World Food Programme estimated that the Covid-19 outbreak has put nearly 14 million people at risk of hunger in Latin America and the Caribbean, quadruple the number estimated the previous year.

The growing number of people in the region who are expected to face challenges securing an adequate amount of nutritious food can be partially explained by the high percentage of people who work in the informal sector in domestic service, agriculture, or as day laborers, many of whom have lost their livelihoods during the Covid-19 crisis.

An estimated 53 percent of the population across Latin America and the Caribbean works in the informal economy. More than 60 percent of women in Central America work informally, while more than 80 percent of all workers in Bolivia are engaged in the informal sector. Across the region, around 62 percent of youth between the ages of 15 and 24 work informally.

Illustration showing the breakdown of the informal economy, desegregated across age, sex, and rural/urban, for the three case study regions: Latin America and the Caribbean, East Africa, and South Asia.

Two billion workers around the world make their living through informal employment, making up 62.1 percent of the world's employed population. Employed in a wide range of jobs that do not offer work-based social protection, these individuals are particularly vulnerable to the negative impacts of the Covid-19 pandemic. See which segments of the population work in the informal sector in three regions where the share of informal work is highest. | CSIS

The outbreak is exposing high levels of social inequality in a region of considerable racial disparities and uneven economic gains in recent years. The United Nation’s Economic Commission for Latin America (ECLA) predicts a 5.3 percent drop in economic activity for the region for 2020. This decrease will likely be driven by reduced trade with China, a slowdown in remittances from migrants living abroad, and the collapse of the tourism industry. The number of unemployed people in the region is expected to rise to 37.7 million, which will push an additional 16 million people into extreme poverty.

In locales where children from economically vulnerable families depend on public school programs for nutritious food, the suspension of classes last spring meant that a large segment of the youth population in the region had to forego access to fresh vegetables, fruits, and proteins. However, the pandemic has also led to the adoption of innovative approaches to ensure children can access healthy meals.

In Honduras, the National School Feeding Program that normally provides meals to more than 1 million children a month was shuttered for several months in the spring. The World Food Programme and UNICEF thus invited families in need to pick up the unused supplies. The organizations also arranged for teachers to deliver rations to dependent families, including those living in remote areas. In other areas, the two organizations are providing children with vouchers or cash transfers so that their families can purchase fresh food when they need it.

Finally, natural disasters may also compound economic challenges and complicate efforts to improve nutrition within the regional Covid-19 response. In Haiti, uneven rainfall over the past several months has disrupted agricultural production, while the closure of the border with the Dominican Republic at least temporarily stopped the back-and-forth flow of labor migrants and curtailed remittances to the country. That the number of Covid-19 cases on the island of Hispaniola is increasing during a time of year when damaging storms and hurricanes are most likely threatens to compound an already challenging nutrition environment.

Nutrition and the Pandemic in East Africa

While the number of cases of Covid-19 in sub-Saharan Africa is not yet equal to that in the Americas, the numbers are rising. With nearly 650,000 cases, South Africa ranks among the top 10 countries worldwide. Case numbers in Nigeria, Kenya, Ethiopia, and elsewhere are also increasing in a region that was already vulnerable to malnutrition before the pandemic.

In May 2020, AFRO, the regional arm of the World Health Organization, noted that 20 percent of the population in sub-Saharan Africa is considered to be undernourished and that nearly 60 million children are stunted. These figures make it the region with the highest proportion of malnutrition in the world.

As in Latin America, a high percentage of the population in sub-Saharan Africa works informally. According to the International Labour Organization (ILO), nearly 87 percent of adults and more than 95 percent of youth between the ages of 15 and 24 work in agriculture or service or undertake other kinds of informal work. Health insurance schemes in the region have become more common in recent years, but few people working in the informal sector are adequately covered by insurance or social safety programs. Even before the pandemic, there were already an estimated 237 million people in sub-Saharan Africa facing chronic undernutrition, and the situation is likely to worsen in the months ahead.

The situation in East Africa, where more than 26 million children are considered to be stunted, is particularly challenging. Not only is the percentage of people working informally high, at 91 percent, but Kenya, Somalia, Sudan, South Sudan, and the Democratic Republic of the Congo all experienced devastating flooding between March and May of this year, with an estimated 1.1 million people displaced from their homes due to the floodwaters. The flooding disrupted agricultural production and food supply chains and has made it especially challenging for impoverished families to access nutritious food.

