Institute Insights: June 2020


iStock photo by ThamKC

From the Director

The painful and heartbreaking killings of Breonna Taylor and George Floyd, the latest at the hands of police officers, are weighing heavily on me and on my colleagues. We join with all those who are protesting against police brutality and systemic racism and seeking justice. Communities of color are disproportionately affected by hunger and poverty. The cumulative and compounding impacts of racist policies over centuries, including criminal justice policies, have systematically contributed to the social and economic inequities that African Americans face. The killings and nationwide protests are coming in the middle of the COVID-19 pandemic, which has also laid bare racial inequities and taken a heavy toll on communities of color.

From all of this, we finally see a growing national recognition that the status quo is unacceptable and that hunger, poverty, and inequality, like harmful policing policies, persist because of a failure of governance. In our July issue, we will explore the intersections of equity, governance, and hunger. This is an incredibly difficult time for so many people in our country and around the world. But I do want to acknowledge the courage and sense of hope that enable anti-hunger advocates to persevere, even when faced with many simultaneous losses—personal, community, and/or global.

We are now getting a better understanding of the global health and secondary impacts of the coronavirus crisis around the world. This issue of Institute Insights reflects on some of these. One piece of good news, of course, is that children seem far less likely than adults to become seriously ill if they contract the virus. But as COVID-19 forced people all over the world into isolation to avoid overwhelming even the best equipped health systems in wealthy countries, which shut down much of the global economy, the ensuing economic crisis set the stage for a rapid rise in hunger and malnutrition, with particularly devastating consequences for pregnant women and young children.

In fact, COVID-19 is an immediate, urgent danger to global child survival. Malnutrition is the cause of nearly half of all preventable deaths among children under 5. Based on analyses of the consequences of the 2014 West Africa Ebola outbreak, World Vision estimates that the pandemic will lead to 5 million additional children suffering from wasting, or life-threatening acute malnutrition, over the next six months. Without urgent and targeted action, The Lancet projects, an estimated 6,000 additional children under 5 will die every day for the next six months, with wasting as the leading cause. These additional deaths would be directly attributable to the COVID-19 pandemic.

Bread for the World has always emphasized that the world is capable of ending hunger and malnutrition if national governments and the global community make it a top priority—and this has not changed. Since 1990, child mortality has been cut in half, to about 15,000 per day. This is significant progress even though it is obvious that far too many children continue to die of preventable causes. If the world does not act in time to prevent the pre-pandemic figure from rising to 21,000 per day, COVID-19 would undo much of the progress of three decades in just six months.

An additional 1.2 million children dead, and 56,700 mothers along with them, over six months, is unacceptable—and it is preventable. It is imperative for the global response to COVID-19 not to underestimate the threat posed by the primary and secondary impacts of the pandemic to the survival of all these vulnerable children.

Here in the United States, the pandemic also caused a rapid economic downturn, with unemployment now at its highest level in decades. Many more children are at risk of hunger now than at the worst point of the Great Recession a decade ago. According to a recent study by the Brookings Institution, 40 percent of mothers with children under 12 could not afford enough food in April 2020. That is an enormous increase over the rate for all of 2018, when 3.1 percent of mothers reported that children were not eating enough because the family could not afford to buy enough food. Brookings concluded that “the incidence of hardship among children … has increased 460 percent.”

The design of the Supplemental Nutrition Assistance Program (SNAP) makes it effective in reducing hunger. It is an entitlement program, meaning that in hard times, its budget increases so that all who are eligible can receive benefits. The benefits are not enough to last the entire month, however, so Bread for the World is pressing for a 15 percent increase in benefit levels. Bread is also emphasizing the need for federal funding to extend the P-EBT (Pandemic -- Electronic Benefits Transfer) program. P-EBT has been providing families with benefits to replace the free and reduced-price school meals that children are not receiving since schools were forced to close. States do not have the resources to fund P-EBT during the summer months, yet clearly children still need these meals.

Devastating as the immediate impacts of the pandemic on hunger among children have been, and will continue to be if not addressed, the solutions are still available. Mobilizing the political will to do what needs to be done is more urgent than ever.

Asma Lateef is director of Bread for the World Institute

Asma Lateef is director of Bread for the World Institute.

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Every patient admitted to a hospital in the ProMedica network is screened for food insecurity, and those who screen positive receive an emergency food package along with community resource information. Zach Blum for Bread for the World

How COVID-19 Could Change Our Thinking on Health Care

By Todd Post

Because of COVID-19, I’ve been thinking back to Bread for the World Institute’s 2016 Hunger Report, The Nourishing Effect, which focuses on the relationship between hunger and health. Diseases and health problems tied to people’s diets, such as diabetes, kidney disease, hypertension, and high blood pressure, put those who have them at higher risk of dying from COVID-19 if they contract the novel coronavirus.