Residential areas and farming fields remain flooded at the outskirts of Beledweyne, Somalia. The rains have forced thousands of people to leave their houses and look for humanitarian assistance while living in displacement camps. | LUIS TATO/AFP via Getty Images

Residential areas and farming fields remain flooded at the outskirts of Beledweyne, Somalia. The rains have forced thousands of people to leave their houses and look for humanitarian assistance while living in displacement camps. | LUIS TATO/AFP via Getty Images

At the same time, the worst swarm of desert locusts in 70 years descended on East Africa in late 2019 and early 2020, destroying crops and pasture lands throughout the region. A swarm of locusts can contain between 40 and 80 million insects per square half mile and can cover an area of up to 100 square miles. Experts estimate that in a single day a swarm the size of about one-third of a square mile can consume enough grain to feed 35,000 people. The Food and Agriculture Organization (FAO) anticipates that by the end of September 2020 an additional 1.5 to 2.5 million people in East Africa will be considered food insecure as a result of the swarms.

This map shows the progression of desert locust swarms between January 1 and September 1, 2020. | CSIS

For countries where a high proportion of the population works in agriculture and is facing economic disruptions due to the pandemic, the desert locust swarm is exacerbating ongoing challenges. In Ethiopia’s Afar Regional State alone, the swarm has destroyed crops on more than 240,000 hectares of land.

And Somalia is expected to be especially hard hit, with more than 50 percent of cultivated land there affected by the locust swarms. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), at least 3.5 million people in Somalia will face acute food insecurity, driven not just by the flooding and locusts but also by the decline of remittances from Somalis living abroad who have faced their own job losses.

Some countries in East Africa are taking proactive steps to prevent the nutrition situation from worsening. In Eritrea, for example, stay-at-home orders related to Covid-19 threatened to prevent children under the age of five, along with pregnant and lactating women, from utilizing critical nutrition services. To ensure these populations were able to continue to access supplements and high-impact foods, UNICEF arranged to provide Vitamin A to families visiting clinics for routine immunizations, not just those children previously identified as at risk for nutrition complications.

Nutrition and the Pandemic in South Asia

In the South Asia region, the impacts of the Covid-19 outbreak on the population’s access to nutritious food have been pronounced, compounded by the desert locust swarm reaching India and Pakistan earlier this year. Economically, the region is expected to suffer a 2.7 percent economic contraction in 2020. India, Bangladesh, and Pakistan, in particular, have increasing numbers of Covid-19 infections, with more than 6 million confirmed cases in India alone.

When Prime Minister Narendra Modi of India announced the first shelter-in-place order on March 24 for the country’s more than 1.3 billion people, it left families little time to gather food in preparation for lockdown measures. Farmers found themselves forced to burn or discard recently harvested crops, leading to the loss of access to nutritious food and livelihoods for millions. Some programs in India worked to match farmers with communities needing food. The food was purchased at a price that allowed farmers to realize some earnings and then sold to needy families before the food could spoil.

India’s National Nutrition Mission normally delivers food to millions of communities each day but had to be adapted under the lockdown procedures. Workers now deliver supplements to peoples’ homes rather than central locations. The Western Railway line has dedicated special trains to move milk and other essential commodities from areas of production to major markets such as Mumbai.

Workers load cartons of milk powder and baby food on a train in Ahmedabad during a nationwide COVID-19 coronavirus lockdown on March 31, 2020. | SAM PANTHAKY/AFP via Getty Images

Workers load cartons of milk powder and baby food on a train in Ahmedabad during a nationwide COVID-19 coronavirus lockdown on March 31, 2020. | SAM PANTHAKY/AFP via Getty Images

In Bangladesh, which has reported more than 360,000 cases of Covid-19, the pandemic is creating a nutrition crisis for rural and urban populations alike. The collapse of economic activity in the capital, Dhaka, and other urban centers has had a negative impact on farmers. Growers dependent on migrant workers have reported leaving fruit and vegetable crops to rot in fields rather than harvest them and send the food to market. For some producers, the loss of other forms of family income meant less money available to purchase food, such as for poultry and egg production, or to secure grazing rights for livestock, such as milk-producing goats.