Limited access to nutritious foods is associated with all of the above-mentioned diseases. As I noted last month in Institute Insights, “Without good nutrition to boost their immune systems, no individuals are well prepared to survive COVID-19 when it arrives in their community.”

The Nourishing Effect champions good nutrition as preventive medicine. In households that may lack health insurance coverage and/or the resources to pay for expensive prescriptions and medical appointments, the Supplemental Nutrition Assistance Program (SNAP) often functions as preventive medicine. Research shows, for example, that among eligible seniors, participating in SNAP reduces the likelihood of hospital admission by 14 percent and nursing home admission by 23 percent.

Prevention has never been a top priority of the U.S. healthcare system, which is one reason people in this country pay more for health care than people in other industrialized countries, yet have poorer health as measured by a range of indicators, from lower life expectancy to higher rates of infant mortality. The lack of focus on preventing dietary-related conditions that, it turns out, put patients who have the virus at higher risk of death, is one reason our country has lost so many people in this pandemic (more than 110,000 at the time of writing).

The Affordable Care Act (ACA) sought to encourage health care providers to pay more attention to the social determinants of health, both to improve our population’s overall health and well-being and to slow the country’s rapidly rising national healthcare expenditures. Limited access to nutritious foods is one among many social determinants, which together determine as much as 80 percent to 90 percent of health outcomes—far more than medical care, which we often assume is the most important factor in our health. More and more Americans are living in neighborhoods of concentrated poverty, where 20 percent, 40 percent, or even more of the residents live below the poverty line. Such neighborhoods have been growing at an alarming rate, and their residents face a barrage of harmful outcomes of social determinants.

The ACA used carrots and sticks to spur health care providers to respond to social determinants. For example, in Medicare and Medicaid, providers were penalized if patients required multiple hospital stays for the same condition, but if the number of repeat visits fell, providers got to keep a share of the savings.

Promedica, a nonprofit health system based in the Midwest, was quick to recognize nutrition and food security as central to improving patient outcomes and reducing unnecessary costs. Randy Oostra, the chief executive of Promedica, has been a leader in the field, advocating for SNAP, school meals, and other nutrition programs that improve food security.

We featured Promedica in the 2016 Hunger Report. Since then, it has founded the Root Cause Coalition, made up of 76 healthcare organizations along with some of the nation’s leading anti-hunger organizations, including Feeding America and Share Our Strength. The Root Cause Coalition is dedicated to finding solutions to a range of harmful social determinants. I highly recommend the coalition’s 2020 Status of Heath Equity Report.

One way that Promedica and other health systems help reduce food insecurity is by adopting a two-item food security screen that is used during patient intake. The screen is a simple way of identifying households at risk of hunger, asking whether people had recently run out of money to pay for food or had worried that they would run out. Advocate Health Care, another large health system in the Midwest and a member of the Root Cause Coalition, demonstrated a healthcare savings of more than $3,800 per patient from supporting patients whose screenings identified them as at higher risk with nutrition coupons.

The 2020 presidential election is likely to be a consequential one for healthcare reform. COVID-19 has exposed so many weaknesses and inequities within U.S. health care. People are talking about building back better, and meeting that very general goal has to begin somewhere. The healthcare system as well as the food system, which is the focus of the recently released 2020 Hunger Report, are good places to start.

Todd Post is senior researcher, writer, and editor with Bread for the World Institute.

Photo: WHO/Sergey Volkov

Measuring other devastating health impacts of the COVID-19 pandemic

By Tanuja Rastogi

Early in March 2020, India ground to a sudden halt in the face of the COVID-19 pandemic. The BBC reported on the impact of the nationwide shutdown on people like Mohammed Sabir, a street vendor based in New Delhi. He anguished, “I fear that hunger may kill many like us before coronavirus." Mr. Sabir’s comments reflect a cruel irony of the global pandemic: the same public health measures that are necessary to protect people’s lives, such as closing businesses and other places where people gather,  are likely to cost lives because these measures also have impacts, such as unemployment, that have harmful consequences , such as hunger and lack of treatment for other health problems.

With few available options to stop the spread of the virus, and no vaccines or treatments, the Indian government acted swiftly, imposing some of the most restrictive public health measures of our lifetimes. Protecting millions of vulnerable people, particularly elderly people and people with weakened immune systems, from death due to COVID-19 infection was the overarching goal. Schools, workplaces, and markets were shut down with little or no time for people to prepare. People came to understand that a whole-of-society effort was required to prevent hospitals from becoming overwhelmed and thus unable to treat many of the most desperately ill patients. “Flattening the curve”—slowing transmission of the virus so that severely ill people arrive at hospitals at a manageable rate—became the new catchphrase. This is one of the most important strategies available to public health officials in the face of an infectious disease pandemic.

As global understanding of the direct impacts of the COVID-19 pandemic improves, the realization that it also has many harmful indirect impacts is growing as well. These are considered “indirect” because they are caused by the shutdowns imposed to limit the spread of the virus. They may be expected, but they are inadvertent—restricted food and health systems worsen hunger, malnutrition, disease, and other health problems. They affect poor and vulnerable people disproportionately, just as COVID-19 itself does. Many are serious problems in and of themselves. For example, an additional 500,000 people are expected to die of HIV/AIDS-related illnesses such as tuberculosis—over a period of only six months—because COVID-19 has disrupted their access to the anti-retroviral medications they need.

Such alarming predictions are leading government authorities and the public alike to realize that it is essential to implement a broad public health approach to counter the many impacts of the pandemic. Experts such as those at the Center for Global Development are developing tools to enable decision makers to make informed choices. The new COVID-19 net health impact calculator adopts a “whole of health” perspective by taking into account non-COVID health impacts on groups of people and individuals. It recognizes that to the extent COVID-related restrictions remain, so will disruptions to other health services.

National leaders need an accurate count of “lockdown victims,” additional deaths caused by pandemic-related restrictions, in order to identify effective public health responses that protect as many lives as possible. This is particularly important in contexts such as the Sahel, a vast area comprising parts of several countries just south of Africa’s Sahara Desert. There is a high burden of infectious diseases, so basic health services are critical. The researchers who developed the net health impact calculator explain that the question is not whether or not public health measures that restrict activity to slow COVID-19 should or should not be imposed, but rather, what degree of “lockdown” saves the greatest number of lives while causing the least possible harm.

Tanuja Rastogi is senior global nutrition policy advisor with Bread for the World Institute.


COVID-19 compounds the problems of people in fragile contexts such as Yemen

By Jordan Teague

Yemen has been in crisis since its brutal civil war began in 2015. The country’s people have spent years living in the world’s worst humanitarian crisis. 80 percent of the population relies on humanitarian assistance to survive. One major reason is displacement—Oxfam reports that every hour of the past five years, more than 90 people have been forced to flee their homes. At this point, nearly 4 million people are displaced within their country. More than 100 additional people fall into hunger every hour, and more than 50 suspected cholera cases are reported.

The war plus the economic policies of the Yemeni government have put Yemen at risk of famine repeatedly. Nearly 20 million Yemenis are food insecure and can rarely afford to eat nutritious foods. The rate of child malnutrition is one of the highest in the world, with 3.2 million women and children acutely malnourished.

Yemen’s first confirmed case of COVID-19 was on April 10. The coronavirus is particularly dangerous in fragile contexts—in Yemen, only half of the country’s health centers are functional. The United Nations warned that the virus is likely spreading undetected, and a cluster of cases in the city of Aden confirms this.

Despite the desperate situation of so many people in Yemen, humanitarian relief workers continually encounter obstacles to reaching people in need. For example, the Houthi government, which controls the northern part of the country, has imposed restrictions on humanitarian assistance, such as taxes and delays in granting travel permits, that have delayed the delivery of needed assistance. In March 2020, the U.S. government responded by suspending more than 85 percent of its funding to humanitarian programs in the region.

But now is not the time to suspend aid to Yemen. According to the head of the U.N. Office for the Coordination of Humanitarian Affairs (OCHA), Mark Lowcock, funding for nutrition and healthcare programs is essential to more than 2 million severely malnourished children who would not receive treatment, including treatment for deadly infections, without it. An additional 1 million people would not receive critical hygiene supplies to protect them from COVID-19. The war has left many of Yemen’s people with no choice but to rely on assistance from outside donors, such as the United Nations and the United States, to help meet their most basic needs.

The Yemeni people are not the only ones facing the pandemic in the midst of continuing conflict and other fragile situations. Sources indicate that 1.8 billion people – nearly a quarter of the world’s population – live in fragile contexts, including more than 513 million people living in extreme poverty. Refugees – especially those living in inhospitable countries, those from politically unstable nations, and people who have lived through armed conflict--are all especially vulnerable during the pandemic. Many people in higher-income countries are relying on their governments to enable them to meet their basic needs, and people living in fragile contexts do not have such a safety net.

There is much that can be done, however. First, the U.N. Secretary-General has called for “an immediate global ceasefire in all corners of the world.” A ceasefire would allow humanitarian access to populations in need and would stop the destruction of vital health infrastructure. Second, more aid is needed to help meet humanitarian needs. The United Nations has released an appeal asking for $6.7 billion for a global response and $2.4 billion for assistance to Yemen. All people are at risk if exposed to COVID-19, but we must be sure not to overlook low-income people trapped in situations that make them especially vulnerable.

Jordan Teague is senior international policy advisor with Bread for the World Institute.

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