With supplies of dairy, poultry, eggs, and other fresh foods limited because of labor shortages and disrupted supply chains, the government of Bangladesh has extended access to cash and food transfers for vulnerable populations. At the same time, access to the Public Food Distribution System has been expanded, and a subsidy for rice, a critical staple for many families, put into place. Yet while public programs to improve the access of those negatively affected by the pandemic have grown to include a greater proportion of the population, many Bangladeshi families report they are still not able to secure sufficient food for their needs, raising the risk of undernutrition.

A special focus on the nutrition needs of women and children during Covid-19 has led to an increased use of mobile phone technologies to ensure continuity of counseling and food distribution. With expectations that at least 2.4 million children will be born in Bangladesh this year, health workers have shifted to using mobile phones to deliver nutrition messages to pregnant women and lactating mothers. And parents of young children who are eligible for school-based nutrition services can receive mobile bank transfers of cash to support the purchase of nutritious food.

A woman carries a basket with vegetables recently harvested in Srinagar on April 20, 2020. | TAUSEEF MUSTAFA/AFP via Getty Images

A woman carries a basket with vegetables recently harvested in Srinagar on April 20, 2020. | TAUSEEF MUSTAFA/AFP via Getty Images

While the outbreak of Covid-19 has affected world regions in distinct ways, people working in agriculture, transportation, education, and health have coordinated to assess the nutrition challenges faced by the populations they serve and to adapt their services to the limitations imposed by the pandemic. Regaining lost ground and preventing further losses as a result of the outbreak will require additional coordination and a commitment to innovation to address the challenges of nutrition within and beyond the Covid-19 crisis.

Building Resilience Beyond the Pandemic

The pandemic is threatening fragile gains in nutrition services in diverse regions over the past decade. The ways in which the pandemic is affecting access to nutritious food are complex but closely related to disrupted agricultural activities, supply chains, and markets; economic dislocations and loss of income due to stay-at-home orders; and curtailed travel and trade.

Health officials, aid workers, and communities around the world are working to identify ways to address nutrition needs during the Covid-19 crisis by:

  1. Integrating a focus on nutrition for children and vulnerable adult populations into routine health services and the Covid-19 response;
  2. Crafting innovative approaches to nutritional counseling, including supporting mothers in breastfeeding infants, through telehealth and mobile phone services; and
  3. Integrating nutrition supplementation with other routine child and antenatal services.

To mitigate a worsening nutrition landscape, bilateral and multilateral health response funding should prioritize the maintenance of school and clinic-based programs and ensure nutrition services are fully integrated into pandemic response. Before the pandemic, global efforts had led to a greater profile and visibility of nutrition services within health programs. Maintaining a political focus on nutrition and ensuring attention to nutrition within the health services associated with pandemic response can help build resilience and chart a path for new gains as communities begin to look beyond the Covid-19 crisis.

About the Author

Katherine E. Bliss

Senior Fellow, Global Health Policy Center

Katherine E. Bliss brings her expertise in the social sciences, Latin American studies, and international relations to her work analyzing U.S. government support for health programs in low- and middle-income countries. She is particularly interested in how political and cultural perspectives shape approaches to such global health challenges as HIV/AIDS; vaccine-preventable diseases; and access to safe drinking water and sanitation. Trained as a historian, Katherine spent the early part of her career teaching at the university level and publishing books and articles on gender relations and public health in twentieth-century Mexico. A Council on Foreign Relations International Affairs Fellowship enabled her to shift her focus to global health policy, placing her at the U.S. Department of State, where she worked on environmental health issues and the development of foreign policy approaches to pandemic preparedness.

At CSIS, Katherine has previously served as deputy director and senior fellow within both the Americas Program and Global Health Policy Center, where she oversaw a multi-program project on the influence of the BRICS countries on the global health agenda and directed the Project on Global Water Policy. Her recent work has examined the health situation in the context of the Venezuelan political crisis and the challenges facing immunization programs within fragile or disordered settings. Katherine received her A.B. in history and literature, magna cum laude, from Harvard College and her Ph.D. in history from the University of Chicago. She completed a David E. Bell Fellowship at the Harvard Center for Population and Development Studies.

Full Bio Here


The author thanks Michaela Simoneau and Samantha Chivers from the CSIS Global Health Policy Center and Sarah Grace and Rebecka Shirazi from the CSIS iDeas Lab for their assistance, support and advice. 

This project is made possible by the support of the Bill & Melinda Gates Foundation.


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